Canada Methadone Prescribing Changes Drug Supply
New Canadian Guidelines for Methadone prescriptions Show promise,But Implementation Lags
New data suggests that Canada’s updated methadone-prescribing guidance is influencing clinical practice,leading to positive changes in how clinicians approach opioid agonist treatment (OAT). However, a recent study reveals that some key recommendations, particularly rapid dose titration, are not being fully implemented, possibly hindering optimal patient outcomes.
The study,published in JAMA Network Open on August 15,examined the impact of the 2020 META-PHI (Mentoring,Education,And Clinical Tools for Addiction-Partners in Health Integration) guidance on methadone prescribing practices in Ontario. Researchers, led by ria Garg, PharmD, PhD student at the University of Toronto’s Leslie Dan Faculty of Pharmacy, analyzed methadone initiations between July 1, 2013, and July 31, 2023, to assess changes in prescribing patterns following the guidance’s release.
Key findings from the study include:
Decline in Monotherapy: The introduction of the META-PHI guidance was associated wiht a decrease in the initiation of methadone monotherapy, suggesting clinicians are increasingly utilizing combination therapies.
higher Starting Doses: The study observed a trend toward higher initial methadone doses (30 mg to < 40 mg), reflecting the guidance's proposal for higher starting doses, particularly for patients with opioid tolerance.* Limited Rapid dose Titration: Despite the guidance emphasizing the importance of rapid dose titration, the study found that a meaningful proportion of patients (45.7%) did not receive any dose adjustments within the frist two weeks of treatment. Furthermore, early dose titration within 4-6 days was less common in combination therapy initiations (29.2%).
“Though we noticed that there was an increasing trend toward higher doses in the second week of treatment, this was primarily driven by these patients being prescribed a higher dose,” garg explained. “But most patients were not receiving an early dose titration within 4-6 days as recommended. We felt that this was a missed opportunity for reaching therapeutic effects.”
The need for optimized methadone treatment is particularly pressing in Canada, where the illegal opioid supply is dominated by potent substances like fentanyl. Health Canada reports that fentanyl was involved in 74% of opioid-related deaths in 2024,with the majority of these deaths occurring in British Columbia,Alberta,and Ontario. Methadone and buprenorphine are considered first-line OAT options, with methadone demonstrating effectiveness in reducing treatment dropout and subsequent overdose.Leonora Regenstreif, MD, assistant clinical professor (adjunct) of family medicine at McMaster University in Hamilton, Ontario, and coauthor of the META-PHI recommendations, emphasized the importance of achieving adequate methadone doses to retain patients in treatment. “The goal for clinicians is to get patients to show up for treatment and engage. So, if you are not getting them over 60 mg, it is a missed opportunity to keep them coming back,” she stated.
The META-PHI guidance recommends starting doses of 40 mg for patients with opioid tolerance, followed by rapid titration, increasing the dose by 10