Editor’s Note: The Northern Hoot acknowledges that methadone treatment has been a life changing and life-saving option for many people addicted to opioids. The narratives shared by the three First Nations women in this series reflects a different viewpoint about the methadone option. Their experiences may not speak for everyone who has used or loved a person that uses methadone, but these are their unique stories. *Names have been changed in the interests of privacy and job security.
A report by the Globe and Mail shows a 23% increase in the prescribing of opioids in Canada over a four year period. In 2010, 17,542,822 opioid prescriptions were dispensed compared to 21,716,832 prescriptions in 2014. In 2016 there were an estimated 22 million opioid prescriptions written in Canada and an estimated 2,000 overdose deaths linked to opioids. There are two trends within the opioid epidemic: overdose deaths involving prescription painkillers and a recent surge in overdose deaths due to illicit opioids such as synthetic fentanyl and carfentanil.
A July 2015 report by the Canadian Centre on Substance Abuse found “among First Nations individuals aged 18 and older living on-reserve or in northern First Nations communities across Canada, 4.7% reported past year use of illicit (heroin) or prescription opioids.”
A 2016 report by the Canadian Medical Association Journal reports that, “In Canada, the United States and Australia, rates of opioid dependence tend to be higher in Aboriginal than in non-Aboriginal communities, as are the rates of associated harms and death.”
A 2011 report published in the Official Journal of the College of Family Physicians in Canada found “in northern Ontario, narcotic abuse (in particular oxycodone in long-acting OxyContin or short-acting Percocet) has become an increasing problem. Remote First Nations communities with high rates of unemployment, poverty, and overcrowding bear the additional social and economic burden of narcotic abuse and addiction, with profound narcotic abuse in some of these communities. A 2008 survey carried out in the northern Ontario reserve of Constance Lake revealed that 46.3% of respondents abused prescription drugs and 39.6% abused illegal or street drugs.”
‘Lorraine’ is a First Nations woman and a social worker in Sault Ste. Marie. She contacted the Northern Hoot regarding her personal as well as professional observation that First Nations people are over-represented in the prescribing of opioids and methadone treatments.
“We take the lead in missing and murdered aboriginal women, we take the lead in suicide-especially amongst youth, we take the lead in the criminal justice system, and pretty much in Canada we take the lead in child welfare- a lot of our First Nation children are in the Children’s Aid Society system,” remarked Lorraine. “And now we are also taking the lead in prescription medicine, and opiates are prescription medicine – and methadone is included in that. I look at it as just another form of oppression being directed at First Nation people.”
Within the opioid epidemic, some experts have identified a second epidemic –the epidemic of treatment. A paper titled, Treatment of Prescription Opioid Disorders in Canada: Looking at the ‘Other Epidemic’?, reports in Ontario alone 50,000 people are on methadone maintenance treatment programs. Researchers articulate they are not opposed to methadone treatment, but express concern that methadone is misused and overused, and “has proliferated as the de facto first-line treatment”.
Methadone is an opioid and an agonist –it can suppress craving, but some experts believe that methadone can be addictive. The Centre for Addiction and Mental Health (CAMH), however, offers a more gray assessment of methadone as an addictive opioid stating: Modern definitions of “addiction” look at many factors in assessing a person’s drug use. People in methadone treatment do become tolerant to certain effects of the drug, and will experience withdrawal if they do not take their regular dose. But methadone fails to meet a full definition of “addictive” when we look at how and why the drug is used. In their handbook, Making the Choice, Making it Work, CAMH suggests that physical dependency is merely one criterion of addiction.
“They’re scared to bits about not having that drink,” remarked Lorraine who has noted that many fear withdrawal or returning to narcotics without their methadone. “There is that fear of both things. Fear of failure, fear that they are not going to be able to make it out ok.”
Dosage varies from patient to patient but people on methadone require one ‘drink’ a day. Urine testing is done regularly –sometimes daily, to ensure the absence of substances that could contribute to overdose if mixed with methadone. After a period of clean urine testing, patients are rewarded with ‘carries’, typically six days’ worth of methadone.
“It’s a very oppressive system,” commented Lorraine. “That person has to arrive down at that place every single day to get a drink- whether they’re trying to get a job, trying to better themselves by going to school, taking care of children. Rain, sleet, snow they have to get down there every day to get that drink. If they’re lucky and they’ve maintained positive urines for a significant length of time, they allow a few carries to take home with them. And if they mess up they start right back at square zero. For some it is hard to stay on the right track. The people that are coming to them for help are subjected to urine tests, constant scrutiny and then when they are having difficulty because they are on this never ending program they are falling into the hands of CAS which is further difficulty for them.”
Methadone and the Next Generation
Methadone is long-term with treatments lasting a minimum of one year, and life-long methadone maintenance can be recommended for patients. This fact troubles many, including Lorraine.
“I think it could be carried out more compassionately for the long term health and well-being of the individual for the rest of their life,” commented Lorraine who wishes doctors would decrease dependency by decreasing methadone doses. “That’s humane in my point of view. But to just put someone on it and keep them on it forever –like that’s just replacing one drug with another and you’re creating that dependency. How is that helping? Especially when it’s extended to the next generation.”
Women who become pregnant while using opioids are encouraged to begin opioid agonist therapy (OAT) –like methadone, as soon as possible. The Centre for Addiction and Mental Health (CAMH) explains “opioids such as heroin and oxycodone are short acting, which means that withdrawal comes on quickly. Sudden withdrawal from opioids can cause the uterus to contract, which can bring on miscarriage or premature birth. OAT prevents withdrawal for 24 to 36 hours. It is safe for the baby, and gives the woman who is pregnant a chance to take care of herself.”
CAMH also explains that “some babies born to mothers on OAT will go through withdrawal after birth. Withdrawal usually begins a few days after birth but symptoms could arise two to four weeks after birth and may last several weeks or months. Infants in withdrawal may be cranky, not eat or sleep well, or have a fever, vomiting, trembling and occasionally seizures.” In cases where symptoms are severe, babies may be medicated by medical professionals to ease withdrawal.
CAMH reports “while it is not known for certain what long-term effects the exposure to OAT” may have on a baby “babies born to mothers of OAT usually do as well as other babies, and have a much greater chance at doing well than babies born to mothers on other opioids. Taking OAT while pregnant will not result in any deformities or disease in the baby.”
The Research Council of Norway published a doctoral thesis that studied the cognitive development of four year old children prenatally exposed to methadone or Subutex. Findings from the 2005-2006 research revealed “these children develop more problems involving attention span; fine motor coordination, self-control of behaviour and working memory –symptoms known collectively as disorders of behavioural and emotional regulation.” Researchers did conclude that the children born of mother’s participating in opioid agonist treatment –like methadone, fared much better then children exposed to narcotic substances in-utero.
“I know it’s affecting the broader society as well, but we’re fighting all the time for one thing or another –the fight to keep our children and have equality for them, the fight to have equity, to have our land, to have our language, to have everything that belongs to us,” commented Lorraine. “And now it’s like these babies are being born this way- these are our future leaders, they are our future generation and now the most vulnerable of our population is subjected to this. And it’s fully legal and that’s what gets to me the most.”
The Business of Methadone Treatment
In 1996 Ontario had 3,000 methadone patients, 29,000 patients in 2010, and around 55,000 patients as of January 2017. Between 2011- 2014 the Chief Coroner’s Office reported 432 deaths, attributing methadone as a factor. Suboxone, an alternative opioid maintenance treatment, is considered six times less likely to cause overdose.
The upward growth in methadone patients is problematic for researchers who observe that “the pharmaceuticals industry’s corporate greed and tactics have been popularly blamed for the prescription opioid abuse epidemic” and “economies within the health care system…appear to exert an undesirable dynamic” in the treatment of those who misuse prescription opioids.
Researchers criticize provincial incentives that provide hearty reimbursement for opioid maintenance treatments- like methadone, within Ontario’s public fee-for service-based health care system. “The province introduced additional financial ‘incentives’ in 2011 to entice more community physicians and pharmacies into methadone maintenance treatment delivery. In this context, an extensive proliferation of numerous ‘for-profit’ Methadone Maintenance Treatment-only clinics occurred focusing on economies-of-scale – i.e., large patient numbers – yet also featuring treatment quality problems (e.g., compromised patient care, inappropriate take-homes or “carries”, excessive urine testing).”
Methadone is big business for doctors who oversee methadone prescriptions. It is estimated that methadone treatment costs the Ontario health care system $250 million in reimbursement fees.
In Sault Ste. Marie obtaining an accurate number of patients participating in methadone programs is difficult. Locally, there are three entities that offer methadone treatment –Algoma Public Health, the Ontario Addiction Treatment Centre (OATC) on Queen St., and Road to Recovery –the newest clinic in town, also located on Queen St.
Algoma Public Health’s methadone program, launched in 2003, is funded by the Local Health Integration Network serving a small patient load of 35 active clients. Over the past 3 years, APH has provided this service to 51 clients. Leo Vecchio, wrote on behalf of APH, “Due to these programs being ‘maintenance programs’ and based on the client’s goal around maintenance and tapering there is little turnover. The program is not-for-profit, staff support is provided in-kind and we maintain a lower caseload to best support the clients of our clinic.”
The OATC did not provide requested statistics regarding caseload in time for this article, however a prior interview with The Northern Hoot revealed that the clinic was supporting up to 300 patients in 2015.
A staff person at the Road to Recovery, was agreeable enough relaying the request for information to appropriate sources but did admit that what was being sought was likely not for public knowledge stating, “Some of this is too private- such as number of patients. It’s a business right? For other clinics to know this kind of information –usually you don’t disclose that stuff.”
The statement is an interesting contrast to Vecchios comment where he writes, “There are currently 2 other clinics that are ‘for profit’ providing opiate replacement therapies, including methadone maintenance and suboxone, in Sault Ste. Marie. OATC have 4 prescribing physicians and Pharmacy on site, and Road to Recovery Clinic. These programs are much larger in scale and have a substantially higher caseload.”
*Several attempts were made to engage the prescribing medical community though time restraints or disinterest precluded opportunity for discussion. Through social media and through clinics, the Northern Hoot attempted to find candidates to interview who had positive stories about methadone treatment though no one came forward in time for this series.