Sylvia's Side

A DRUG DOCTORS CAN'T GIVE

Canadians have three things upon which they can depend: death, taxes
and constitutional barriers. Take the situation with methadone. In
what other country would the dispensing of methadone by doctors
become a constitutional issue?

Methadone is a synthetic narcotic, first developed in Germany in 1937
as a pain killer that would be easier to use during surgery than
morphine and potentially less addictive post-op. It was brought to
the United States in 1947 by Eli Lilly and Company and marketed under
the trade name Dolophine. Since the 1990s, its best known application
has been in the treatment of narcotic addiction. It is also used to
manage chronic pain because of its long duration of action and low
cost. It is rigorously well-tested, and is safe and effective for the
treatment of opioid withdrawal and dependence when carefully
monitored by a physician.

When it is unmonitored it can, like any narcotic, be deadly. While
the drug is cheap when prescribed, it has a street value of upwards
of $20 for up to 100 milligrams, and $25 to $35 for anything more
than 100 milligrams which will give people with a strong tolerance to
opioids a nice high. It's a dangerous practice though; if a person
who does not have a tolerance to opiates takes a dose of methadone
intended for someone on a maintenance program, they will quickly overdose.

In Canada, methadone falls under the Controlled Drugs and Substances
Act, a piece of federal legislation. Physicians who provide methadone
maintenance treatment must obtain a special exemption from Health
Canada. Last January, the College of Physicians and Surgeons of
Ontario approved a policy establishing parameters for physicians
wishing to delegate methadone administration to patients within a
multidisciplinary care setting. To facilitate this, Health Canada has
created a new class of exemption, called a "delegation exemption." It
allows exempted physicians to delegate the act of methadone
administration to other qualified health professionals.

But there is a sticking point. Health Canada insists that only
pharmacists can dispense methadone. Physicians, regardless of the
circumstances, cannot. Dispensing is a controlled act which
physicians are legally entitled to perform under Ontario's
legislation. But methadone is a narcotic, and therefore under Health
Canada's jurisdiction. So, while Ontario allows doctors to dispense
drugs, the federal government says not methadone.

You have to wonder why Health Canada is so adamant that only
pharmacists can dispense this drug. To a cynical eye, it looks like a
bit of a power trip.

There appears to be little thought given to the patients who rely on
a proper dose of methadone at the proper time. There are times, for
example, when patient safety may be compromised due to a risk of
withdrawal or overdose. This is the first of only three circumstances
under which the College of Physicians and Surgeons is proposing that
physicians should be able to dispense individual doses of methadone
to a patient without a pharmacist.

The second is if, in the physician's clinical judgment, a new or
modified dose is necessary to avoid patient withdrawal or overdose.
The third is if no pharmacist is available within a reasonable period of time.

There are situations when a patient has missed three or more
consecutive days of dosing and requires stabilization to prevent
further withdrawal. In other cases a doctor may witness a patient
vomiting a dose. In the case of a pregnant woman this could
compromise the well-being of her fetus.

None of this seems to matter to Health Canada. Under its new
delegation exemption policy, a doctor cannot under any circumstance
dispense methadone. If a patient dies as a result, whose
responsibility will that be? Has Health Canada asked itself that question?