After September 1, 2022, pharmacies will be working together with people taking methadone and their prescribers to change methadone formulations. Methadone will no longer be compounded (prepared from powder) in the pharmacy. The kind of methadone liquid given at the pharmacy will be different. It will have a new brand name since the liquid will be made by a drug manufacturer – these are called commercially available products. All people on methadone will need a new prescription for a new commercially available methadone product by November 30, 2022.

It is important to note that all pharmacies in Saskatchewan will be making this change. Whenever possible, people taking methadone should keep the same methadone prescriber and pharmacy. They can help support the change.

See the attached posted for more information.

 methadone infographic image
     Click to see poster

Saskatchewan is joining the rest of Canada, where this change has already happened. Other provinces have used these products for over 8 years.



Talk to your methadone prescriber and/or pharmacist if you have any questions about the information provided here, or call/email the pharmacists working at medSask at 1-800-665-3784 or med.sask@usask.ca.

Many people have questions about why this change is being made. This change is being made to improve safety.

Some of the ways commercially available methadone can be safer include:

  • It avoids accidental mistakes. This can happen when pharmacies prepare (compound) methadone from the powder form.
  • It avoids accidental exposure of the pharmacy team to the methadone powder. Methadone powder is a toxic substance for workplace safety, particularly for people not taking the medication themselves.
  • The commercial products are pre-mixed in facilities with strong quality controls. There is less chance of there being impurities in the product. It also means the prepared dose is more likely to be the same from dose to dose.
  • It allows pharmacy computers to use automated systems to check for drug interactions. Methadone can interact with many other medications.
  • It is being used in the rest of Canada. People can move between provinces and territories without the product changing.

These reasons are all believed to be important.

Three brand name products will be made available to people taking methadone in Saskatchewan.

These brands and formulations are:

  1. Metadol-D®
  2. Methadose™ Sugar-Free
  3. Methadose™ Cherry-Flavoured

Talk with your methadone prescriber and pharmacist about these options, in order to decide together which product to choose.

There are important differences between the commercially available methadone products. Some are known differences, and some are not well understood. It is important for people taking methadone to understand these differences to support making an informed choice as to which one to pick.

The factors people might consider when choosing a product include: how well they work, safety considerations, properties of the products, convenience, cost, and understanding the perspectives and preferences of some other people who have already tried these products.

Recommendation from medSask:

Metadol-D® may be preferred by people taking methadone and healthcare providers, and is recommended by medSask as a first choice.

There are no strong studies to direct the choice now, but, there are studies and reports from people with lived experience, which are important considerations in making this recommendation.

  • Metadol-D® is most likely to be similar in taste and appearance to compounded methadone. It is also reported to be similar in effect to compounded methadone.
  • The Methadose™ Cherry-Flavoured product potentially has serious safety concerns associated with a lack of effect. It will look and taste different, and it is not recommended as a first choice.
  • The Methadose™ Sugar-Free product may be considered, but has also been associated with a lack of effect.

See below for a more detailed description of the different considerations.

How well they work
  • These products were designed to be similar to methadone compounded from powder; however Health Canada has reviewed how similar they are, and has identified that there might be a lack of effect when switching between some products. Reasons for this are not clear. When someone finds a product that works well for them, it is recommended not to switch products unless it cannot be avoided.
  • There are reports out of British Columbia that the Methadose™ Cherry-Flavoured product caused a lack of effect and withdrawals for a number of people taking methadone when they were switched to this product in 2014 (references 1,2,3,4,5,6). In these cases, some reports have said the product doesn’t last for a full 24 hours, and wears off after 14-16 hours (e.g., someone described it as, “It doesn’t have legs!”).
  • It is unknown whether the lack of effect associated with the Methadose™ Cherry-Flavoured product is similar with the Sugar-Free formulation. There are no studies reporting on the Sugar-Free formulation, however there are some anecdotal reports of lack of effect with this formulation in Canada as well.
  • Comparatively, some advocacy groups and physicians in British Columbia have reported that Metadol-D® seems to work most similarly to the compounded methadone (references 1,2).
How safe they are
  • The products are all prepared in manufacturing facilities, so are anticipated to be made consistently and without impurities from dose to dose.
  • However, if some of the products do not work as well as compounded methadone, this can be very dangerous because it can cause a person to feel “dope sick”, have withdrawals, and possibly “top up” from the contaminated “street supply”. See the comparison of how well the products work above.
Properties of the products
  • Metadol-D® and Methadose™ Sugar-Free are both clear and unflavoured products. They can be mixed in the same type of juice as the compounded methadone, so people are not likely to notice a difference in the appearance or taste of these products, compared to compounded methadone.
  • Methadose™ Cherry-Flavoured is red, cherry-flavoured, and thicker than compounded methadone. It can be mixed in the same type of juice as the compounded methadone, but it will look and taste different, and will probably be thicker to drink than the compounded methadone powder was. Some people dislike the product for these reasons.
  • Methadose™ Cherry-Flavoured contains sucrose and Metadol-D® contains dextrose. Both sucrose and dextrose are forms of sugar. However, the amount of sugar in the Metadol-D® product is low enough that people who need to keep their sugar intake low (such as diabetics), can still take it. The Methadose™ Sugar-Free product has no sugar.
Convenience
  • All products should initially be prescribed at the same dose as the compounded methadone was.
  • However, if a product does not last a full 24 hours (e.g., wearing off early), as has been described with the Methadose™ Cherry-Flavoured, then the person might have to visit the methadone prescriber more often, lose access to take-home doses, or need to go to the pharmacy twice in a day for dosing.
  • Based on reports, Metadol-D® is the most likely to last the full 24 hours, so may be more convenient.
Cost
  • There are no cost differences between the different brand name methadone products.
Perspectives and preferences of people taking methadone
  • Board members from an advocacy group comprised of people with lived experience in British Columbia (e.g., the British Columbia Association for People on Opioid Maintenance – BCAPOM) advise to, “Avoid Methadose™. Choose Metadol-D®.”
  • A podcast by people with lived experience has supported the use of Metadol-D®, reporting that it, “seems to work better” (than the Methadose™ Cherry-Flavoured) and, “… doesn’t have a dose-holding problem.” (references 2,3)
References
  1. Raski M, Sutherland C, Brar R. From methadone to Methadose: Lessons learned from methadone formulation change in British Columbia. Can Fam Physician. November 2020;66(11):797-98. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302423/
  2. Mullins, G (Host). Change Intolerance (Episode 2). [Audio Podcast Episode]. In Crackdown. British Columbia. Feb 27, 2019. Available from: https://www.crackdownpod.com/episodes/c698nin092b486ji2hycfuf9gpo15v
  3. Mullins, G (Host). Change Intolerance Part 2 (Episode 9). [Audio Podcast Episode]. In Crackdown. British Columbia. Oct 31, 2019. Available from: https://www.crackdownpod.com/episodes/pmbyiswxmpr3hxnbee3qjt1nz50ylm.
  4. Greer AM, Hu S, Amlani A, et al. Patient Perspectives on Methadone Formulation Change in British Columbia, Canada: Outcomes of a Provincial Survey. Subst Abuse Treat Prev Policy. 2016;11(3). https://doi.org/10.1186/s13011-016-0048-3
  5. McNeil R, Kerr T, Anderson S, et al. Negotiating Structural Vulnerability Following Regulatory Changes to a Provincial Methadone Program in Vancouver, Canada: A Qualitative Study. Soc Sci Med. 2015;133:168-176. https://doi.org/10.1016/j.socscimed.2015.04.008
  6. Socias ME, Wood E, McNeil R, et al. Unintended impacts of regulatory changes to British Columbia Methadone Maintenance Program on addiction and HIV-related outcomes: an interrupted time series analysis. Int J Drug Policy. 2017;45:1-8. https://doi.org/10.1016/j.drugpo.2017.03.008