To get basic standard addiction treatment, Americans should move to Canada

As a Canadian-born physician who has treated people with opioid use disorder on both sides of the U.S.-Canada border, I know that if I ever needed addiction treatment I’d head to the Great White North.

Deaths from drug overdoses are twice as high in the U.S. as in Canada. Some of that difference stems from how people with opioid use disorder are treated in the two countries.

Drug overdose deaths in the U.S. surpassed 100,000 people per year in each of the last two years, an ignominious marker that has rightfully spurred policy changes. They include the Biden administration publishing new rules to make it easier for people to access lifesaving methadone at opioid treatment programs. In Congress, legislators are weighing a measure to expand which care providers can prescribe methadone, and they reauthorized state grants for overdose data collection.

These moves represent modest progress, but I fear they will do little to change foundational policies that handcuff addiction care providers and diminish their patients’ outcomes. Until people with opioid use disorder can access effective therapy in the same way as people with most other chronic diseases can do, the U.S. will continue to lag behind Canada and all other developed countries in addiction care.

In the U.S., people with opioid use disorder can get methadone, an extremely effective therapy, only by physically visiting a methadone clinic every day. They cannot go to a retail pharmacy and fill a prescription from their primary care doctor; only an attending physician at an opioid treatment program clinic can prescribe it.

This system presents several challenges for people with opioid use disorder, some of whom also have mental illness or are experiencing homelessness.

They need to show up at an addiction treatment clinic every day, except Sundays, during limited operating hours. The opioid treatment program clinics I refer my patients to generally operate between 6 a.m. and 12 p.m. That forces hourly wage workers to sacrifice income, parents to find childcare, and those without a car to navigate public transit, all while trying to manage a serious chronic disease often accompanied by comorbidities like severe depression and post-traumatic stress disorder. Most of my patients genuinely want to honor their appointments, but the logistical hurdles often prove insurmountable.

Once they arrive at the clinic, people sacrifice their right to confidentiality, as overcrowded clinics can force them to wait outside in public view. That may be fine in the anonymity of a big city, but in a small town where everyone knows everyone, is there any mystery to why someone is waiting in line at a methadone clinic? When I prescribe methadone to a patient, I ask if they are willing and able to go to a clinic every day. Many say no.

In Canada, people with opioid use disorder can obtain a prescription for methadone from their primary care physician, a physician in training (resident), or a nurse practitioner, as well as from physicians at outpatient addiction treatment clinics. They pick up the medication at community or retail pharmacies. Canada also lets people refill their methadone prescriptions via telehealth — a point that the Department of Health and Human Services included in its most recent rules revision, though it still limits the pool of prescribing physicians to those at opioid treatment programs.

Buprenorphine is another gold-standard treatment, and is more readily available in the U.S. than methadone. I prescribe it often, but with the overwhelming presence of fentanyl in the drug supply — an epidemic in the U.S. — people tend to have less severe side effects with methadone. Because of the toxic drug supply, the U.S. will never achieve the requisite level of patient access to opioid use disorder treatment until it modernizes its rules around prescribing methadone.

The U.S. could expand access to opioid use disorder therapy through its vast network of pharmacies, but this may be countered by the U.S. Drug Enforcement Agency, which has disincentivized treatment because of recurring raids on pharmacists it claims are prescribing improperly. Canadian pharmacies do not face nearly the same level of threat from law enforcement.

A study in Vancouver, Canada, showed that up to 85% of people with opioid use disorder had access to addiction therapy, compared to only about 20% in the U.S. Canada’s total number of opioid-related deaths are dwarfed by the same number in the U.S. because of how Canadians access therapy. I constantly ask my U.S. patients to jump through hoops that deter even the most motivated people. In Canada, patients benefit from a system that erases stigma and encourages adherence to undeniably effective therapies.

Sens. Edward Markey (D-Mass.) and Rand Paul (R-Ky.), along with Representatives Donald Norcross (D-N.J.) and Don Bacon (R-Neb.) introduced the Modernizing Opioid Treatment Access Act in 2023 to improve access to addiction therapy. It’s a small step in the right direction but it falls woefully short in achieving truly expanded care. Along with other recent proposals, it retains a church and state divide between treatment for opioid use disorder and every other chronic illness by marrying care delivery to opioid treatment program clinics — more than 60% of which are for-profit with heavy investment from private equity. And, as Lev Facher reported in STAT, methadone clinics have balked at expanding access to this therapy and sacrificing their monopolies.

If Congress wants to help end the overdose epidemic, it must learn from Canada, and most other developed countries, and treat people addicted to opioids like every other person with a chronic illness such as diabetes or heart disease, who aren’t shackled by rigid and archaic limitations to medication access. As a chronic condition, opioid use disorder requires fundamental changes that allow treatment to occur in primary care settings, which is not addressed in any proposed legislation.

The inexcusable number of overdose deaths in the U.S. would immediately improve if the U.S. followed a model similar to Canada’s and changed the who and where around prescribing and medication access.

Safina Adatia, M.D., is an addiction medicine physician in Boston and Canada who specializes in treating substance use disorder in urban communities and rural Indigenous populations.