Full length articlePatterns of physician prescribing for opioid maintenance treatment in Ontario, Canada in 2014
Introduction
Opioid maintenance treatment (OMT) has been shown to improve patients’ physiological, psychological, and social functioning (Bagley et al., 2014, Carrieri et al., 2006) and is currently recommended as the first-line treatment for opioid use disorder in clinical guidelines in North America and various jurisdictions around the world (Handford et al., 2011, National Institute for Health and Care Excellence, 2007, Substance Abuse and Mental Health Services Administration, 2015, The College of Physicians and Surgeons of Ontario, 2011). With continued daily therapy, OMT also helps patients develop a more stable lifestyle that may lead to improved relationships and the ability to maintain long-term employment (Carrieri et al., 2006; Vavrinková and Binder, 2007). While studies have shown a lower quality of life and potential impairment when driving in people using OMT when compared to healthy controls (Karow et al., 2011, Strand et al., 2013), numerous controlled trials and observational studies have demonstrated OMT’s effectiveness relative to no treatment or psychosocial treatment only (Mattick et al., 2003, Mattick et al., 2014, Mattick et al., 2009, Srivastava et al., 2017). Abstinence-based treatment is an alternative to OMT, however it is often only recommended for patients with a high recovery prognosis as it is associated with higher rates of relapse and mortality than OMT (Dunlap and Cifu, 2016, Nielsen et al., 2016, Srivastava et al., 2017). Two of the most common pharmacotherapies for OMT are methadone and buprenorphine. Both medications are synthetic opioid agonists that aid in the prevention of opioid withdrawal, cravings, and can block the euphoric effect of other opioids (The College of Physicians and Surgeons of Ontario, 2011). Methadone and buprenorphine are of comparable effectiveness, but buprenorphine, as a partial opioid agonist, has a far lower risk of overdose than methadone (Mattick et al., 2014, Veilleux et al., 2010).
In Canada, strict requirements are placed on the provision of methadone that result in a limited number of physicians available to provide this service. Licensed physicians who wish to prescribe methadone must acquire an additional federal exemption under the Controlled Drugs and Substances Act. This is provided to physicians who complete specialized clinical and course-based training (Centre for Addiction and Mental Health, 2008). Although the prescription of buprenorphine in Ontario does not require a federal exemption, its use for OMT is much lower in this province when compared to methadone. Buprenorphine was listed as “limited use” on the public drug formulary until 2016, which restricted access to patients who were unable to use methadone for OMT due to pharmacological contraindications or because they resided in areas where a methadone maintenance program was not readily accessible (Mamakwa et al., 2017, Ministry of Health and Long-Term Care, 2016a). In 2016, buprenorphine was listed as a general benefit on the formulary, allowing broad access to this drug. Both methadone and buprenorphine are usually dispensed daily under the supervision of a pharmacist and once urine drug screens (UDS) indicate that the patient has stopped using concurrent opioids, the physician may begin to prescribe take-home doses. However, patients tend to achieve take-home doses much earlier when on buprenorphine due to less stringent prescribing regulations. In Ontario, OMT is available primarily in specialized private and government funded clinics; however, it is also available from individual physicians who acquire the federal exemption and who provide OMT as a part of a general primary care practice (Luce and Strike, 2011).
OMT prescribing regulations in the United States of America, Australia, Italy, and Germany are very similar to that in Ontario. All providers of methadone must be specially trained and certified by local regulating bodies and buprenorphine prescribing tends to be subject to less stringent guidelines (Bourkaib et al., 2014, Carrieri et al., 2006, Korthuis et al., 2017). In contrast, OMT provision in France is much less regulated since all licensed physicians may prescribe OMT as a part of their general practice without supplementary training (Carrieri et al., 2006, Fatseas and Auriacombe, 2007). Furthermore, while most jurisdictions around the world have primarily used methadone in OMT, buprenorphine has been the first-line therapy in France since the early 1990’s (Fatseas and Auriacombe, 2007).
Due to an increase in the prevalence of opioid use disorder and the subsequent demand for OMT, the government of Ontario introduced financial incentives in 2011 for physicians to provide OMT (Fischer et al., 2016). In response, family physicians set up clinics that solely provide OMT (Luce and Strike, 2011). In these clinics, patients are provided with physician assessments, UDS testing, addictions counselling and daily doses of methadone or buprenorphine. While these clinics have helped thousands of people who use opioids, they have also generated controversy regarding their high patient volumes and frequent UDS billings, which has called into question the quality of care provided to this vulnerable population of patients. A government task force noted in 2007 that frequent UDS and office visits can interfere with patients’ work and family responsibilities (Hart, 2007), and thus decreases the patients’ quality of life. Regular UDS testing is not a requirement in the French model of OMT provision (Carrieri et al., 2006, Fatseas and Auriacombe, 2007), further suggesting that frequent UDS billings may not be necessary for all patients. In 2015, the Ontario Ministry of Health reduced the fee paid to physicians for performing urine drug screens (Cressy, 2016), an action that prompted some OMT physicians to close their clinics (Church, 2015). This likely placed patients at risk for relapse and overdose if they were unable to find another provider of OMT within an already limited pool of physicians who prescribe methadone or buprenorphine.
Currently, little is known about Ontario’s OMT prescribers and their practice patterns despite these controversies. Due to the growing population of patients with opioid use disorder in Ontario and the restrictions placed on OMT prescribing, we hypothesized that OMT services are provided primarily by a small group of physicians in Ontario who care for a high daily volume of patients and order frequent UDS. We undertook a study to examine concentration of OMT services, the characteristics of physicians prescribing OMT, and to determine the frequency of patient visits and urine drug screens.
Section snippets
Setting
We conducted a population-based, cross-sectional study among physicians who prescribed methadone or buprenorphine to Ontario residents eligible for public drug coverage between January 1, 2014 and December 31, 2014. These patients have universal access to hospital services, physician care, and prescription drug coverage. Eligibility criteria for public drug coverage includes receipt of social assistance, residence in a long-term care home, receipt of home care services, high drug costs relative
Results
We identified a total of 1235 active OMT prescribers in Ontario in 2014. After excluding one-time prescribers, a total of 893 physicians remained in the cohort, of which, 307 (34%) prescribed both methadone and buprenorphine, 258 (29%) prescribed only methadone and 328 (37%) prescribed only buprenorphine (Fig. 2). In 2014, a total of 7,348,789 days of methadone (88.4% of all OMT) and 966,333 days of buprenorphine (11.6% of all OMT) were dispensed to 31,600 patients, and 1,350,754 UDS were billed.
Discussion
In this population-based cross-sectional study, we found that OMT services are highly clustered among a small number of OMT physicians in Ontario who tend to be older, male, and practice in urban settings. These physician characteristics are largely representative of Ontario physicians with the exception of gender as 62% of Ontario physicians in 2014 were male, compared to 91% and 84% of the high-volume methadone and buprenorphine prescribers, respectively, in this study (Canadian Institute for
Role of funding source
This study was funded by a grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC) as well as the Ontario Strategy for Patient-Orientated Research (SPOR) Support Unit, which is supported by the Canadian Institutes of Health Research and the Province of Ontario. This study was also supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results and
Contributors
All authors assisted in the study design. WK undertook the statistical analysis and all authors contributed to the interpretation of the data. QG wrote the first draft of the manuscript. All authors participated in reviewing and editing the final manuscript and have approved it.
Conflict of interest
Dr. Meldon Kahan has received honoraria from Reckitt-Benckiser for continuing medical education events on Suboxone (buprenorphine-naloxone). No other authors have any conflicts of interest to declare.
Acknowledgement
We thank Brogan Inc., Ottawa for use of their Drug Product and Therapeutic Class Database.
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