a qualitative study of prescribing doctor experiences of methadone maintenance treatment

A Qualitative Study of Prescribing Doctor Experiencesof Methadone Maintenance Treatment

Marie Claire Van Hout & Tim Bingham

# Springer Science+Business Media New York 2013

Abstract Methadone maintenance treatment [MMT] is recognized as an effective treatmentfor opiate dependence. It is provided in Ireland in addiction clinics and for stabilized patientsin primary care. The aim of the study was to explore doctor’s experiences of methadoneprescribing, therapeutic alliance and methadone treatment pathways. Semi structured in-terviews were conducted with a convenience sample of prescribing doctors (n=16). The-matic analysis of narratives was undertaken. Observations around MMT were positive inreducing harm associated with injecting drug use and opiate dependence, and represented animportant turning point for patients. Doctor efforts to assist their patients were grounded inpositive, empathic relationships. Some concerns were relayed with regard to prescribingrestrictions. Participants commented on the need for policy makers to consider the expansionof MMT provision to include alternative pharmacological approaches, improvedinteragency, psychosocial and detoxification supports, community based nurse prescribingand adjunct treatment for poly drug and alcohol use.

Keywords Methadone . Shared care . Opiate dependence

Methadone maintenance treatment (MMT) has long been recognized as an effective treat-ment for opiate dependence (Amato et al. 2005). However, MMT provision is not withoutproblems. Commentaries have discussed these issues as grounded in MMT’s status as ‘nontreatment’ where one drug is essentially replaced by another, and its challenge of abstinencefocused ideologies (Lloyd 2010). Difficulties also exist in terms of patient uptake, retentionand organization of the treatment (Joseph et al. 2000; Bell et al. 2006). It remains evidentfrom the literature that a great variation of health professional attitudes toward MMTprovision exist (Gjersing et al. 2010; Lloyd 2010). Research has underscored the presenceof public, institutional and private stigma associated with MMT on the part of patientsthemselves, health professionals, health care and pharmacy settings and the general public(Luoma et al. 2007; Ormston et al. 2010; Harris and McElrath 2012). This has served to

Int J Ment Health AddictionDOI 10.1007/s11469-013-9436-3

M. C. Van Hout (*) : T. BinghamSchool of Health Sciences, Waterford Institute of Technology, Waterford, Irelande-mail: [email protected]

contribute to MMT patients’ continued identity as ‘drug addict which exposes them as socalled ‘undeserving’ customers in the public domain, and subsequently encourages patientsto act as passive recipients of treatment (Harris and McElrath 2012; Van Hout and McElrath2012). This element of control has compromised relationships between patients and treat-ment providers, and restricted its efficacy (Joseph et al. 2000; Bell et al. 2006). Research hascommented on conflicting evidence in terms of patient satisfaction with methadone pre-scribing doctors (McLaughlin et al. 2000; Winstock et al. 2011), and experiences ofprejudice and discrimination (Holt 2007; Järvinen 2008). Indeed, patients with a history ofdrug use, particularly that of heroin may believe doctor attitudes towards them to be negativeand prejudicial, which highlights the need for recruitment of doctors with positive attitudestowards helping those with drug dependence (Gabbay et al. 1996; Abouvanni et al. 2000;Kelly and Westerhoff 2010).

Prescribing doctor attitudes to MMT are frequently grounded in drug use as socialmanifestation, with a medicalized and abstinence based focus (McKeown et al. 2003; Vanden Brink and Haasen 2006; Ford and Ryrie 2010). Reluctance to provide MMT is groundedin perceived lack of skills and expertise in the area of MMT, practice workload, concernsaround safety, stereotypical attitudes toward drug users and concerns around practice stigma(Abouvanni et al. 2000; Matheson et al. 2003; Kapadia et al. 2007; Lloyd 2010; Ford andRyrie 2010). Doctor attitudes can be particularly negative toward intravenous drug users asthese often present with manipulative, aggressive and chaotic behaviors, with fluctuatinglevels of motivation impacting on the doctor patient therapeutic alliance (Gruer et al. 1997;Gabbay et al. 2001; Butler 2002). However, of interest is that newly qualified doctorsindicate greater acceptance of problematic drug users, and self-awareness of their compe-tency to treat dependencies (Carnwath et al. 1999). Research on MMT consistently high-lights training and drug awareness needs for health professionals in this area (Gabbay et al.2001; Strang et al. 2004; Ford and Ryrie 2010). The aim of this research was to undertake anexploratory qualitative study on doctor’s experiences of methadone prescribing, patientrelations, training needs and recommendations for improved methadone treatment pathwaysin Irish addiction clinics and primary care settings. Findings are intended to inform contin-ued debate in Ireland on how best to provide and progress current MMT provision.

MMT has been available in Ireland since 1992, with initial provision of treatment inDublin. In 1998, the ‘Misuse of Drugs (Supervision of Prescription and Supply of Metha-done) Regulations’ were introduced, with specific data monitoring systems designed andimplemented so as to track patient trends (Central Treatment List). The ‘Methadone Treat-ment Protocol’ was devised by the Irish College of General Practitioners (ICGP) in 1998,and consists of a series of guidelines for methadone prescription and patient management inclinic and primary care settings (Butler 2002; Methadone Prescribing ImplementationCommittee 2005; Farrell and Barry 2010). Most recent Irish statistics show that 259 doctorscurrently provide MMT, with two-thirds of MMT patients treated in specialized addictionclinics and one third (on stabilization) treated by primary care settings (Health ServiceExecutive 2011). Prescribing doctors have completed a recognized MMT training (Level 1and 2) provided by the ICGP (Delargy 2008). Doctors who have undergone the advancedtraining program (Level 2) can treat up to 35 patients (or a maximum of 50 in a partnershipof two or more doctors in a private practice), and are qualified to initiate treatment, stabilizedoses and provide ongoing maintenance treatment (Delargy 2008). In contrast, Level 1trained doctors are restricted to 15 patients, and cannot prescribe a supply of methadone forlonger than 7 days (Delargy 2008). Of note is that doctors may operate as Level 1 in theirprivate practices, but work as Level 2 in addiction clinics. The research was undertaken aspart of a larger scale study on MMT provision in Dublin involving the triangulation of

Int J Ment Health Addiction

perspectives from patients, treatment providers and community workers (Van Hout andBingham 2012). This paper provides detail on the experiences of Level 1 and Level 2trained doctors who provide MMT in addiction clinics and in primary care. To date, no suchqualitative study has been undertaken in Ireland.

Methods

Ethical approval for the study was granted by the Waterford Institute of Technology’s (WIT)Ethics Committee in 2011. Semi structured interviews with Level 1 and 2 doctors were chosenin order to optimize on data triangulation with patient and community workers perspectives inthe larger study (Van Hout and Bingham 2012). Participants were interviewed using aninterview guide developed from issues identified in the MMT literature, themes emerging frompatient and drug worker interviews, and in consultation with the Dublin North East Drugs TaskForce Research Sub Committee. The interview guide was piloted with four prescribing doctorsin another area, with minor amendments made prior to fieldwork (Table 1).

A Health Service Executive (HSE) list of Level 1 and 2 prescribing doctors (15 Level 1 and23 Level 2) practicing in Dublin was utilized to invite participants to partake in the study.Prospective participants were contacted a maximum of three times via email and if absent fivetimes via telephone message. Two doctors declined to outright to partake and 20 did notrespond to email and telephone messages. Ten Level 2 and six Level 1 prescribing doctorsagreed to partake in the study. Five participants worked in specialized addiction clinics and inprivate primary care practice, three worked only in specialized addiction clinics, and eightworked only in private primary care practice. Three participants were certified as Level 1 intheir private practices and operating as Level 2 in specialized addiction clinics (Table 2).

Fieldwork for the study commenced in November 2011. Each participant was emailed aninformation leaflet and was verbally informed as to the research aims, objectives andprocedures prior to participation. All participants gave written consent, were assured ofanonymity and allowed to withdraw if and when they wished. Interviews were conducted byauthor two an experienced interviewer in the drugs field at a pre-arranged time with theparticipants, with all interviews audio recorded with permission. Each interview was under-taken using a conversational tone and began by asking the participants to provide their initialopinions on MMT, prior to use of the semi structured interview guide. Participant responses

Table 1 Interview guide

• What is your perception and knowledge of problematic alcohol and drug use in the Dublin area where yourclinic or practice is located?

• What are your opinions on Methadone Maintenance (MMT) as treatment for opiate dependency?

• Can you describe your relationships with MMT clients?

• Can you describe any issues regarding the implementation of MMT in your clinic or practice?

• Are you confident in your ability to provide quality MMT in the area?

• What is your opinion on shared care approaches in MMT provision?

• What are your perspectives on guidance provided by the Methadone Protocols?

• What are your perspectives on the continued use of heroin and other drugs whilst on MMT?

• What are your perspectives on methadone dosage and tapering?

• What are your perspectives on client detoxification and community rehabilitation?

• Can you identify any training needs in relation to MMT?


were allowed to direct the flow of the conversation, by use of the interview guide to directquestioning. Participants were encouraged to ask for clarification if needed throughout theinterview, and were encouraged to explore their opinions, experiences and perspectives onMMT. Interviews lasted between 45 and 70 min, with a mean length of 50 min. The samplesize, whilst small, represents half of prescribing doctors operating in the research area, withdata saturation in the form of several recurrent themes noted by the authors after approxi-mately two-thirds of the interviews had been conducted.

Interviews were transcribed shortly after each interview and were supported by supple-mental data in the form of digitally recorded post interview researcher field notes. Names ofrespondents and services were omitted from transcription. Audio recordings of the inter-views were destroyed following transcription of narratives. All transcripts were stored in alocked cabinet and password protected computer. Data analysis commenced with severalreads of the interview transcriptions and the supplemental data. This analytical strategyaimed to develop themes by generation of key words, phrases, opinions, thoughts, reflec-tions, meanings and attitudes of the participant toward MMT, using these ideas to formulatecategories and placing these narratives into identifiable categories, examining the content ofeach category for sub topics, and selecting the most useful and illustrative narratives forsame (Taylor and Bogdan 1984). The authors identified emerging themes and categories,and developed coding schemes with assistance from the computer package NVivo (Richards2005). Patterns in the data were analyzed both independently and as a team by using spiderdiagrams and a system of corroboration and comparisons between participant narratives.Periodic briefing sessions were held between authors. Six major themes were identified fromthe data.

Results

Viewpoints Relating to Opiate Dependency and MMT

Several participants described the interplay between genetic predisposition to addiction,drug availability and socio economic environmental factors in the form of poverty, unem-ployment, marginalization, family history of problematic substance use, childhood trauma,early school leaving, peer drug use, and personality factors, all of which were observed tocontribute to the escalation of opiate and other drug addiction, negative health consequencesand criminal activity. All participants described opiate dependency as a bio psycho socialissue, but observed that the current approach to treating opiate dependence was confined tothe medical approach, despite this recognition of a multiplicity of personality, social andpsychological influences on addiction and recovery. They highlighted the need to recognize

Table 2 Sampling frame of participating Level 1 and Level 2 prescribing doctors

Gender Age (Years) Years in practice Level 1 Level-1/Level2 Level 2

Male 30–40

40–50 (11) 10 year + (2) (1) (8)

50+ (2) (1) (1)

Female 30–40 (1) 5–10 year (1) (1)

40–50 (2) 10 year + (1) (1) (1)

Total 16 3 3 10


both the pharmacological and psychosocial complexities of opiate addiction and the need totreat using combined approaches.

‘Drug addiction always had two responses from the community and the professionals.The professionals tended to treat it as an isolated medical problem, and the communitytreated as it was meant to be treated, which was a social psychological and a biologicalmodel. The problem was that these two sectors didn’t work as well as they could, andcontinues to remain a problem.’ Participant 1

Many participants described MMT as essentially a successful medical and harm reducingtreatment approach to addressing opiate dependence and harmful injecting drug use, and thatit is supported with a strong evidence base.

‘It is fantastic, it is wonderful, it’s a wonderful drug, it has immediate benefits in prettymuch every aspect of a person’s life, that have been dysfunctional or impaired in anyway, it effects every part of their life, it’s just wonderful.’ Participant 6

All participants observed that MMT offers patients the opportunity to lead a [semi]normal lifestyle, but described negative abstinence focused opinions around MMT amongstsome community based services and also the general public. Whilst offering the patientsome normality in daily life, and the relinquishing of prior addictive behaviors, all partic-ipants described MMT as restricting patient freedom. Examples included remembering totake the methadone dose every day, going to the pharmacy at least every week, having toattend the doctor for prescriptions and urine screening, and planning ahead for holidays.

‘I think it’s great, but a bit limited. By its very nature it is addictive, so you’redependent on it, you don’t have quite the same freedom, as someone who is notdependent on something.’ Participant 2

Several participants described issues relating to the long term maintenance of patientswith MMT, the tapering of methadone dosage and the chronic nature of relapse. Medicalimplications relating to blood borne virus [BBV] transmission [Hepatitis C, HIV], infectionfrom injecting drug use, and co-occurring psychiatric illness were also described.

‘The biggest problem with methadone is getting them off methadone, it’s a bit likeusing the nicotine patches for nicotine, we are aware we need to get them off thepatches, but we don’t seem to have a handle on this thing, where they should be off themethadone within a certain amount of time.’ Participant 6

Alcohol, Illicit and Licit Drug Use in MMT Patients

The majority of participants stated that excessive alcohol consumption, and alcohol depen-dency was common amongst their patients, with some participants estimating that 25–40 %of their patients were misusing alcohol. Participants in some cases appeared restricted to thesubstitution treatment of opiate dependence via MMT, and described difficulties in treatingalcohol misuse and managing potential overdose.

‘A lot of doctors don’t really engage with those who use alcohol, we have preciouslittle to offer them… all we have is methadone for heroin users.’ Participant 8

Patient poly drug taking whilst engaging in MMTwas mentioned by several participants, andincluded drugs such as cocaine, cannabis, amphetamine, ecstasy, street and prescribed benzodi-azepines, new psychoactive substances [‘mephedrone’] and heroin. Participant views on


continued opiate, other drug and alcohol use whilst in MMTwere mixed, with some participantsaccepting of continued licit and illicit drug use whilst onmethadone, and others strongly opposedto supplying methadone [particularly ‘takeaway doses’] in these circumstances.

‘I am always disappointed, but I would always continue to give them their usualmethadone dose.’ Participant 2

Continued dialogue between doctor and patients was viewed as paramount in reducingharm associated with continued heroin injecting, smoking and the use of other substances.Several participants described screening difficulties in distinguishing the chaotic heroin userfrom the occasional heroin user, and additionally distinguishing potential harms associatedwith the injecting versus smoking of heroin. Participants described dealing with positiveopiate urine screens by increasing methadone dosage to try and keep patients from usingheroin, probing their patients about discontinuing the program, and working towards a harmreduction dose. The prescribing of benzodiazepines was viewed as problematic, withconcerns centering on difficulties in controlling their patients’ use of benzodiazepines, andpotential development of benzodiazepine dependency.

‘Benzos are not indicated for anything more than short term and I don’t even believethey are for that. I don’t see any role for benzodiazepines in the treatment for anunderlying condition, particularly in this cohort of patients’. ‘Participant 9

Methadone Prescribing Guidelines

The majority of participants described difficulties in the prescribing of methadone as per thenational prescribing guidelines and related audits as 'big brother looking over you’, andreported conflict between the protocols, and real life practice. Several participants describedthe national prescribing guidelines as a policing system rather than therapeutic interventionfor opiate dependents, with little evidence consulted in the design of these specifiedguidelines or the evaluation of individual outcomes.

‘The audit is about process and not about outcomes. This is a glaring failure, it wouldbe so much better to audit outcomes.’ Participant 7

Variation in doctor approaches to methadone prescribing and levels of patient centered-ness in the MMT treatment pathway were mentioned. Several participants described ignor-ing the national prescribing guidelines or simply not reading them, and adapting theguidelines to suit their practices. The Methadone Protocols were observed to place unnec-essary and unwanted restrictions on MMT patient numbers and their freedom to prescribe asnormal doctors, particularly in the case of prescribing doctors placed in addiction clinicsettings, as opposed to doctors operating in general practice. These caps on patient numbersand regulations around methadone prescribing at Level 1 and 2 also appeared to restrictnumbers of treatment places.

‘They restrict my private practice, I am Level 1 and there is a restriction on numbersbut there are people like me who are Level 2 in the clinic and Level 1 in privatepractice. When they say that you cannot initiate your own patients when you’re Level1, and when you have been initiating very chaotic clients in the clinics, then yes, itsrestrictive and there are a lot like me..’ Participant 7

The national prescribing guidelines were observed by some participants to contribute topatient institutionalization, and in some instance an unequal, punitive doctor-patient


relationship. The requirement for regular patient urine screening was observed by mostparticipants to be degrading and unnecessary. The management of methadone prescribingwas observed to be restrictive and related to the 7 day methadone prescription pads providedby national prescribing guidelines. Despite this, all participants observed that levels ofmethadone dosage were dictated by the patient’s wishes with support from establisheddoctor-patient collaborative work within the therapeutic alliance. Only in the case ofpsychiatric disorder, underlying health condition [i.e. HIV] or other drug dependencies[i.e. alcohol, benzodiazepines] would the doctor take control and dictate methadone dosage.

‘In principle you would like to them to receive a dose that makes it easier for them toabstain from heroin.’ Participant 14

The Doctor-Patient Relationship

The majority of participants described that the doctor patient relationship differed fromnormal general practice due to the weekly contact with their patients, variance in levels ofpatient cooperation, and varying degrees of positive therapeutic alliance. Many participantsdescribed positive relationships encompassing supportive roles with their patients and withina regular routine of weekly consultations. Some participants observed that their role wasrestricted to methadone prescribing and social consequences of opiate dependence, withsome patients seeing their own doctor in general practice for other general health concerns.

‘I get on well with them. I find I am a bit of a social worker, bit of a police person,school teacher and then a medic. I find that I fill a lot of roles because they trust me.’Participant 12

No participants distinguished MMT patients from other patients attending their practices,but some participants described MMT patients as ‘difficult to deal with’ at times. Issuesrelating to mistrust, control and sanctioning [in some instances] were observed to form thebasis for the MMT based doctor patient relationship, and appeared related to the patientstage of stabilization and recovery.

‘I am not sure if it would be typical of a doctor client relationship in general practice,it’s an ongoing relationship, so it’s not quite like an ordinary general practice rela-tionship, it can be a bit traumatic and confrontational at times, because there is anelement of control with the methadone that introduces a different dynamic, so withinthat you have very good relations with some of the patients, middling with others andnot great relations with some.’ Participant 4

Treatment Care Planning

Collaboration in treatment care planning between the doctor and MMT patient wasunderscored by all participants, despite observations around the restrictions of methadoneprescribing and necessity for patients to attend the doctor weekly. Patient empowerment inrecovery was described as the ultimate goal. Participants were described as controlling thestarting dose, and the rate of increase, with patients controlling a slow tapering and finaldetoxification under doctor supervision and advice. Participants described that patient re-quests to reduce or increase methadone were heard and facilitated within a supportive patientled approach so as to avoid potential destabilization and overdose risk. Mixed feelings wererecorded, with some participants describing reluctance to encourage full detoxification, due


to the high rates of relapse, and others encouraging full patient detoxification, andrehabilitation.

‘I never impede anyone who wants to detox. I don’t keep anyone on methadone. I givethem my opinion, we discuss it and they make a decision. I facilitate their detoxbecause they will do it on their own, and it’s better to have me with them than to do iton their own.’ Participant 5

All participants described instances of successful patient detoxification from methadone,but also observed patients reducing to 40 mls or less, and then destabilizing. Descriptions ofthe ‘revolving door’ of relapse and MMT uptake were common, particularly among youngdependents attempting fast reduction of methadone, in some instances resulting in high ratesof overdose. Some participants described a need for community detoxification ‘in the realworld’ and observed the small success rates recorded in inpatient settings.

‘I would say that the majority of patients have done this at some stage, especially whensomeone becomes stable and just takes methadone. A lot of patients do try and detoxthemselves, people forget there are physical and psychological components to addic-tion, they may get over the physical withdrawals within a day, it’s the psychologicalissues such as triggers that can lead to problems.’ Participant 3

The need for shared care services and the need for a shift away from strict MMT andtoward community based treatment for alcohol, opiate and mental health was highlighted.This could potentially increase treatment uptake and remove the stigma attached to clinics.

‘In hindsight, we got an awful lot of things wrong, we should have been looking at amodel of community pharmacies and small clinics, we need to normalize the treatmentand make it as small as part of the patients life.’ Participant 4

Others described the difficulties of classification as Level 1 or Level 2 as difficult toimplement in practice, and particularly given the nature of relapse where unstable patientsnecessitate greater levels of support within an interagency support network. Several partic-ipants described the need for alternative forms of opiate substitution treatment such asbuprenorphine, the need for specialized in patient stabilization, in patient benzodiazepinedetoxification, and support structures for those with underlying psychiatric conditions.

‘The theoretical concept of Level 1 and Level 2 is excellent, but the practicalimplementation is a totally different story. The clinics do need to concentrate onchaotic patients, these patients should be treated in controlled environment, until theyhave become stable and then passed onto the community doctors.’ Participant 1

However, several voided concerns around community service competencies, level ofstaff training in the area, and service philosophies around harm reduction versus absti-nence, and issues around patient confidentiality. Several comments were made withregard to service rigidness with regard to patients needs [i.e. location, opening times],and the need for development of community nurse prescribers with minor input fromprescribing doctors.

‘I personally believe that methadone prescribing is a technical task, it’s very, verysimple and very easy. There is no great scientific or other knowledge required toprescribe methadone. My thoughts are that methadone prescribing would be betterdone by nurses and probably should be done by nurses, and that the doctors willhave a role of overseeing the treatment and providing for primary care more so.’Participant 16


Doctor Training Needs

Some comments were made about the lack of formal training in the addiction field fordoctors in clinics and community practice, and the failure of the national organizations toprovide adequate training, practitioner networking, and continuing education credits.

‘It’s bad, the training is awful, the guidelines, they have failed miserably in traininggeneral practitioner doctors. A lot of the training needs to be scrutinised, it’s notevidenced based and it is damaging to have something that has poor evidence.’Participant 15

A minority of participants working in private general practice described feeling isolatedand a need to meet and network with practitioners in clinics in order to update and consultaround MMT issues. Supports for clinical practitioners were described as very good.

‘The doctors who don’t work in clinics have no opportunity to meet, there seems to bea policy for isolating us and making sure we do not meet. In the long run, it cannot beconducive to good practice or consistent practice across the country.’ Participant 7. Asynopsis of key findings is presented in (Table 3).

Discussion

Qualitative research on prescribing doctors’ experiences of MMT remains scant, with mostresearch efforts concentrating on health professional attitudes to drug users, MMT patientsoverall life functioning, MMT drug, treatment, health, social and rehabilitative outcomes(Gerra et al. 2003; Mattick et al. 2009; Corsi et al. 2009; De Maeyer et al. 2011). Despite theexploratory nature of the study using a small convenience sample of prescribing doctorslocated in Dublin, Ireland, the research yielded a rich and illustrative data set of narrativesand provided a unique ‘snapshot’ of doctor observations and perspectives on MMT in a citywhere MMT services are concentrated. Whilst their views cannot be generalised or viewedas representative of all prescribing doctors in Ireland, findings are useful to provide a contextfor improved and progressive MMT service design and implementation. Regrettably, it wasnot possible to engage in a gender analysis of narratives, as some participants may have beenidentifiable.

MMT has been evaluated with regard to its efficacy in reducing heroin and other forms ofsubstance use, reducing risk behaviors associated with injecting drug use and the transmis-sion of blood borne viruses such as HIV and Hepatitis, reducing criminal activity andoverdoses, with psychosocial improvements in MMT client individual and social function-ing relating to family relationships, employment, education and community integration(Sheerin et al. 2004; Teesson et al. 2006; Simoens et al. 2005; Gowing et al. 2006; Matticket al. 2009; Corsi et al. 2009; Coviello et al. 2011; De Maeyer et al. 2011). Prescribingdoctors supported these claims and observed MMT’s effectiveness in reducing a range ofpatient harms in the form of injecting drug use, continued opiate use, transmission of bloodborne viruses, and stimulating recovery processes. However, they observed the need for abio psycho social approach to treating opiate dependence within expanded community basedmedical and psychosocial treatment provision. Indeed, contemporary research underscoreshow long term and multi component treatment modalities for opiate dependence shouldinclude pharmacological, psycho-social rehabilitation and relapse prevention interventionswithin specialized stabilization and primary care settings (World Health Organisation 2009).


Despite reporting favorable outcomes in the reduction of opiate use and harmful routes ofadministration, prescribing doctors observed problematic issues relating to restrictions ofpatient day to day freedom, issues around the tapering of methadone and long term MMT,patient self-detoxification, destabilization and treatment re uptake. Structural factors relatingto MMT were described as creating conditions for premature treatment exit, and included

Table 3 Summary of key findings

Viewpoints relating to opiate dependency and MMT

Opiate dependency is viewed as a bio psycho social issue.

There is a need to treat using combined pharmacological and psychosocial approaches.

MMT is a successful medical and harm reducing treatment approach.

MMT restricts patient freedom in daily life.

MMT confounding issues relate to long term maintenance of patients with MMT, the tapering of methadonedosage and the chronic nature of relapse.

Alcohol, illicit and licit drug use in MMT patients

Excessive alcohol consumption, and alcohol dependency was common amongst patients.

Difficulties were observed in treating alcohol misuse and managing potential overdose.

Patient poly drug taking whilst engaging in MMT (drugs such as cocaine, cannabis, amphetamine, ecstasy,street and prescribed benzodiazepines, new psychoactive substances [‘mephedrone’] and heroin) is aproblem.

Mixed views were observed relating to the prescribing of methadone for MMT patients who continue illicitdrug use.

Doctor –patient dialogue is needed to reduce patient harms associated with alcohol and drug use.

Prescribing of benzodiazepines and MMT patient dependency was viewed as problematic.

Methadone Prescribing Guidelines

There is a conflict between the Methadone Prescribing Protocols, and real life practice.

Protocols were described as a policing system rather than therapeutic intervention for opiate dependents.

Variation in doctor approaches to methadone prescribing and levels of patient centeredness in the MMTtreatment pathway were described.

The requirement for regular patient urine screening was observed to be degrading and unnecessary.

The Doctor -Patient relationship

The doctor patient relationship differed from normal general practice due to the weekly contact with theirpatients. Variance in levels of patient cooperation, and varying degrees of positive therapeutic alliance weredescribed.

Some MMT patients were difficult to deal with.

Issues relating to mistrust, control and sanctioning related to the patient stage of stabilization and recovery.

Theme Five: MMT Treatment Care Planning

Collaborative treatment care planning between doctor and MMT patient is vital.

Patient empowerment in recovery is identified as the ultimate goal.

Mixed views on full detoxification and rehabilitation were described.

The revolving door of relapse and treatment reuptake was described.

Community based treatment, detoxification and a system of community nurse prescribers supported bydoctors needs further development.

Provision of open access services and improved staff training in MMT is needed.

Theme Six: MMT Training needs

There is a lack of formal training in the addiction field for doctors in clinics and community practice.

There is a need for continued and targeted ICGP support for training, practitioner networking and continuingeducation credits in Ireland.


daily collections of methadone, supervised consumption and urine analysis, clinicsanctioning of ‘dirty screens’, restricted ‘takeaways’ and subsequent impact on clientday to day freedom. Harris and McElrath (2012) in their studies on MMT in north andsouth Ireland, observe that MMT in Ireland is best viewed as an intervention ratherthan a treatment modality, with pharmacological aspects to treatment undermined byclient service experiences typified by social control. This restriction of patient freedomand anxieties around chronic dependence is present in many studies on MMT(McKeganey et al. 2004; Holt 2007; Van Hout and Bingham 2012), despite thecorrelation between longer term methadone treatment duration, stabilization and im-proved psycho-social outcomes, reduced morbidity, poly drug use and criminal involve-ment (Winstock et al. 2011).

The continued use of other drugs and alcohol whilst in MMT was observed, and canoccur particularly in abstinence based modalities as methadone does not have a specificpharmacological effect on non-opioid drug use (Schuckit 2006). Research commentariesshow that abstinence based models MMT incurs greater rates on poly drug use(Caplehorn et al. 1996, 1998). Research by Bennett and Wright (1986) reported onthe high rates of continued illicit drug use among methadone attendees. Researchershave commented on the need for research on methadone diversion and factors impli-cated in enabling or reducing this behavior, within the context of supportive MMTtherapeutic relations (Gabbay et al. 1999). Prescribing doctors described dealing withpositive opiate urine screens by increasing methadone dosage to try and keep patientsfrom using heroin, probing their patients about discontinuing the program, and workingtowards a harm reduction dose. Studies do show that MMT programs differ in terms ofclinical practices (Stewart et al. 2003), with objectives ranging from harm reduction(Roe 2005), to long term maintenance (Ball and Ross 1991) to abstinence from alldrugs (Gossop et al. 2001). The need for a combined approach by utilizing harmreduction such as methadone maintenance in conjunction with abstinence based approachesto treatment has been extensively proposed (Broekaert and Vanderplasschen 2003;McKeganey et al. 2004; McKeganey 2005).

In all instances, client requests to reduce or increase their methadone dose wereheard and facilitated within a supportive patient led approach. However, instances ofself-detoxification and dose tapering were common, and are reflected in the literature(Noble et al. 2002; Dennis et al. 2005; Hopkins and Clark 2005; Ison et al. 2006; Van Hout andBingham 2012). The disparity between medical service provider and client experiences isevident with medical supervision of opiate dependence promoting treatment retention, incontrast to patients requesting treatment completion (Winstock et al. 2011). Research indicatesthat between on average 40 and 60 % of MMT patients drop out of treatment within 12 to14 months with relapse to heroin use (Nosyk et al. 2010), with a majority of opiate dependentsremaining on the periphery of treatment systems (Friedman et al. 2004; Bobrova et al. 2006;2007; Petersen et al. 2010; McDonnell and Van Hout 2010; 2011). An effective treatmentsystem for drug and alcohol dependence requires the availability of inpatient and communitybased detoxification to individuals, in the context of provision of managed withdrawal (Gowinget al. 2000a, b). Additionally, research shows that detoxification and the achievement ofabstinence is possible without formal treatment (Bobrova et al. 2006, 2007; Ison et al. 2006),and is often preferred with community based supports from local doctors, family and other users(Appel et al. 2004; Hopkins and Clark 2005; Grella et al. 2009).

It is evident from the research that the prescribing doctors cared deeply for their MMTpatients, and acted beyond their remit as prescribing doctor by providing crucial social andconfidential support. Of note, is that although they observed being restricted to methadone


prescribing, many described providing their patients with a range of psychosocial sup-ports within a positive, supportive and patient centered approach. According to Dole andNyswander (1980) mutual respect between the MMT client and treatment staff is funda-mental to reduce perceived structural and interpersonal factors which impact negativelyon treatment progression. Research has also underscored the need to reframe MMT astreatment modality to view clients in a more positive accepting manner as customers orconsumers (Luty and Grewal 2002; Luoma et al. 2007; Reisinger et al. 2009), rather thanpassive recipients of treatment (Harris and McElrath 2012; Van Hout and McElrath2012). In some instances, participants described knowing their patients much better thanthe patients’ main permanent general practitioner consulted for general health conditions.Primary care settings are generally the first ‘port of call’ for opiate dependents seekingtreatment, and present a unique opportunity to assist patients early for health complica-tions associated with injecting drug use, and with minimal stigmatization (Bennett andWright 1986; Abouvanni et al. 2000; McKeown et al. 2003). Research shows thatproblematic drug users reportedly consult their general practitioner significantly moreoften than non-drug using patients, and particularly those with HIV infection (Neville etal. 1988; Robertson 1989; Leaver et al. 1992).

Research on doctor roles call for expansion of these roles and responsibilities intoother health services, and continued professional development (Wynne-Jones et al.2010). Prescribing doctors was described as centered within a multiplicity of roles, withreported difficulties relating to methadone prescribing where doctors reported leading‘dual roles’ as patient advocate, medical expert, and detoxification gatekeeper. At timesand depending on client stabilization, the therapeutic alliance was compromised byinstances of mistrust and loss of respect, with prescribing doctors assuming a policingrole. Research commentaries have been made around such ‘dysfunctional consultations’in doctor patient consultations (Gabbay et al. 1999), with the sanctioning nature of MMTcomplicating traditional doctor patient roles. Relationships between doctors and MMTpatients were described as not quite fitting into the normal doctor patient consultationdue to the control of a prescribed drug, the level of contact between individuals on aweekly basis, and enforced urine screening. Despite the best efforts of prescribingdoctors in this research to undertake shared doctor patient decision making, in MMTthe relationship remained doctor centered, by the very virtue of methadone prescrib-ing. MMT patients in the first phase of research described the lack of perceived parityin doctor –patient consultations, which were observed to contribute individual attemptsto taper methadone dosage, self-detoxify and with frequent relapse (Van Hout andBingham 2012).

Finally, the national prescribing guidelines appeared to place unnecessary and unwantedrestrictions on their freedom to prescribe as normal doctors, with differences evidentbetween those in specialized clinics and those operating in general practice. Lastly, theprescribing doctors highlighted the need to measure MMT in relation to its outcomes, andnot as methadone prescribing process as advocated by the national prescribing guidelines. Itis evident however, that MMT outcomes are dependent on timely treatment entry, adequatemedication dosage, duration, support and continuity of treatment, levels of engagement inconcurrent counseling and presence of cohesive support networks of adjunctive medical,social and community services, and successful detoxification (World Health Organisation2009). Training needs, practitioner networking, continuing professional development andevidence based guidelines for MMT provision were also highlighted as necessary to improveMMT provision. This is supported by the literature (Ford and Ryrie 2010; Gabbay et al.2001; Strang et al. 2004; Delargy 2008).


Conclusion

The research, however small scale, exploratory and confined to a convenience sample ofmethadone prescribing doctors in specialized and primary care MMT sites in Dublin,Ireland, represents a unique description of doctor’s experiences of MMT provision, nationalprescribing guidelines, their relationships with their patients, observations around licit andillicit substance use, and identified needs around training, networking and support. Policymakers would be advised to consider the expansion of MMT provision to promote referralinto primary care settings, improve interagency community based psychosocial and detox-ification supports, develop a network of community nurse prescribers, consider alternativesubstitution medication, and appropriate treatment modalities for poly drug and alcohol use.Future research efforts could explore the comparative outcome evaluation of specializedversus shared care MMT provision in the long term.

Acknowledgments The authors would like to thank the doctors who participated in the study.

Declarations The research was funded by the Dublin North East Task Force, Ireland. The opinionsexpressed in this article are of the researchers and are not necessarily those of the Dublin North East TaskForce.

Conflict of Interest The authors report no conflict of interest.

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