Changing treatment choices

The wider use of Suboxone is happening just as the methadone programme enters its third decade. David Lynch reports on trends in opioid substitution treatment

Just over 200 patients were on Suboxone treatment in April, according to figures provided to this newspaper by the HSE. This contrasts with 10,464 patients attending for methadone treatment in the same month. However, both the Department of Health and the HSE say that the Suboxone figures represent progress. Suboxone (the brand name for buprenorphine/naloxone) is an alternative substitution treatment for opioid drug dependence.

New regulations were introduced in November 2017 to provide access to certain buprenorphine-based medicinal products for the opioid substitution treatment (OST) system on the same statutory basis as methadone.

“The numbers of individuals in receipt of OST has continued to increase during 2019,” a HSE spokesperson told the Medical Independent (MI).

“There will continue to be an emphasis on expanding the numbers of individuals who can avail of buprenorphine/naloxone throughout 2019.”

A Department spokesperson noted Suboxone treatment “is not suitable for all patients”. However, the spokesperson added there had been a “significant increase” in the number of patients in the system. There were 110 patients in receipt at the end of 2017, 144 by mid-2018, and by April this year over 200. 

Advocating

The ICGP has been taking a leading role in training doctors in the system.

“The ICGP has been advocating for some time around making Suboxone more readily available to patients and we are very pleased to see this medication now available throughout the country,” ICGP spokesperson Dr Ide Delargy told MI.

“Having it available nationally allows for increased patient choice and also facilitates its use as the medication of choice for certain addictions, such as codeine and opiate analgesic medications.

“[The] ICGP is very supportive of this initiative and acknowledge the role that GPs have in the roll-out of this successful programme.

“To support GPs in this role, the ICGP is providing ongoing training and education around the prescribing of Suboxone.

“We would support the view that with the appropriate training more GPs can make it available to patients in the primary care setting, which is a more suitable location for certain patient groups.”

GPs who spoke to this newspaper welcomed the introduction of Suboxone, but in the short- to medium-term they did not foresee it rivalling methadone for the number of patients prescribed.

“I have applied for someone to go on it, but I haven’t anyone on it yet,” Dublin GP Dr Austin O’Carroll told MI.

“I’m delighted it is coming on. But I still think that the majority of people will be treated on methadone, which works very well, and to be honest from my understanding is significantly cheaper.

“Now Suboxone definitely gives us some flexibility, if methadone does not suit [a patient]… So absolutely it’s good that it is there as a choice [for patients], and it is great to see. But I don’t think we are going to have a flood of people transferring from methadone,” Dr O’Carroll predicted.

Opportunities

Dr O’Carroll said not many of his patients enquired about buprenorphine/naloxone.

“I don’t encourage it, because if you are stable on methadone I would not encourage moving on to it, because it is significantly more expensive… I would think ‘why acquire that expense if people are doing well on methadone?’

“But I think it offers opportunities for people for whom methadone does not suit, and there are certain clinics where it may help.

“My gut feeling will be that it will be a minority [of patients], but I don’t know.”

Dublin GP and addiction specialist Dr Garrett McGovern told MI that he now has a number of patients on Suboxone. Asked about the 200 patients on buprenorphine/nalaxone compared to the over 10,000 on methadone, Dr McGovern said that while the lower figure for Suboxone  may not “look great” the extension of the treatment is to be welcomed.

“I suppose I can only speak for myself and that is I have about four or five patients on Suboxone now, I’ve not seen any restrictions,” Dr McGovern said.  

“If I want to see someone on Suboxone I can. There are a few little difficulties, which are nothing to do with policy, more around suitability of patients for it.”

He said that Suboxone did not work for one or two patients who went over from methadone.

However, he added that so far he has not “encountered difficulties” with the programme.

“People [Dr McGovern’s patients] who have needed it, have been able to get it, which I have been delighted about.”

Alternative

Dr McGovern said Suboxone may suit some patients as an alternative to methadone.

“They are different medications. Subjectively they are different,” he said. 

“I think it is good to have choices. There are people who just don’t do well on methadone. And the patient cohort is becoming more knowledgeable, and some are seeking out Suboxone.

“And there is the whole thing of stigma. Whether we like it or not, there is a stigma associated with methadone, that Suboxone hasn’t reached, because methadone has dominated this area.

“Now I am a big advocate of methadone and I prescribed it for many years. [But] people say one of the greatest things about suboxone is that it isn’t methadone, there is no doubt about that.”

Echoing Dr O’Carroll’s observations, Dr McGovern said he believes it is unlikely that large numbers of patients will shift from methadone to buprenorphine/naloxone. This is both due to expense and because methadone is currently working for many patients.

“I think people need choices. Again, it comes down to all these things. And it [Suboxone] probably is still too expensive,” said Dr McGovern.

“The HSE need to be mindful of this. Although you could argue you get costs back in terms of savings you make in an otherwise untreated drug user. It [cost] has been an age-old problem in terms of pharmaceuticals in Ireland… in time I think the way the drug companies will work is that the more people get on this, the price will fall. The more units there are out there, the more likely the price will fall.

“But the access is better. I agree 200 is not a huge amount, [but] you have to remember as well there are quite a lot of people on methadone who are quite happy. It’s not a case of those people suddenly going on Suboxone.”

Methadone

Buprenorphine/naloxone has been extended as the more established methadone system celebrates just over two decades in existence.

Often criticised among the general public and media as a system that replaces one drug with another or keeps patients on drugs indefinitely, within medical circles there is a far more nuanced debate about the programme, and strong support from many GPs.

A recent Twitter debate on methadone facilities led to many GPs going online to defend the programme, with Prof Tom O’Dowd, Professor of General Practice at Trinity College Dublin tweeting: “The most rewarding clinical work I’ve done over the last 20 years is providing a GP methadone service. Patients have gone on to become taxpayers, mothers and fathers.”

This is something that Dr O’Carroll agrees with. “I have seen people’s health that has blossomed [on methadone], they have put on weight, they stopped getting abscesses, we have them all in getting treated for hepatitis C, they are back with families, back with kids, back into jobs,” said Dr O’Carroll.

“I think the main criticism you hear is that you are just replacing one addictive drug with another addictive drug. I absolutely agree, you are. The difference is the addictive drug heroin causes death. We have one death a day from overdoses from people on drugs, and heroin is one of those main drugs.”

Dr O’Carroll said there are numerous major health problems linked to heroin addiction that is not the case with methadone.

At an organisational level in primary care, the ICGP remains supportive of the methadone programme.

“The methadone treatment programme celebrated 20 years in existence since October last year,” said Dr Delargy.

“Overall it is regarded as a very successful, structured initiative which has saved many lives.

“The main challenge for the methadone programme are the waiting lists that exist in some areas of the country particularly in areas outside of Dublin. This is an unacceptable situation given the adverse health consequences to drug addiction. Drug-related deaths are also increasing.

“ICGP believes that the HSE needs to be creative in addressing the waiting lists and look at ways of maximising existing resources as well as considering additional resources in certain areas.

“Another area of concern is the ageing population who are on methadone. They will have additional health concerns and often need additional supports as well.

“Great improvements have been made in addressing and treating the hepatitis C issue in the methadone cohort. The ICGP welcomes this and supports the move to community-based treatment.”

Addicted

In terms of the general discussion around methadone, Dr O’Carroll said he thinks there remains a debate between those who support a detox method, and those who champion a harm reduction model.

“But they [detox advocates] constantly criticise the methadone programme [saying] that we are transplanting one drug with another,” said Dr O’Carroll. 

“This is where you get moralistic about the concept of addiction. There is a confusion I think. The problem is not so much with addiction, but what you are addicted to and the consequence of that addiction.

“So, for example, if you are addicted to sport, the consequence is that you get fit and improve your health.”

Dr O’Carroll added that “obviously I’m a fan of methadone. I’m not saying that people need to be on methadone for the rest of their lives. If anyone wants to come off it, that is fantastic. But [it’s wrong] to think that it doesn’t have something to offer.”

He urged a more holistic view of addiction.

“What is missing in the whole argument is that the vast majority of people who go on drugs are there because they are born into poverty and suffer the consequences of adverse childhood experience… ultimately people fail to realise that we live in a society that has high levels of inequality, we are creating the drugs problem.”

Step up

Dr O’Carroll said that more GPs should “step up to the mark” to provide methadone.

“There are very few GPs who provide methadone treatment, there are huge black spots down the country,” he said.

He added that the treatment is “one of  the easiest, nicest things to provide. You see peoples lives transformed.”

He said he believes that the supports for the methadone treatment service exists, and he praised the work of the ICGP in this area.

Dr O’Carroll said that while he accepted that there is a shortage of GPs and that those working in general practice are overworked, he believed that GPs who are not taking on patients for methadone treatment are “way overestimating the amount of work required. It is one of the simplest [treatments] and it transforms lives.”

Disappointment with new possession laws

In early August, Minister for Health Simon Harris announced new regulations around possession of drugs for personal use. 

According to the Department, there are two components to the ‘health diversion approach’. A person in possession of drugs, determined by An Garda Síochána to be for personal use, on the first occasion would be referred by An Garda Síochána on a mandatory basis to the HSE for a health screening and brief intervention. On the second occasion, An Garda Síochána would have discretion to issue an adult caution.

Asked whether he believed these measures were a step in the right direction, Dr McGovern told MI “no I don’t”.

“I am deeply disappointed with it. It is still criminalising people… this idea if you are caught once you deal with it in a health sort of way,” but then if you are stopped on a subsequent time “suddenly you’re criminalised”.

“This is essentially, criminalisation in de-crim clothing. It is still criminalisation,” said Dr McGovern.

“We need to still keep campaigning on this. I really thought we were going down the route of decriminalisation and it looks like it isn’t going to happen.”

Dr McGovern also said he was “deeply disappointed” by Dublin City Council refusing planning permission for a pilot medically supervised injecting facility (SIF) at Merchants Quay Ireland (MQI). He added that he supported MQI’s appeal of this decision.

A Department spokesperson told MI that Minister of State for Health Promotion and the National Drugs Strategy Catherine Byrne, “is disappointed by this further delay in implementing the Government decision to establish a medically SIF in Dublin city”.

“This is a key action in the national drugs strategy and an important policy response to the high incidence of drug-related deaths due to heroin overdose in Dublin city centre.”