Methadone Maintenance Treatment
Concerns in Ontario

History:



Over the last decade, methadone maintenance as a treatment option for opiate addiction has increased significantly in Ontario. A continuum of treatment programs began to evolve, offering different services to different client groups. Some programs were abstinence based, while others operated from various points on the harm reduction continuum. Initially two types of programs existed: those operated by community agencies usually overseen by the Ministry of Health and Long Term Care (MoHLTC) and those operated by physicians in private practice governed by the College of Physician and Surgeons. In the last five years, a large number of clinics operated by a physicians group have opened up across Ontario. These clinics are very large, often with client bases of 200 to 300 people



Issues:



Initially there was excitement in the field about the creation of a continuum of treatment options for methadone clients, in keeping with best practices philosophy that clients have different needs and thus require different treatment options for effective treatment. A continuum similar to what exists for residential treatment programs was evolving. However, as the larger clinics developed and multiplied, there has been a number of closures of smaller, community run clinics due to lack of funding. Thus two distinct and very different streams of treatment approaches have evolved: a) MoHLTC funded programs and b) those programs run by physician groups under the College of Physicians and Surgeons. This evolution has created several dilemmas, specifically in regard to accountability.



Issues identified with these Large Clinics:



· Lack of case management for larger caseloads of over 200 clients

· Lack of treatment for concurrent disorders

· Very high doses of methadone dispensed (280 mg in some cases)

· Low levels of monitoring for methadone diversion

· Methadone prescribed for those without prior opiate addiction

· Methadone dispensed to those under the influence of alcohol and other substances

· Drug dealing on the premises

· Lack of linkage or physician follow up when clients are admitted to withdrawal management or other programs



One of the major concerns is the inability to file a complaint against a program operated by physicians under the College of Physicians and Surgeons. Through the College complaints procedure, only a patient of a clinic can lodge a complaint or raise a concern. A community agency or group cannot, as there is no patient-doctor relationship. As these clinics, operated by a physicians group, create a monopoly of methadone services in Ontario, clinic clients are very hesitant to lodge a formal complaint out of fear of being terminated from the only program that may exist in their city or community. Others are concerned that, given their opiate addiction, their complaint will not be taken seriously. The MoHLTC has no mandate to involve themselves with these clients



The number of deaths from methadone diversion/overdose is significantly rising, resulting in several inquests in the province. Methadone clients and service providers are concerned that methadone treatment will be viewed in a negative light given these deaths as opposed to a successful treatment option if delivered effectively with clinical and administrative accountability.



As the number of smaller “community run” clinics decrease, it is becoming harder and harder to evaluate different streams of treatment and their effectiveness.



Options/Solutions:



Advocacy is required to lobby the College to create another avenue for formal complaints or concerns to be lodged. Community agencies and client advocate groups need an avenue to voice their concerns regarding methadone treatment at these clinics.



Advocacy is also required with the Corners Office in regard to inquests involving methadone diversion/overdose so that the issues can be heard and highlighted



Research is required to compare outcomes from various treatment options to determine clinical and cost effectiveness. Only through sound evaluation can funding issues be addressed.