Physicians’ Attitudes to Methadone Maintenance Treatment in Nova Scotia
Jessica Dooley*, M.Sc. CandidateDr. Susan Kirkland*, Ph. D.Dr. Mark Asbridge*, Ph. D.
Dr. John Fraser †, M.D.
*Department of Community Health and Epidemiology, Dalhousie University† Direction 180, North End Community Health Centre
Introduction 60,000-90,000 Canadians misuse opioids Methadone Maintenance Treatment (MMT) is an
effective treatment Daily dosing with methadone (a long-acting opioid
agonist) to prevent withdrawal symptoms, cravings and euphoric effects of opioids
Extent to which policies and programs are developed and accessible varies between geographical/professional settings and facilities
Office-based delivery suggested as a way of improving access and capacity
Success of such a model depends on willingness of physicians to deliver it
Public health implications of opioid misuse Associated conditions include:
HIV, hepatitis C, overdose, suicide, endocarditis, abscesses, infection, poor nutrition, adverse drug interactions (Fisher et al., 2004, Hser et al., 2001, Health Canada, 2007)
Associated co-morbidities include: Poly-drug dependence, hypertension, diabetes, asthma,
chronic liver disease, cirrhosis(Gossop et al., 1997; Haydon, et al., 2003, Brooner et al., 1997; Darke and Ross, 1997)
Premature mortality is characteristic(Hser et al., 2001, Millson et al., 2004)
Effects extend to families and communities Blood borne diseases, criminality, economic implications
(Fisher et al., 2004; Hser et al., 2001; Wall et al., 2001)
Efficacy and effectiveness of methadone
Randomized controlled trials have shown methadone to be pharmacologically efficacious and safe
(Novich et al., 1993; Kreek, 1973, Donny et al., 2005) Reduces opioid use, use of other illicit drugs, frequency of drug
injection, high risk drug use behaviours, criminal activity, morbidity, mortality
(Strain et al., 1993; Thiede et al., 2000; Johansson et al.; 2007, Fairbank et al., 1993, Dolan et al., 2003; Gossop et al., 2003, Willner-Reid et al., 2007; Millson et al., 2007; Fabris et al., 2006; Bell et al., 1997, Langendam et al., 2001; Brugal et al., 2005; Caplehorn and Drummer, 1999)
Office-based MMT shown to be effective in numerous RCTs (Fiellin et al., 2001, Gossop et al., 1999, 2003)
High patient and provider satisfaction(Fiellin et al., 2001)
Advantages may include reduced stigma, more attention to medical and mental health concerns, easy geographical access, improved treatment retention
(Fiellin et al., 2001; Salsitz et al., 2000).
Current Canadian context
(Popova et al., 2006)
Overall objectives
Assess acceptability of office-based MMT among non-specialist physicians in Nova Scotia
Determine extent to which office-based MMT has the potential to enhance accessibility and capacity
Establish the context in which office-based MMT could be integrated in Nova Scotia
Methods
E-mail survey of population of all non-specialist physicians in Nova Scotia (1170) using OPINIO software Administered twice, 10 days apart Clarify attitudes about:
Illicit drug use and maintenance-oriented treatment Treatment of opioid-dependent individuals in their
practices Barriers and facilitators to MMT delivery in private office-
based practice
Acceptability of office-based MMT
Key Measures: Willingness to participate in office-based MMT Perceived barriers and facilitators to office-based
MMT Attitudes towards drug use
Disapproval of drug use scale (DDU) Attitudes towards principles of harm reduction
Abstinence orientation scale (AOS) Knowledge of the risks and benefits of MMT
Test of knowledge of MMT (KNOW)
(Caplehorn, 1996)
Preliminary Results (n=124)
Age Sex Community Size
Medical School Training in Addiction Medicine
License to prescribe methadone for opioid dependence
Scale Scores
Scale Group Mean SD
KNOW All (n=123) 6.69 3.33
Licensed (n=11) 8.09 3.83
Unlicensed (n=112) 6.55 3.27
DDU All (n= 124) 3.19 0.68
Licensed (n=11) 3.03 0.78
Unlicensed (n=113) 3.20 0.66
AOS All (n=122) 2.98 0.53
Licensed (n=11) 2.79 0.41
Unlicensed (n=111) 3.00 0.54
Barriers influencing decision to be involved in MMT delivery
70%
69%
66%
53%
47%
41%
39%
33%
8%
0% 10% 20% 30% 40% 50% 60% 70% 80%
Difficult patient population
Lack of training or experience
Lack of support services
Lack of interaction with other MMT providers
Too much time
Don't want it known that they have a methadone license
General discomfort treating opioid dependence
Not enough reimbursement
Community resistance
Willingness to provide office-based MMT
12
47
46
1
2
5
0 10 20 30 40 50 60
Willing under currentcircumstances
Willing under differentcircumstances
Unwilling under anycircumstances
Unlicensed
Licensed but notcurrently providers
Potential limitations
Response rateSurvey errorResearcher biasResponse selection biasItem biasSocial desirability biasGeneralizeability
Preliminary Conclusions
Considerable acceptance of MMT in the province
Potential for improved access to MMT in the province
Areas for improvement for integration of MMT clearly highlighted Education Interaction with other providers Support Services
Support
In association with: The Atlantic Interdisciplinary
Research Network for Social and Behavioural Issues in HIV/AIDS and Hepatitis C (AIRN)
The College of Physicians and Surgeons of Nova Scotia
Funded by: Canadian Institutes of Health
Research Master’s Award Dalhousie University Faculty of
Medicine Marvin Burke Award