Something extraordinary happened at a recent conference of Ontario doctors who use methadone to treat people addicted to heroin and other drugs.
The usually well-behaved and deferential physicians booed and jeered their licensing and regulatory body – the College of Physicians and Surgeons of Ontario – and they were joined by patients and other health-care professionals.
The unprecedented public derision erupted during an attempt by the college to justify its targeting of these doctors with special audits, and for singling out methadone patients for invasive monitoring. The outburst was the culmination of 13 years of increasing resentment, and will hopefully herald bold new opposition to the unfair regulatory system that burdens these doctors and their vulnerable patients.
Methadone is a legal substitute therapy for patients addicted to opioids, such as heroin, and prescription narcotics like OxyContin. Taken orally – dissolved in orange juice – it has negligible euphoric effects. Patients are usually on it for life, and those who stay on it experience substantially reduced rates of death and diseases like HIV and hepatitis. They also engage in much less criminal activity.
The 280 Ontario physicians who prescribe methadone are among the most heavily regulated doctors in the profession. They are subject to frequent audits to ensure compliance with rigid methadone guidelines. True, the issuing of this drug has been marred, in the past, by isolated cases of physicians relying on underqualified staff, and overbilling by performing too many tests. These problems were highlighted in a series of Toronto Star investigative stories. Such abuses, however, were a rare exception rather than the rule.
Only methadone patients must disclose personally identifying information to the college as a condition of receiving treatment. Most are unaware that their names are entered permanently into a college registry. The college provides information from the registry, and from the physician audits, to researchers who publish on the methadone program – all done without the knowledge or consent of either patients or physicians.
The drawbacks of this heavy-handed regulation aren't restricted to inconvenience, or even undue invasiveness. It actually harms people's health. There is solid evidence that Ontario's methadone-related death rate has risen, despite introduction of the college's methadone program in 1996. Contrary to what's claimed on the college's website – that this death rate fell from 4.2 fatalities per 1,000 patients to 1.7 by 2000 – a more rigorous examination of the data shows that under the college's watch, the rate actually rose, from 1.4 deaths per 1,000 to 1.7.
In its communications, the college continues to wrongly maintain that there has been a "marked improvement in patient safety" since 1996. On the same website, the college correctly notes that studies show methadone patients are more likely to die if they stop receiving this drug than if they were maintained on treatment. But the college stops there – failing to mention a 2005 study on methadone patient retention rates (using the college's own data) showing that 50 per cent of patients who enter methadone treatment in Ontario have left the program at the two-year mark. The college's heavy regulation does nothing to keep these people in treatment and is more likely to drive them away. That puts patients at higher risk of drug relapse, harm and death – hardly the "marked improvement in patient safety" that the college claims.
Meanwhile, ironically, the college pays far less attention to the harmful and fatal consequences of prescribing drugs that are at least as dangerous as methadone, such as morphine and OxyContin. The college also has no equivalent system for monitoring physicians prescribing such medication, or for controlling their patients.
No wonder methadone physicians are agitating to be unshackled from a regulatory system that controls every aspect of their professional judgment and drives patients out of treatment.
The college's motto is "Quality Professionals, Healthy System, Public Trust." For methadone patients and their physicians, the college has failed on all three counts.
Dr. Philip Berger has been prescribing methadone to addicts for 18 years. He and a patient have lodged a complaint against the College with the Ontario Human Rights Tribunal.
Dr. Philip Berger
November 22, 2009
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Heavy-handed rules harm methadone treatment