Methadone medical maintenance in primary care

Abstract

Background: Methadone is effective treatment for opioid addiction, but regulations restrict its use. Methadone medical maintenance treats stabilized methadone patients in a medical setting, but only experimental programs have been studied. Objective: To evaluate the implementation of the first methadone medical maintenance program established outside a reseach setting. Design: One‐year program evaluation. Setting: A public hospital and a community opioid treatment program. Participants: Methadone patients with >1 year of clinical stability. Eleven generalist physicians and 4 hospital pharmacists. Interventions: Regulatory exemptions were requested. Physicians and pharmacists were trained. Patients were transferred to the medical setting and permitted 1‐month supplies of methadone. Measurements: Patient eligibility and willingness to enroll, treatment retention, urine toxicology results, change in addiction severity and functional status, medical services provided, patient and physician satisfaction, and physician attitudes toward methadone maintenance. Results: Regulatory exemptions were obtained after a 14‐month process, and the program was cited in federal policy as acceptable for widespread implementation. Forty‐nine of 684 patients (7.2%) met stability criteria, and 30 enrolled. Twenty‐eight were retained for 1 year, and 2 transferred to other programs. Two patients had opioid‐positive urine tests and were managed in the medical setting. Previously unmet medical needs were addressed, and the Addiction Severity Index (ASI) medical composite score improved over time (P=.02). Patient and physician satisfaction were high, and physician attitudes toward methadone maintenance treatment became more positive (P=.007). Conclusions: Methadone medical maintenance is complex to arrange but feasible outside a research setting, and can result in good clinical outcomes.

The role of medicinal cannabis in clinical therapy: pharmacists’ perspectives

“…This, along with maintaining open lines of communication may help mitigate errors and ensure improved patient outcomes following the facilitation of medicinal cannabis [29,30]. Successful specialised treatment programs, for example buprenorphine provision, have often utilised inter-professional training for pharmacists and specialist physicians [31,32]. Similar methods need to be applied in the case of medicinal cannabis as well.…”

Traitement de la dépendance aux opioïdes : évaluation d’un projet montréalais de transfert d’usagers stabilisés vers des soins de santé généraux

“…Les écrits scientifiques présentent plusieurs études américaines portant sur le transfert de la clientèle. Ces transferts permettent entre autres d'accéder à un traitement plus avantageux tel que l'obtention de doses non supervisées supplémen-taires ainsi que des rendez-vous de suivi plus espacés (Fiellin & al., 2001 ;Merril & al., 2004). Les principaux obstacles au transfert sont l'accès difficile aux services de santé mentale, le manque d'accessibilité aux intervenants en toxicomanie ainsi que la continuité du traitement des patients lors de l'absence des omnipraticiens des services de soins primaires (Fiellin & al., 2004 ;McMurphy & al., 2006).…”

“…La situation rapportée semble correspondre en plusieurs points à celle observée aux États-Unis en rapport avec la légis-lation fédérale qui encadre le traitement de substitution (Fiellin & al., 2001 ;Fiellin, O'Connor, Chawarski, & Schottenfeld, 2004 ;Harris & al., 2006 ;King & al., 2006 ;McMurphy, Shea, Switzer, & Turner, 2006 ;Merril & al., 2004). Ces politiques visent à prévenir la vente illégale des médications de substitution et à assurer la présence d'un accompagnement psychosocial à la pharmacothérapie (Harris & al., 2006).…”

“…Malheureusement, jusqu'à présent peu de généralistes offrent ces traitements. Le transfert de la clientèle vers les soins primaires est donc rare et souvent limité à des personnes très stables, répondant à des critères élevés, par exemple : l'absence de toute dépendance sauf à la nicotine, l'absence de condition médicale ou psychiatrique ainsi qu'un lieu de résidence et des revenus financiers stables (Fiellin & al., 2001 ;Fiellin, O'Connor, Chawarski, & Schottenfeld, 2004 ;King & al., 2006 ;Merril & al., 2004). Au Québec, la situation est analogue, mais elle se caractérise par l'accès limité pour la clientèle aux médecins dans le réseau de la santé, ce qui complique évidemment le transfert de celle-ci vers les soins primaires.…”

A 5-year evaluation of a methadone medical maintenance program

“…Two randomized controlled trials demonstrating comparable outcomes at 6 months between the MMM approach and standard methadone maintenance have been published (Fiellin et al, 2001;King et al, 2002). Four additional MMM programs in the United States have been evaluated in the literature, including a specialized clinic (Senay, Barthwell, Marks, & Bokos, 1994), private offices (Salsitz et al, 2000;Schwartz, Brooner, Montoya, Currens, & Hayes, 1999), and a primary care clinic (Merrill et al, 2005). Physicians in these MMM programs either had extensive prior experience with methadone maintenance or received training and had access to more experienced methadone providers.…”