Opioid addiction treatment in North America: Can we better the gold standard?

Canada Health’s current projections of opioid-related deaths for the rest of 2023 show that deaths won’t decrease to pre-pandemic levels.

Julian Dean wakes before sunrise, and spends his days climbing ladders, carrying tools to the roofs of houses, replacing, installing and removing tiles. With no appetite, he doesn’t stop for lunch. He finally arrives home after the sun sets.

Most people can’t tell if a roof is failing. There aren’t always striking indicators like holes in the wood or broken shingles. Instead, there are silent clues: damage you can’t see from the outside, some rust behind the trim.

This applies to people, too. You can’t always tell who is struggling.

Dean is 47 years old and he’s been running a successful roofing business in Ontario for over a decade. Because of the nature of his work, he developed back pain, and about 20 years ago, before had had his own company, his doctor prescribed him the opioid Percocet. 

Dean took the pills, unaware of their significance; 20 years ago, opioid addiction wasn’t being talked about like it is today. The pain lingered and even got worse – his tolerance to the drug was building.

Then, his prescribing doctor retired. He started to go through withdrawals without even knowing what withdrawals were. 

The only thing Dean was sure about when it came to how he was feeling, was that he didn’t want to feel that way. He reached out to some people he thought could help. “The streets prescribed me heroin.” 

Making good money with his business, Dean could buy the opiates he needed easily. For about 15 years, he has been dealing with opioid addiction. He quit fentanyl cold turkey twice, and each time he would be off it for several months before relapsing. 

He’s not alone.

There is an opioid crisis in North America, and it continues to grow. In 2021, almost 8000 people died from opioid overdoses in Canada – almost one an hour. (In the U.S., more than 80,000 – almost one every six minutes.) In order to really help people, we have to understand the complexities of opioid addiction and the treatment options. 

The problems with treatment

People die every day from opioid use, and when people want to get help, the treatment options given to them are vague. Some people start medication-assisted treatments without knowing what they really are, and other people are told they will never recover without such medication. 

The options are presented as requirements, and access to additional support is hard to come by. 

Medications like Suboxone and methadone are standard treatments, but what works best for one person may not work for somebody else. Since these treatments are the standard, they are easy to start, but lack of support makes it difficult to stop. 

For there to be realistic expectations and goals for recovery, experts agree there needs to be more attention paid to the nuances within treatments and the uniqueness of each person seeking help.  

Everything came crashing down for Dean in March 2022, with the death of his girlfriend.

“That was the wake-up call,” he said, choking up. He sought help, knowing he didn’t have the strength to quit cold turkey again, and that’s when he started taking Suboxone, and the real challenge began. 

“It has been helpful, but people seem to not realize that it’s a transitional drug. It’s not something you just stay on forever,” Dean said. “Yes, it comes in handy when you’re ready to make that change, but you have to continue making that change.”

For Dean, the changes he had to make were as silent as his struggles. He always went to work, his kids were fed and taken care of, and the bills were paid. He referred to himself as “functional,” but that didn’t take away the guilt and self-loathing he experienced as a result of his addiction — he had to address it.

The first-line treatment option for opioid dependency – and possibly the most polarizing – is opioid agonist treatment (OAT). The stigma associated with drug use is so strong that any idea except abstinence is met with resistance. 

Think of the brain as a switchboard, with dozens of toggles and switches being activated and deactivated depending on the input it gets. Heroin, hydromorphone, oxycodone and fentanyl are short-acting opioids, meaning the opioid receptor, or switch, in the brain is activated quickly, but doesn’t stay on for long. A brain that is dependent on opioids wants the opioid switch turned on. When it’s off, withdrawal symptoms happen. 

People who use short-acting opioids and develop opioid use disorder often feel the need to use more, and more often to sustain the high and avoid withdrawals. 

Dean reflected on the withdrawals he had. He had physical ailments, such as muscle aches and pains, nausea, that lasted about two weeks, but the emotional part was the worst. “It’s the deepest, darkest depression you could ever imagine.” 

Problems with evidence

There is a lot of conflicting information about methadone and Suboxone. Provincial health publications and mental health and addiction centres distribute documents saying methadone and Suboxone treatments don’t cause dependency, and can’t get somebody high.

The national Centre for Addiction and Mental Health (CAMH) writes in its information sheet for OAT that the treatment helps with cravings and withdrawals “without causing a person to get high.” 

Renew Medical Clinics, a public corporation that runs addiction clinics in Ontario, published a Methadone Myths section on its website. One myth is: “methadone will get you high.” 

It wrote: “If you’re looking for a high, you’ll be disappointed with methadone.”

AddictionCenter.com is one of the most widely visited websites about addiction. Its methadone information page says that a high can be achieved with methadone, and “some addicts, in fact, prefer Methadone as their substance of choice.” 

What about Suboxone? How could people misuse it if taking more doesn’t increase its effects?

The ceiling effect in buprenorphine doesn’t mean it can’t be misused, but it means that people who misuse Suboxone usually do so to avoid the withdrawal symptoms that occur when they stop taking it. 

Dean described himself as being “fortunate” when talking about his experience with Suboxone because it’s not the same for everybody. He was at the point where there was no more denial, and was fully focused on taking the steps he needed to get better.

Conor Mackey’s story

Conor Mackey grew up in an average middle-class household in Massachusetts and never thought that he would use opioids. He had a family member overdose on heroin when Mackey was a child, which made him hate the idea of it. As he entered adolescence, he experimented with drugs, but still wouldn’t touch opioids. 

That changed when he was 17. His mother had surgery and was prescribed Percocet; he was curious one day and took some. “Within two years, I was a full-blown addict,” Mackey said.

Pills became expensive and hard to find, so he started doing heroin. At 21 he went to his first rehab centre, but ended up being in and out of treatment centres across the U.S. He has been on and off Suboxone since 2019. 

He started feeling side effects from taking Suboxone and lost interest in activities he used to enjoy. He described himself as being “fed up mentally” with Suboxone and where he was in his recovery. 

In 2021, Mackey stopped taking Suboxone and decided to look for a natural alternative, but it wasn’t a financially feasible option for him, so he turned back to Suboxone. “It definitely is the lesser of two evils, but I don’t want to be on it for the rest of my life,” he said.

Mackey started his most recent Suboxone taper at eight milligrams and is currently at one milligram, but he feels more confident this time around.

“I’m detoxing, my legs shake, I’m emotional at everything,” he said. “But I’ve done this so many times, you know? It doesn’t feel like the end of the world anymore.” 

Tapering off

Dean started Suboxone treatment in May 2021 and goes to the clinic every week. He has been slowly reducing his Suboxone dose from 10 milligrams to 2 milligrams per week. 

“It’s psychological,” Dean said, talking about addiction. “It’s what’s going through a person’s head.”

Like Mackey, Dean said that the discomfort of tapering off Suboxone doesn’t compare to the pain and anguish he has already endured in his life. Still, Dean noticed the difference a higher dose of Suboxone can make when it comes to coping with past traumas and mental health issues. 

“Two milligrams and under, that’s when it gets hard. It’s not the physical withdrawals, it’s the fact that you have to face your demons. That’s been the most difficult part for me so far,” Dean said. 

Although the gold standard for opioid addiction treatment is OAT – if not paired with some variation of therapy or support – the underlying factors reasons somebody started using substances are neglected.

The support can’t just be limited to when somebody decides they want help, but continue throughout their treatment and after tapering off any medication.

Detoxing affected Dean’s emotional state. “Your brain has to remember how to properly send your body dopamine, serotonin, all of those good-feeling chemicals.” 

Though there may be similarities between stories, everybody’s addiction and recovery is unique to them. So, wouldn’t this call for incorporating more individualized treatment? 

When Dean first got sober, there was a lot of emphasis on how it would affect his body; he knew what physical symptoms and discomforts to expect. “Nobody told me about the mental,” Dean said, “and that is fundamental. That’s where you got to start.”

Tib Mahu is a psychologist who earned his doctoral degree in clinical psychology from Dalhousie University. His doctoral dissertation was on developing personality-matched interventions to go along with methadone treatment. 

“The issues with a lot of substance use treatments, generally speaking, is that they’re not very individualized,” Mahu said. “It’s quite heterogeneous.” 

There is a reason for this. It is more efficient and practical for health care systems to approach treatment as broadly as possible, but it overlooks critical personal factors of addiction. 

“Right now, it’s like a turnstile,” Dean said. ‘“Everybody’s a number, you stand up in line, your number gets called, and you’re treated like an addict.”

Mahu’s research focused on personality and how it impacts substance use. Mahu and his colleagues’ research targets the vulnerabilities that come with each personality trait instead of the substance. Then, coping mechanisms can be taught to understand that trait instead of turning to substances.

“In our society, we often assume that if someone is addicted, it’s their fault or it’s their responsibility,” Mahu said. “That can really harm access to treatment and willingness to go seek treatment.” 

Currently, clinics vary in terms of the additional support they offer. Some clinics only offer OAT, while others provide support groups. Some refer patients to counsellors outside the clinic, but not all health plans cover the fees, wait times for appointments can be long.

Personality-matched intervention is in its early stages, and has only been used as a prevention effort for youth in schools. The next steps are to test the personality-matched interventions, observe their impact on reducing substance use, and see how to implement them in clinics. 

Until then, people like Dean, who aren’t getting additional counselling have to dive deep into themselves and try to figure out the reasons that led them to their substance use and mental health alone. 

For Dean, he’s been spending more time by himself and his kids. After his long work days he returns home, makes food and sits down to relax. He said he’s more focused on getting better than having a social life. “I’m getting to the root of all this addiction,” he said. “I’m taking care of what’s most important for once.” 

​​Like many people recovering from addiction, Dean hides his inner struggles well. To see him, you wouldn’t know how hard he is working.

“Addiction doesn’t discriminate,” Dean said.