A B.C. study tracking more than 30,000 drug users over a decade has found patients prescribed the synthetic opioid methadone were up to 40 per cent more likely to stick to the treatment compared to the alternative front-line medication.
The , published in the Journal of the American Medical Association last week, used anonymous health data of nearly every patient prescribed either methadone or buprenorphine/naloxone, often sold under the brand name Suboxone.
Both drugs, which are under the province’s public health-care system, are prescribed to reduce opioid cravings and withdrawal symptoms without providing the euphoria that comes with illicit drugs.
“By not having that euphoric effect, it’s meant to bring back their quality of life, allowing them to work, repair the relationships in their lives,” said Bohdan Nosyk, the study's lead author and a professor in the Department of Health Sciences at Simon Fraser University.
The findings offer a window into the effectiveness of what have become increasingly ubiquitous treatments at specialized drug treatment centres in B.C.
For decades, methadone was considered the front-line treatment for opioid addiction. In 2018, overtook methadone as the first choice B.C. clinicians should consider when treating opioid addiction. And in 2023, both drugs were put on equal footing in the province.
The latest research shows drug recommendations could be swinging back in methadone's favour. Those who received methadone were found to have a 37 to 40 per cent lower rate of treatment discontinuation compared drug users who were prescribed buprenorphine/naloxone.
That matters because people who give up on either of the opioid alternatives have their risk of dying from an overdose spike.
“When people are engaged in treatment, they are nearly two and a half times less likely to die,” Nosyk said.
Rise of powerful street drugs
Nosyk carried out the research with 21 colleagues from institutions spanning the BC Centre on Substance Use, the University of British Columbia, McGill University, Harvard University in the United States, and Cambridge University in the United Kingdom, among others.
Data in the study spanned 2010 to 2020, ending just a day before B.C. declared a public health emergency over the COVID-19 pandemic.
Over that period, B.C. saw a massive increase in the number of overdose deaths in the province — largely driven by the rise of the incredibly powerful opioid fentanyl.
Fentanyl was first detected by the BC Coroners Service in 2012. Within four years, health authorities declared a public health emergency as the drug became the leading cause of overdose deaths.
By August 2024, fentanyl was detected in 83 per cent of drug deaths, and an estimated six people were dying every day from a drug overdose, according to the Coroners’ .
In only eight years, B.C.’s toxic drug crisis has claimed the lives of more than 15,000 people.
Declining effectiveness of opioid alternatives
As the drug supply has become more toxic, patients have struggled to stay on either methadone or buprenorphine.
“The percentage of people who have been able to stick with it for 12 months, it’s halved in the last 12 years,” said Nosyk.
Within two years of starting the medication, 88 per cent of people taking buprenorphine and 81 per cent of those taking methadone stopped taking the drugs, found the study.
Nosyk said that since the start of their research, only two per cent of patients successfully weaned themselves off either opioid alternative.
Those numbers are indicative of a wider understanding among doctors that treating opioid addictions with even front-line treatments rarely leads to abstinence.
“It just doesn’t work very well,” said Nosyk. “We need to treat this as a chronic disease.”
“Some people see that as a difficult message to digest. But this is what we’re seeing.”
Still many barriers to methadone access
Dr. Paxton Bach, a clinical assistant professor in the Department of Medicine at UBC and a co-author of the study, said that despite the struggle to keep people on the drugs, methadone and buprenorphine remain the gold-standard opioid treatments used daily across B.C.
“To me as a clinician, both of these medications were extremely effective of reducing risk of overdose death — as long as people are taking them,” he said.
The opioid alternatives were found to lead to a particularly low rate of overdose deaths. Those who stay on methadone or buprenorphine/naloxone were found to have a mortality rate of 0.13 per cent or less — even after the arrival of fentanyl, the study found.
Bach said the challenge now is figuring out how to further lower barriers to access, so people stick with the drugs.
The study does not distinguish why people stopped taking their medication, but Bach said many of the reasons are clear.
For some, he said the drugs don’t sit well — they might make them feel ill or trigger other health problems. Stigma around the opioid alternatives is also a problem.
“Some people don’t want to take the medication for the rest of their lives,” Bach said.
For others, the barriers are more structural. The doctor and researcher said more than 2,000 doctors in B.C. can now prescribe methadone or buprenorphine — including through a new dedicated phone line and online referrals.
But those patients still have to get to a pharmacy to pick up the drugs on a regular basis, a challenge for those who are disabled or who live in many rural parts of the province.
For Nosyk, doctors and researchers need to keep innovating in their treatments — combining new medications and regimes to adapt to the evolving reality of potent drugs and multiple addictions in one patient.
Bach says more attention needs to be paid to how a person’s circumstances can impact their ability to stick with the opioid alternatives.
That means doing a better job at addressing basic access to social services like housing and treatment of chronic pain and mental health problems.
Drug crisis levered by politicians
​As toxic drug death rates have persisted, B.C. has embarked on a number of harm reduction strategies alongside treatments like methadone and buprenorphine.
Many communities now have supervised consumption sites, where people can get illicit drugs tested, and smoke or inject drugs under the supervision of a health professional.
Then there's safe supply, pilot projects that distribute fentanyl-free illicit drugs. Recent peer-reviewed suggests safe supply can reduce overdose deaths; but another study found it increased hospitalizations.
​The programs have become a political lightning rod, attacked by conservative leaders like John Rustad in B.C. and Pierre Poilievre federally. The policies have even triggered a proposed against the provincial and federal government after one girl overdosed and died and another ended up in hospital.
Bach said politicization of the toxic drug crisis into a black-or-white argument between abstinence and harm reduction is not helping anyone on the ground.
​“It’s really simplifying a complicated situation,” he said. “This needs to move beyond an 'either-or' conversation.”
“This is not about two different sides. This is about a response that has been inadequate.”
With files from the Canadian Press
