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