Cat. No.: H49-164/2002E
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Methadone maintenance treatment is a key component of a comprehensive treatment and prevention strategy to address opioid dependence and its consequences. A review of the literature (Health Canada, 2002) indicates that methadone maintenance treatment is considered an effective means of reducing the use of other opioids, the use of other substances, criminal activity, and the rate of mortality. Methadone maintenance treatment has also been found to reduce injection-related risk behaviours, other risk behaviours for transmission of human immunodeficiency virus (HIV) and sexually transmitted diseases, and the transmission of HIV (and potentially the transmission of hepatitis C virus (HCV) and other blood-borne pathogens). Methadone maintenance treatment improves physical and mental health, social functioning, quality of life, and pregnancy outcomes. Methadone maintenance treatment has also been found to increase retention in treatment. Health Canada, in collaboration with the provinces and territories, is involved in efforts to increase access to effective methadone maintenance programs.Footnote 1 Part of these efforts includes the development of this document.
This best practices document is intended to help improve the effectiveness of current programs and encourage the establishment of new programs. This document is an educational tool which synthesizes knowledge about best practices in methadone maintenance treatment design and delivery. It contributes to an ongoing process of knowledge development and education for policy makers and health and social services professionals responding to the issue of opioid dependence.
Providing this information is not intended to tell policy makers or people working in the field what they must do; rather, it provides a summary of what current research and expert opinion - from within Canada and abroad - indicate are the best practices in the field of methadone maintenance treatment. It focuses on what a comprehensive approach to effective, accessible methadone maintenance treatment should look like, and how to achieve it.
This best practices resource has been developed as a stand-alone information source, in that it is not intended to replace, but rather to serve as a companion to, existing federal or provincial guidelines for methadone maintenance treatment. For further information on providing methadone maintenance treatment, readers must consult the current national guidelines (Health and Welfare Canada, 1992) and provincial guidelines, where these exist or are being developed.Footnote 2 In addition, readers are encouraged to consult the literature review report which is a companion to this report and was produced on behalf of Canada's Drug Strategy Division (see Health Canada, 2002). A brochure based on this report is also available (see Health Canada 2002b).
In developing this document, the Investigator Team referred to sources that are believed to be reliable. This document, however, is not intended to provide readers with sufficient information to prescribe or dispense methadone.
This document was developed on behalf of the Office of Canada's Drug Strategy, Health Canada. The Investigator Team included
The project was carried out under the guidance of the federal/provincial/territorial Steering Committee on Best Practices in Methadone Maintenance Treatment.
The Investigator Team would like to thank the Steering Committee, the Canadian and International experts who were interviewed as well as service providers, clients/patients and client/patient advocates and regulatory bodies who contributed to the development of this document.
This document is part of an ongoing effort supported by Canada's Drug Strategy to increase access to effective methadone maintenance treatment programs in Canada by promoting and disseminating information on effective strategies to implement methadone maintenance treatment.
As noted in the Preface, this document is not intended to replace, but rather to accompany, existing national or provincial guidelines. Readers must consult the federal guidelines (Health and Welfare Canada, 1992) and existing provincial guidelines for further information on providing methadone maintenance treatment.
This document provides information on evidence-based best practices in methadone maintenance treatment, and the key components of comprehensive methadone maintenance treatment programs.
Links to the published literature are noted throughout the document. A list of references and further suggested reading is included at the end of the document. All other non-referenced material represents the wealth of clinical and consumer wisdom and experience contributed by the many individuals who were consulted during the course of the project.
In this document, the sections entitled "Insights from the Field" represent a summary of some of the comments derived from the three consultation meetings held with experts in the field of methadone maintenance treatment.
Ideally, this document will contribute to:
This document has been developed for use by the many different groups of people who are involved in delivering methadone maintenance treatment in Canada including, among others:
The document is also designed for use by policy and program developers and decision makers who are working in - and across - federal, provincial and territorial government departments and agencies to increase access to methadone maintenance treatment in Canada.
Although this document was not written explicitly for clients/patients or their families, the information it contains may be useful for them as well.
Development Process for MMT Best Practices Products
This document is based on:
According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)Footnote 5, the key feature of substance dependence is "a cluster of cognitive, behavioural and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems...a pattern of repeated self-administration that usually results in tolerance, withdrawal, and compulsive drug-taking behavior." Although tolerance and withdrawal are usual features of substance dependence, the DSM-IV notes that neither is necessary for a diagnosis of substance dependence (Brands and Brands, 1998, 42).
As Brands et al. (1998, 43-44) explain, the term "addiction" is no longer widespread in the medical community, and has been largely replaced by the term "drug [or substance] dependence." They also note that the term "drug [or substance] abuse" is: "a highly complex, value-laden and often excessively vague term that does not lend itself completely to any single definition." Furthermore, because the term has different meanings for different groups of people - and their definition of the term reflects their different perspectives - there is often difficulty in drawing a line between use of substances and abuse of substances (Brands et al., 1998, 45).
According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), (reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association), opioid dependence is a substance dependence disorder. The DSM-IV specifies criteria for opioid dependence (which are the same as for substance dependence) and which include physical tolerance of, and dependence on, opioids, as well as the compulsive use of opioids despite harm:
"A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
People who are dependent on opioids often lead extremely stressful and chaotic lives, and frequently experience serious health and social problems as a result of their dependence. They are at high risk for premature death from accidental drug overdose, drug-related accidents and violence. Sharing needles, syringes, straws, cookers or other contaminated drug-taking equipment, for example, places them at high risk of acquiring human immunodeficiency virus (HIV), hepatitis C virus (HCV) or other blood-borne pathogens. The problem of opioid dependence may be exacerbated by multiple substance use, as well as by factors such as poverty, and homelessness. Mental health disorders - such as depression, antisocial personality disorder and phobias - are common. Often, people who are dependent on opioids have experienced a long history of rejection, exclusion, and incarceration, which reinforces their sense of alienation and antagonism. They may have little sense of control over their lives.
Opioid dependence is a costly social problem. Researchers have estimated that there may be 40,000 to 90,000 people in Canada who regularly use heroin (Fischer and Rehm, 1997, 367). The majority of people who are dependent on opioids are injection drug users.Footnote 6 Untreated, opioid dependence involves costs related to criminal activity, medical care, drug treatment, lost productivity, and, increasingly, transmission of HIV, HCV and other blood-borne pathogens. In 1996, approximately half of the estimated 4,200 new HIV infections that occurred in Canada were among injection drug users (IDUs) (Health Canada, 1999b, 1).Footnote 7 According to the Laboratory Centre for Disease Control (as cited in Health Canada, 2000a, 6), at least 70% of prevalent HCV infections are related to injection drug use. Some populations of individuals who are dependent on opioids are particularly vulnerable to the dual problem of injection drug use and infection with HIV, HCV or other blood-borne pathogens including women, street youth, offenders in correctional facilities, and Aboriginal people (Canadian HIV/AIDS Legal Network, 1999, 11; Health Canada, 2000a, 15-20).
Research by Single et al. (as cited in Fischer and Rehm, 1997, 368) indicates that the costs related to injection drug use and opioid dependence are significant. Overall, illicit drug use cost an estimated $1.37 billion in Canada in 1992, and about 70% of this (or $48 per capita) was attributed to opiate use. The lifetime (i.e. over a 17-year period) costs of treating an individual with HIV infection are estimated at $153,000 (Albert and Williams, 1998, 38).
Although other forms of treatment for opioid dependence continue to be explored, in Canada and internationally, methadone maintenance treatment remains the most widely used form of treatment for people who are dependent on opioids. Methadone itself is a long-acting synthetic opioid agonist, which is prescribed as a treatment for opioid dependence. People who are dependent on opioids may be dependent on either oral or injectable forms of opioids such as heroin (diacetylmorphine), morphine or hydromorphone. Methadone maintenance treatment is an appropriate form of treatment for opioid dependence, regardless of the route of administration (oral or injection).
There is no universal definition of what a methadone maintenance treatment "program" is, although the common basis is clearly the use of methadone. Program components and policies vary widely around the world, and within Canada. A comprehensive approach to methadone maintenance treatment, however, generally includes a number of components - which can be delivered in a variety of ways and at varying levels of intensity - including:
Methadone works by alleviating the symptoms of opioid withdrawal. A stable and sufficient blood level of methadone stems the chronic craving for opioids. Since methadone is a much longer acting drug than some other opioids, such as heroin, one oral dose daily prevents the onset of opioid withdrawal symptoms - including anxiety, restlessness, runny nose, tearing, nausea and vomiting - for 24 hours or longer.
Methadone diminishes the euphoric effects of other opioids (cross tolerance), without necessarily causing euphoria, sedation or analgesia (Lowinson et al.,1997, 407). This means self-administered illicit opioids will not lead to euphoria, making it less likely that clients/patients will either use illicit opioids or overdose.
Individuals in a methadone maintenance treatment program take their medication orally once daily - often it is mixed into an orange drink. Since methadone is long-acting, the need to inject other opioids is decreased and this reduces the health risks associated with injection drug use.
Tolerance to the effects of methadone develops very slowly, allowing many individuals who are dependent on opioids to be maintained on the same dose of methadone safely for many years.
When appropriately prescribed and dispensed, methadone is considered a medically safe medication.
For further information on the pharmacology and pharmacokinetics of methadone, readers are encouraged to consult the references cited in the back of this document.
Methadone was originally developed in Germany as a substitute analgesic for morphine. World War II brought the formula to the attention of North American researchers, who subsequently discovered that methadone could be used to treat heroin withdrawal symptoms. Although the work of American researchers, Dole and Nyswander, in the early 1960s is perhaps best known for demonstrating that methadone was suitable as a maintenance treatment, a Canadian researcher, Dr. Robert Halliday, set up what may have been the first methadone maintenance treatment program in the world in British Columbia in 1963 (Ruel, as cited in Health Canada, 1998, 3; Berger, Carlisle and Marsh, as cited in Ontario Ministry of Health, 1999, 6).
To date, methadone remains the only opioid authorized for long-term (more than 180 days) outpatient pharmacological treatment of people who are dependent on opioids in Canada (Health and Welfare Canada, 1992, 10). In the almost forty years since methadone was first used in Canada, the number of people receiving treatment has fluctuated, as the regulations surrounding methadone have changed. After national guidelines for prescribing methadone were first introduced in 1972, the number of people receiving treatment dropped from 1,700 in 1972 to only 600 in 1982 (Berger, Carlisle and Marsh, as cited in Ontario Ministry of Health, 1999, 5). Since then - as awareness and concern about opioid dependence and related public health risks, notably the increasing rate of infection with HIV, HCV and other blood-borne pathogens among injection drug users has grown - the number of people who are dependent on opioids who are receiving methadone maintenance treatment has increased.
The regulatory and administrative context within which methadone maintenance treatment in Canada is delivered continues to evolve. From the mid-1990s to the present, there have been significant changes in the administration of methadone maintenance treatment. The Office of Controlled Substances, Health Canada, permits physicians to prescribe methadone. In recent years, the provinces have begun to take over some responsibilities for administering methadone maintenance treatment programs. At this time, several provinces have developed - or are in the process of developing - guidelines and training for practitioners interested in providing methadone maintenance treatment.
Current efforts to increase access to methadone maintenance treatment are linked to continued concerns about the relatively low numbers of people who have access to methadone maintenance treatment in Canada, as compared to other countries, such as Australia, that have emphasized methadone maintenance treatment as a key strategy for public health.Footnote 8 Although in recent years, the number of clients/patients enrolled in methadone maintenance treatment has increased to approximately 15,000 (D. Marsh, personal communication, November 2000), critics of the situation in Canada still note that there are still barriers at every level - within society, in systems, in programs, and at the individual level - that need to be addressed.
To date, some of the signs of progress in overcoming barriers include:
Suggestions for increasing the accessibility of methadone maintenance treatment, particularly within programs and for specific groups of people, are included throughout this document.
|Barriers||Potential Ways to Address Barriers|
|Attitudinal barriers to treatment including fear and misinformation||Expand educational efforts - including dissemination of information - among policymakers, practitioners, public and clients/patients|
|Philosophical differences among practitioners||Educate and provide opportunities for dialogue|
|Insufficient resources for treatment||Increase resources and/or reallocate existing resources|
|Lack of practitioners||Link educational strategies with recruitment initiatives. Explore incentives|
|Level of regulation||Ongoing dialogue and consultation with all jurisdictions to clarify roles|
|Uneven or fragmented access to services across jurisdictions and sectors and lack of transferability||Ongoing interjurisdictional and intersectoral dialogue and information sharing to "cross-fertilize" knowledge and experience of best practices|
|Lack of access in rural or remote areas||Increase access - see Section 7.7 - MMT and People Living in Rural and Remote Areas|
|Lack of outreach||Increase outreach - see Section 4.6.7 -Outreach and Advocacy|
|Program Policies (admission criteria, etc.)||Revisit program policies - see Section 5.0 -Best Practices in MMT - Program Policies|
|Lack of supports for clients/patients (costs of treatment, access to and cost of transportation, access to and cost of child care, etc.)||Increase supports for all clients/patients including those with specific needs - see Section 7.0 - Best Practices in MMT -Meeting the Needs of Specific Groups.|
|Lack of supports for team members||Increase supports for practitioners - see Section 6.0 - Best Practices in MMT -Program Team and Environment|
Around the world, methadone maintenance treatment is delivered in many different ways. In addition to differences in national regulatory frameworks, programs differ widely in terms of their philosophy, the extent of non-pharmacologic treatment services provided, their program policies, and program settings. Programs also serve different client/patient groups.
In some countries, efforts are being made to increase access to methadone maintenance treatment. In the United States, for example, attempts to increase access to methadone maintenance treatment have led to new approaches to program delivery, such as:
Other countries have also introduced a range of different program delivery approaches - well-known examples include strategies such as the mobile vans in the Netherlands and Boston (Lowinson et al., 1997, 413).
Methadone Maintenance Treatment in Canada
In Canada, as in many other countries, there is a national level regulatory framework for methadone prescription. The Office of Controlled Substances, Health Canada, works with provincial/territorial governments and medical licensing bodies to facilitate increased access to methadone maintenance treatment. To date, several provinces have developed - or are in the process of developing - guidelines and training for practitioners interested in providing methadone maintenance treatment. Although provinces have become increasingly involved in delineating the conditions under which physicians are permitted to prescribe methadone, methadone can be prescribed only by physicians who have received an exemption under the Controlled Drugs and Substances Act.
There is a dearth of published information about the various types of programs available in Canada. A national survey of substance use treatment programs collected information on 870 programs (estimated to be about 70% of the programs available in Canada). A total of 38 programs reported that they provide methadone maintenance treatment, and about half of those report using a higher dose regimen (60-100 mg/day). The prevalence of, and perceived need for, such treatment varies across the country (Health Canada, 1999c, 1,17,20).Footnote 10 According to a recent national report, many methadone maintenance treatment programs in Canada adhere to an abstinence philosophy, and some do not offer comprehensive services such as primary health care, counseling or education. Furthermore, while some provinces have expanded their methadone programs and made them more accessible, other provinces do not have any methadone programs (Canadian HIV/AIDS Legal Network, 1999, 6,16).
The research for this document, including a search of the Canadian Centre on Substance Abuse Treatment database, suggests that methadone maintenance treatment programs are delivered in a range of different settings including:
Those who are involved in treatment delivery include practitioners and service providers from many different disciplines and backgrounds including medicine, psychology, substance use treatment and rehabilitation, social work, mental health and others. Practitioners' roles in providing treatment tend to vary somewhat depending on a variety of factors including program setting, available resources and geographic location. There also appears to be a significant amount of diversity across jurisdictions and among programs - in terms of program philosophy, range of services provided, client/patient groups served, level of client/patient involvement, program policies, and program settings.
At this time, as Bell (1998a, 161) points out, "despite an extensive research literature, there is no broad consensus on the role of methadone maintenance treatment, or on how treatment should be delivered. Even where there is firm empirical evidence, such as the importance of adequate methadone dose, treatment practices are often out of line with research evidence." Some of the difficulties in developing consensus on the most effective treatment approaches relate to the diversity of treatment goals. Other problems stem from the fact that some types of programs have been extensively evaluated, while others have received less attention. Furthermore, the current constellation of different delivery strategies represent attempts to respond to specific needs or circumstances.
There is evidence, however, that suggests that there are some "cross-cutting" features or characteristics of programs that increase the likelihood of client/patient retention and enhance other outcomes. Retention is a particularly key outcome - if programs cannot recruit and retain clients/patients, the potential benefits of treatment will not be realized. Consequently, this manual focuses on key aspects of:
Program Development and Design
Program Staff and Environment
Meeting the Needs of Specific Groups
Research and Evaluation
Given the diversity of clients/patients' goals and needs, the availability of a continuum of different types of program delivery modes - from "limited service"Footnote 12 to much more intensive levels of services - may be the most important concern. There should be recognition that people who are dependent on opioids are a heterogenous population with diverse reasons for entering (or not entering) treatment. They do not all have the same type or level of need for treatment. Finally, as in all types of treatment, most people's needs will change over time, as treatment progresses. The more flexible, innovative and collaborative are the responses of various treatment delivery communities - including physicians, substance use treatment providers, and others - the better.
Although there are some side effects associated with the use of methadone (see Section 5.3: Adequate Individualized Dosage) - as there can be with any medication - there are many good reasons to provide people who are dependent on opioids with access to methadone maintenance treatment.
A review of the literature (Health Canada, 2002a) indicates that methadone maintenance treatment is effective in reducing:
Methadone maintenance treatment has also been found to improve:
Methadone maintenance treatment is associated with increased retention in treatment. Consequently, methadone maintenance treatment has the potential to benefit, not only people receiving treatment, but also those who are involved in delivering treatment, as well as the wider community and society as a whole.
For people who are dependent on opioids, methadone maintenance treatment provides access to a stable supply of a legal, pharmaceutical grade medication. As a result, people receiving treatment achieve respite from the stress of maintaining a constant supply of illicit opioids often involving criminal activities and high risk sexual and injecting practices. Rather than experiencing a constant cycle of highs and lows - as the result of repeated injections of heroin, for example - their mood and functional state become stabilized (Dole, Nyswander and Kreek, as cited in National Institute on Drug Abuse, 1995, 4-9). Overall, research indicates that people receiving MMT will:
For pregnant women who are dependent on opioids, receiving methadone maintenance treatment, combined with adequate prenatal care, decreases obstetrical and fetal complications (National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction, 1998, 1939). Methadone protects the fetus from erratic opioid levels and frequent opioid withdrawal symptoms, which are common among pregnant women who do not receive treatment for their opioid dependence (Finnegan; Kaltenbach et al., as cited in NIDA, 1995, 1-32, 1-33).
Methadone maintenance treatment has substantially higher retention rates (68% after three months) compared to outpatient counselling without methadone (36%) or residential programs without methadone (45%) (Hubbard et al., as cited in Brands and Brands, 1998, 2).
The longer people who are dependent on opioids remain in MMT, the more likely they are to remain crime-free, to avoid injecting, and to reduce their use of heroin (Simpson and Sells; Ball and Ross, as cited in NIDA, 1995, 4-11, 4-14).
For practitioners involved in treatment delivery, methadone maintenance treatment is an opportunity to:
For the wider community, the potential benefits of methadone maintenance treatment include:
For society as a whole, methadone maintenance treatment may result in:
Given the costs of untreated opioid dependence (see Section 2.3 - Impacts of Opioid Dependence above), methadone maintenance treatment offers significant cost benefits to society, which are worth more than the costs of providing treatment. Studies by the National Institute on Drug Abuse (as cited in Health Canada, 1999a, 12-13) found:
Similar cost benefits are being identified in Canada. In Toronto, the average social cost of an untreated person who is dependent on illicit opioids has recently been estimated to be $44,600 per year (Wall et al., 2000). According to an estimate from the Centre for Addiction and Mental Health in Toronto, methadone maintenance treatment can be provided for approximately $6,000 per year (D. Marsh, personal communication, November 2000).
There is some evidence that, compared to other forms of treatment for opioid dependence, methadone maintenance treatment's high retention rates and lower delivery costs make it a more cost-effective form of treatment (Ward and Sutton, 1998, 117). In one study, the cost effectiveness of methadone maintenance, compared to other treatment modalities, yielded a benefit/cost ratio of 4.4:1(Rufener et al., as cited in Lowinson et al., 1997, 410).
Program philosophy refers to the principles and goals on which treatment is based. A clear articulation of a program's philosophy is an important starting point for developing an effective, accessible methadone maintenance treatment program (Ball and Ross, as cited in Lowinson et al., 1997, 412).
Historically, the prevailing social concerns about drug use and related crime have been a powerful influence on the goals of methadone maintenance treatment programs, and delivery approaches.
In practice, however, society, programs, practitioners and clients/patients often have somewhat different, albeit inter-related, goals for treatment. Consequently, their definition of success may also be somewhat different, and goals may also change over time, as treatment progresses.
For policy makers, methadone maintenance treatment should achieve positive long term outcomes for society (e.g. reduced mortality and morbidity due to opioid dependence; reduced rates of crime; and reduced social and economic costs of opioid dependence). Practitioners may focus on more specific clinical benefits, such as decreased symptoms of opioid withdrawal, and/or reduced needle use over a specific time period. Individual clients/patients may measure success in somewhat different terms, such as reduced risk of infection with HIV, HCV or other blood-borne pathogens, improved family life, getting and maintaining a job, reduced risk of having children apprehended by child protection agencies, or the increased likelihood of remaining in treatment while incarcerated (if they start treatment before being sentenced), and so on.
Programs should examine and clarify their underlying assumptions - about substance use, about opioid dependence, and about the goals of treatment. The program philosophy should be made clear to clients/patients and all other members of the program team. The specific policies and procedures of the program should be consistent with the overall philosophy. The goals of the program should reflect and respect the goals and needs of the clients/patients (see Section 4.4 - A Client/Patient-Centred Approach).
Engagement in treatment is critical - when the opportunity arises, programs should focus on engaging people who are dependent on opioids in treatment in as short a period of time as possible. (See also Section 4.5 - Accessibility and Section 4.6.7-Outreach and Advocacy).
There is a growing emphasis on the importance of meeting the needs of individual clients/patients (NIDA, 1995, 1-38). Linked to this is the recognition that retention in treatment is essential. If clients/patients don't remain in treatment, they have little opportunity to achieve any potential gains from treatment. Retention is also important over the long-term, given that length of time in treatment is positively associated with achieving other positive outcomes of treatment (Ball and Ross, as cited in Lowinson et al., 1997, 410), and specifically, reduced use of other opioids and reduced criminal activity (Simpson; Simpson and Sells; Hubbard et al., Bell et al., as cited in Ward, Mattick and Hall, 1998b, 330).
As noted above, methadone maintenance programs should focus on reducing harm by retaining clients/patients in treatment. The evidence indicates that a long-term maintenance philosophy increases retention in treatment (Caplehorn et al., McGlothlin and Anglin, as cited in Ward et al., 1998b, 324).
Rather than emphasizing abstinence from all drugs - including eventual tapering from methadone - as the primary goal of treatment, methadone maintenance programs should focus instead on maintaining clients/patients on methadone for as long as they continue to benefit from treatment. While some clients/patients may aim to achieve reduced use of, or abstinence from, drug use, and some may wish to taper off methadone, these outcomes should not be the exclusive emphasis of programs or practitioners, particularly in the initial stages of treatment (Ball and Ross, as cited in Lowinson, et al., 1997, 407).
Research reviewed by the National Institute on Drug Abuse has shown that identifying and meeting the needs of clients/patients is associated with better treatment outcomes (NIDA, 1995, 1-38).
A broader definition of the term "client/patient-centred"may also include:
Many people who are dependent on opioids are highly marginalized by society. Their access to treatment is problematic due to numerous barriers - at the societal, system, program and individual level (See Section 2.8: Increasing Access to Methadone Maintenance Treatment: Overcoming Barriers). At the program development and design level, there are many considerations that could enhance accessibility to treatment for all clients/patients including:
More information on enhancing accessibility for specific groups of clients/patients is provided in Section 7.0: Best Practices in MMT - Meeting the Needs of Specific Groups.
People who are dependent on opioids may need access to a wide range of services and supports - in addition to methadone - in order to reduce their use of other opioids and improve their quality of life. Integrated, comprehensive services are associated with better treatment outcomes.Footnote 16
Integrated, comprehensive services help provide continuity of care by effectively linking clients/patients to the individualized range of services and supports they need - recognizing that not all clients/patients will need the same level of services and supports. Programs should use a tailored approach in which the intensity of services and supports varies according to individual needs, choices, and treatment progress.
Comprehensive services are associated with improved treatment outcomesFootnote 17 - the greater the level and intensity of ancillary services, the better the treatment outcomes (Strain et al., as cited in Strain, 1999b, 1000)Footnote 18 Integrated, comprehensive services may be delivered in a variety of ways.
"Integration" may be needed at different levels, for example:
"Comprehensive" services encompass a holistic approach to meeting clients'/patients' needs by providing a full spectrum of available supports and services, either on-site or through effective referral and service delivery networks. There are different approaches that can be used to deliver comprehensive services -depending on the treatment setting and available resources - and often they will require a collaborative approach in which the input of a wide range of players is a key driver in program development and implementation (see Section 4.8 Involvement of Wider Community). Regardless of whether they are provided on-site or through strong linkages with other services, a comprehensive continuum of care includes the following key components:
Those who may be involved in providing a comprehensive approach include a wide range of practitioners from many different disciplines (see Section 6.1 -Multidisciplinary Program Team). The specific roles of each team member will vary according to factors such as level and type of professional training and expertise, as well as differences in program design and delivery. Depending on program type, location, available resources, and other factors, professionals may play a variety of different roles.
Key Components of a Comprehensive approach to MMT
People who are dependent on opioids often have co-morbid medical conditions and unmet needs for medical treatment. Some of the many medical conditions that clients/patients should be assessed for include:
Some conditions may require specialized medical care. For example, appropriate evaluation, monitoring, care, treatment and support for individuals who have acquired HIV, HCV or other blood-borne pathogens is a key component of medical care.
Providing adequate medical care for clients/patients includes appropriate use of medications that may interact with methadone.Footnote 20
More information on the medical needs of specific groups is provided in Section 7.0: Best Practices in MMT - Meeting the Needs of Specific Groups.
People who are dependent on opioids may also be dependent on other substances. Access to effective substance use treatment programs (in addition to methadone maintenance treatment) is essential. Methadone maintenance treatment programs need to be linked with other substance use treatment programs that employ recognized best practices.Footnote 21
There is evidence that providing counselling adds to the effectiveness of methadone maintenance treatment programs.Footnote 22 In the field, the term "counselling" encompasses a wide range of activities which may include, among others:
When they are ready to do so, clients/patients should have access to evidence-based approaches to counselling to address issues of concern to them.
When necessary, clients/patients should have access to mental health services. For more detailed information about the needs of clients/patients who have concurrent mental health disorders, see Section 7.11: MMT and People with Mental Health Disorders.
Methadone maintenance treatment programs are an important tool for reducing the risk of transmission of HIV, and potentially, the risk of transmission of HCV and other blood-borne pathogens, by reducing injection drug use. Programs are also an opportunity to provide other prevention measures - including screening, counselling, information and education on transmission of HIV, HCV and other blood-borne pathogens, and prevention initiatives related to sexually transmitted diseases Other aspects of a health promotion approach, including nutrition and wellness programming, should also be integrated into methadone maintenance treatment programs.
Methadone maintenance programs should either offer - or be directly linked to - a variety of other services and supports that a client/patient may need. These other or "ancillary"Footnote 24 services include those services that are not typically provided by health care professionals or programs - and are sometimes not provided by substance use treatment programs either. They include, for example:
To create effective linkages with other community resources, programs should establish relationships and communications mechanisms with a range of other agencies and facilities in the community. (See also Section 4.8: Involvement of the Wider Community.)
Establishing these linkages is a critical aspect of ensuring continuity of care for clients/patients. They can prevent clients/patients from "slipping through the cracks".
Outreach is a particularly important aspect of methadone maintenance treatment, given the level of marginalization experienced by many people who are dependent on opioids. In order to increase access to treatment, programs should consider proactive measures to reach out to potential clients/patients who are not likely to access treatment without encouragement and support. Outreach is an area in which peer-based strategies and linkages and partnerships with agencies working at the front-line or "street" level are particularly important.
Advocacy is another key area. The role of a client/patient advocate includes providing clients/patients with information about the program and their rights and responsibilities, as well as intervening on clients'/patients' behalf to help access services and supports. (See also Section 4.7: Client/Patient Involvement and Section 6.10: Information Collection and Sharing).
Client/patient input is a key component of program development and implementation. Programs need to value, seek out, encourage and support client/patient involvement. Some of the many different mechanisms for soliciting and supporting client/patient input include:
Community involvement in program development, design and implementation is often a key factor in providing integrated, comprehensive services. Mechanisms such as community advisory boards can broaden the sense of community ownership. These boards can play a number of valuable roles such as:
Examples of those who could become involved include:
Increasing access to methadone maintenance treatment requires adequate resources. The costs of delivering programs depends on the mode of program delivery and considerations such as whether or not all program services are delivered in-house or on-site, or the extent to which there are linkages with other services available in the community. Those involved in the development and design of programs should consider the following questions:
Clear program policies are associated with longer retention in treatment (Ball and Ross, as cited in Lowinson et al., 1997, 412). Program rules should be clearly communicated to clients/patients and consistently applied. Program policies - and the underlying "messages" they convey - should be consistent with a maintenance orientation, and they should promote a client/patient-centred, barrier-reducing, harm reduction approach to providing treatment. The following sections identify important considerations for some of the key treatment policy areas including:
Given the many potential benefits of methadone maintenance treatment - and the individual dangers and social costs of not providing treatmentFootnote 25 - program policies should encourage and facilitate admission to treatment. Admission criteria should be as open as possible, given available resources, and should ensure timely access to methadone maintenance treatment. Ideally, everyone for whom the individual and social benefits associated with treating opioid dependence are likely to be achieved by entry to treatment should be eligible for admission.
Programs should establish that an individual is physically dependent on opioids before they enter methadone maintenance treatment. For example, in Canada, methadone maintenance treatment is generally accepted to be an effective treatment for individuals who meet the criteria for opioid dependence, according to the DSM-IV. There are additional varying treatment criteria - such as varying age restrictions - among different jurisdictions and programs in Canada.
In keeping with standard ethical medical practice, before they enter a methadone maintenance program, clients/patients should be informed of other treatment options that are available to them. They should also be informed of the consequences - and the potential risks - of entering methadone maintenance treatment and practitioners should ensure that clients/patients understand fully what those consequences and risks are. Programs should also provide clients/patients with clear information about the specific program they are entering.
Best Practices in MMT - Program Policies
Assessment is part of the initiation of treatment as well as an ongoing process throughout all stages of treatment, i.e. intake-assessment, stabilization on methadone, maintenance on methadone, and after methadone is discontinued (if appropriate).
The first contact with a treatment agency has been shown to be a strong influence on defining the subsequent therapeutic relationship (Bell et al., Kauffman and Woody; Langrod; Miller and Rollnick; Woody et al., as cited in Ward et al., 1998a, 196). The initial assessment is, therefore, a good opportunity to establish a good working relationship with clients/patients and to establish what their goal and needs are. Subsequent stages of assessment should help strengthen the relationship between clients/patients and members of the program team.
Assessment is also an opportunity to provide clients/patients with information about methadone maintenance treatment, and about the program itself. Program policies and expectations should be described clearly. Clients/patients should be given as much information as possible, to allow them to make informed decisions about whether or not to enter, or continue in, treatment, and what level of services to access. The assessment process is also an opportunity to help motivate clients/patients to change and to improve their receptivity to treatment. A positive assessment experience sets the stage for a positive therapeutic relationship.
Immediate Crisis Management
The initial assessment process is often preceded by a need for immediate crisis management.
Some clients/patients will be dealing with crisis situations when they present for treatment. Programs should be equipped to deal with emergency or life-threatening situations and should be set up to address clients'/patients' immediate needs for safe shelter, food, clothing or other services and supports.
Although there is some debate about the amount of assessment that should be required prior to a client/patient receiving their first dose of methadone, the evidence indicates that rapid access to treatment is associated with achieving retention (Bell et al.; Woody et al.; Maddux et al., as cited in Ward et al., 1998b, 326). Consequently, the initial assessment should facilitate timely access to methadone medication. Once a diagnosis of opioid dependence is made, and the suitability of the individual for treatment is determined, clients/patients should receive their first dose of methadone as soon as possible. Beyond the initial assessment, a more comprehensive assessment can be done at a later stage to establish treatment goals and facilitate linkages to other services that may be needed (see Comprehensive Assessment below, and Section 4.6: Integrated Comprehensive Services.) The initial assessment should include:
Once a person has entered a methadone maintenance treatment program - and when it is appropriate for the client/patient - a comprehensive assessment of all relevant medical, social and mental health factors should be conducted. Programs should rely on validated and reliable assessment tools and techniques to identify and address clients/patients' treatment goals, and their needs.
In addition to a medical assessment for the DSM-IV diagnosis of opioid dependence (Brands and Brands, 1998, 29), a comprehensive assessment process should include:
Information from the comprehensive assessment should be used to identify and make diagnoses, evaluate a client's/patient's need for services, and develop a comprehensive treatment plan (see Section 4.6: Integrated Comprehensive Services).
In order to be an effective therapeutic tool, assessment should be ongoing throughout treatment. For example, once a treatment plan has been developed, it should be revisited and revised as needed, especially at key decision points. It can be helpful, in working with clients/patients, to track progress toward specific personal and program goals over time.
Many clients/patients will be involved in methadone maintenance treatment for an extended duration. For clients/patients who taper from methadone, however, no longer taking methadone does not necessarily mean the end of all treatment. Ongoing assessment can help identify and address the need for other interventions, and determine further progress toward treatment goals. If clients/patients consent to, and are available to participate in, long-term follow-up assessments, the information obtained can be useful for research and evaluation purposes - both to increase knowledge about methadone maintenance treatment, and to improve program delivery.
The assessment process should also take into account the needs of specific groups of clients/patients. (See Section 7.0 - Best Practices in MMT - Meeting the Needs of Specific Groups).
Given that individuals vary in how they respond to doses of methadone, programs should have a flexible, individualized policy on dosage. Each individual needs to be carefully assessed by a clinician who is experienced with treating opioid dependence, and the initial dose should be assessed on an individualized basis. Client/patient input should be taken into account in determining the dosage.
Extra care should be taken in dosing people who have severe liver dysfunction, cardio-respiratory dysfunction or who are pregnant. Specific considerations for methadone dosage during pregnancy are discussed in Section 7.4: MMT and Pregnant Women.
Clients/patients should be advised to store methadone safely out of the reach of children.
Clients/patients should be informed that the first or "initial" dose will be relatively low (10-30 mg), due to medical risk of overdose (Payte, 2000, 113-114). The initial dose represents a "balancing act" for physicians - they must balance the risk - if the initial methadone dose is too low - of clients/patients either leaving treatment or using other substances and risking overdose, against the risk of death if the starting dose of methadone is too high.
Dose adjustments should take place in phases, and should be done slowly to avoid problems created by rapid increases. In the "induction" phase, the dose is increased to a safe, adequate level to relieve withdrawal symptoms and cravings. The dose may then be further increased (or decreased) to achieve other desired effects.
Since methadone accumulates in the body over successive doses, the effects of the drug can increase over time even if the dose is not increased.
Common side effects
Methadone may cause some side effects in the early stages of treatment including increased sweating, constipation, libido abnormalities, orgasm abnormalities, insomnia, appetite abnormalities, nausea, drowsiness, anxiety, headaches, body aches and pains and chills. These side effects, however, tend to largely disappear with long-term, high-dose methadone maintenance treatment (Kreek; Jaffe and Martin; Hartel; Hartel, as cited in NIDA, 1995, 1-37).
Maintenance on an adequate dosage
Once someone is receiving an adequate, stable dose of methadone, they are not impaired. They can be "maintained" on methadone indefinitely. Some people stay on the same dose of methadone for many years.Footnote 28
There is an ongoing debate about the level of methadone dose that should be used in treatment. The evidence supports the need for an "adequate" individualized dose of methadone to increase retention.Footnote 29 Higher doses of methadone have been associated with greater decreases in other opioid use and enhanced treatment retention (Strain; Stitzer et al., Caplehorn and Bell, as cited in Brands et al., 2000, 236). Some people may require significantly higher doses than others (Strain et al., as cited in Leavitt, Shinderman, Maxwell, Chin and Paris, 2000, 408). The key aspect in determining dose, according to Brands et al. (2000, 236) is to provide an "optimal dose", i.e. one that "relieves withdrawal symptoms and drug cravings without sedation or other side-effects." In its 1995 review of the evidence, the National Institute on Drug Abuse (1-39 to 1-40) concluded that: "The specific dosage for a patient cannot be arbitrarily determined since patients metabolize methadone at different rates. In addition, the appropriate dosage may change over time or in response to specific situations such as pregnancy or the use of other medications. Overall, methadone dosage should be based on the patient's individual needs, the goals of treatment, and the progress in treatment."
There are many specific considerations related to the dispensing of methadone, and pharmacists - particularly community-based pharmacists - are playing an increasingly important role as members of program teams providing methadone maintenance treatment.Footnote 30
Ongoing monitoring of methadone dosage is an important aspect of treatment, in the initial stages of treatment as well as over time to ensure adequate dosage and minimize the risks.
Individuals who are receiving methadone maintenance treatment may also need -and should receive - appropriate treatment for chronic or acute pain. This includes standard pharmaceutical or non-pharmaceutical treatments for mild to moderate pain. In addition, for more severe pain, opioid analgesics may also be needed, and should be provided in the usual dosage for the level of pain being experienced. Given that clients/patients may have developed tolerance to the analgesic effects of opioids, frequent reassessment is advised to ensure adequate dosage of analgesics for effective pain management (Brands and Janecek, 2000, 28).Footnote 31
Directly observed vs. take-home doses
Flexibility in take-home doses has been associated with increased retention in treatment (Ball and Ross, as cited in Lowinson, et al., 1997, 412). Nonetheless, the way in which the actual dose of methadone is administered to clients/patients is a subject of much discussion and debate. For many clients/patients, daily attendance to receive a supervised dose of methadone is, among other things, inconvenient and disruptive. Compulsory supervised dosing can interfere with holding a job, attending school, caring for children, and travelling. It also implies a lack of trust, given that one of the main reason for supervising dosages is to ensure that clients/patients actually take their methadone.
At the same time, there may be a therapeutic benefit to either daily attendance or providing take-home doses (or "carries"). Daily attendance, particularly in the early stages of treatment, may be beneficial in increasing contact between clients/ patients and the program team, and may be helpful in building a daily routine that is less stressful or chaotic than previous drug-seeking behaviours. Early in treatment, frequent, observed dosing can be an aid to establishing a properly adjusted dose, resulting in a stable opioid effect over time. Since this effect is the principal advantage of methadone, compared to other opioids, it can be undermined by clients/patients consuming their medication at irregular intervals.
Increasing frequency of take-home doses may be an effective incentive for reducing the use of other substances. Programs should balance the advantages of ensuring compliance and having regular contact with clients/patients with the need for flexible, client/patient-centred treatment that takes into account the realities of clients'/patients' lives.
The extent to which diversion of methadone actually happens - or represents a significant danger to the community - is an area of ongoing debate. The Institute of Medicine's (IOM's) 1995 report (as cited in Joseph, Stancliff and Langrod, 2000, 354) concluded that, while diversion is a concern, it "does not appear to be serious enough to take precedence over accessibility to treatment for untreated addicts." The IOM report (as cited in Joseph et al., 2000, 360) also concludes that the level of regulation of methadone (which is linked in part to concerns about diversion): "...puts too much emphasis on protecting society from methadone, and not enough on protecting society from the epidemics of addiction, violence, and infectious diseases that methadone can help reduce." Programs should balance measures to prevent potential diversion with the need to provide effective treatment.
Properly prescribed and dispensed, methadone maintenance treatment is considered a medically safe treatment for pregnant women who are dependent on opioids.
For women who become pregnant while receiving methadone maintenance treatment, tapering from methadone is not recommended, as it can rarely be achieved without relapse or obstetrical complications. Pregnant women who wish to withdraw from methadone should be given as much information and counselling as possible so they can make an informed choice about tapering.
The pharmacokinetics of methadone are altered throughout pregnancy, especially in the third trimester (Jarvis, Wu-Pong, Kniseley and Schnoll, 1999). Methadone dosage should be carefully monitored and adjusted throughout pregnancy.
Dosage levels should be determined by the individual woman's need. There is no compelling evidence to reduce a woman's methadone dose to avoid neonatal abstinence syndrome (Kaltenbach, Berghella and Finnegan, 1998, 147-148). (See also Section 7.4: Methadone and Pregnant Women.)
Other treatment considerations for pregnant women receiving methadone maintenance are discussed in Section 7.4: MMT and Pregnant Women.
Increased length of time in treatment is associated with improved treatment outcomes including reduced use of other opioids and reduced criminal activity. Short-term methadone maintenance treatment is associated with poorer outcomes (Ward et al., 1998b,330-331).
The duration of methadone maintenance treatment should be based on individual need rather than pre-determined time limits. It is not possible to determine an optimal duration of treatment for all individuals. The optimum duration is for each individual to continue receiving treatment for as long as they continue to benefit from it. Indefinite or lifetime maintenance on methadone is an option for some clients/patients.
Studies have shown that the vast majority of people who are dependent on opioids will relapse to other opioid use once discharged from methadone maintenance treatment (Ward et al., as cited in Ward, Mattick and Hall, 1998c,337). As well, they may experience other serious harm, and even fatal, consequences. A study by Dole and Joseph (as cited in Lowinson, et al., 1997, 411) found that, among people discharged from methadone maintenance treatment, the rate of opioid-related deaths was twice as high compared to those retained in treatment. The major difference in the cause of deaths was the increase in drug-related deaths after discharge. Since that study was conducted, the epidemics of infection with HIV, HCV and other blood-borne pathogens among injection drug users has added to the risk for those who are discharged from treatment.
Involuntary discharge from treatment should be approached with caution and avoided, if at all possible. Programs should adopt a problem-solving rather than a punitive approach when considering involuntary discharge of a client/patient. Ideally, tapering from methadone should be a mutual decision between a client/patient and his or her prescribing physician and other members of the program team. (See also Section 5.8: Client/Patient-Centred Management of Tapering.)
Although there will be an element of discretion in any decision to discharge a client/patient, programs should establish clear and reasonable criteria for considering discharge. These criteria should be clearly communicated to clients/patients at the outset of treatment. Where possible, there should be appropriate follow up of people who are discharged, and mechanisms for recourse.
Ideally, clients/patients should be retained in treatment for as long as they are benefiting from treatment.
Federal and provincial guidelines include requirements for treatment programs to conduct urine toxicology screening. Monitoring of clients/patients use of other drugs during treatment is done by methadone maintenance treatment programs to determine:
Programs should keep in mind, however, that reducing other drug use is not the primary goal of - but rather only one possible outcome of - methadone maintenance treatment.
Urine toxicology screening
Urine toxicology screening is widely used to monitor clients/patients' use of drugsFootnote 32. However, programs should clarify the purpose of, their approach to, and their use of the urine toxicology screening results.
There have been many suggested benefits of urine toxicology screening, including:
At the same time, however, there are disadvantages. Despite its widespread use in the field, critics add that urine toxicology screening is expensive, may be relatively inaccurate as an indicator of drug use, and can have a negative effect on clients/patients.Footnote 33 Furthermore, it has not been shown to be an effective means of deterring drug use.Footnote 34 Providing urine samples, particularly directly observed urine samples, can be humiliating for clients/patients - which may discourage them from staying in treatment - and it implies that clients/patients cannot be trusted to tell the truth about their drug use, which is not likely to contribute to positive relationships with team members.
Without condoning other drug use, programs should adopt a non-punitive and therapeutic, rather than a punitive, approach to other drug use during treatment. For example, a therapeutic approach includes using urine toxicology screening results as the basis for discussing treatment progress - and as an opportunity to problem-solve with clients/patients and provide information to clients/patients -rather than a means of "policing" clients/patients drug use or "catching" non-compliant clients/patients may also be useful.
Other suggestions related to the use of urine toxicology screening include:
Research has shown that self report reveals as much information about drug use as urinalysis does (Magura et al., as cited in Ward et al., 1998i, 255), and the use of self report may foster better relationships with clients/patients.
New technology, such as hair analysis, may be considered in the future as it becomes more accessible, accurate and affordable.
Information about the treatment of multiple substance use is provided in Section 7.1: MMT and People with Multiple Substance Use Behaviours.
Tapering from methadone should be a mutual decision that involves the client/patient and his or her prescribing physician and other members of the program team. Ideally, tapering from methadone should be voluntary -clients/patients and the program team should decide together if and when clients/patients will taper.
For many clients/patients, tapering from methadone can be a frightening prospect, and a difficult process. Clients/patients may be fearful and apprehensive about this decision.
Clients/patients may consider leaving treatment for a variety of reasons including:
Regardless of their reason for attempting tapering, the client's/patient's decision should be respected, and the appropriate supports should be provided (see Tapering Management below). There should also, however, be a flexible approach to tapering, e.g. clients/patients should be assured re-entry into the program.
Clients/patients who decide to reduce their dose, or stop taking methadone altogether, should receive support and assistance to cope with withdrawal symptoms and other consequences of their decision.
A managed approach to tapering from methadone involves a stepwise approach, and it should include:
In this document, the program "team" is defined very broadly to include all those who may be involved in integrated comprehensive program delivery (see Section 4.6: Integrated Comprehensive Services). Depending on the program and setting (see Section 2.9: What is the Status Quo - How is Methadone Maintenance Treatment Delivered in Canada?), the program team may include - in addition to the prescribing physician - a large, multidisciplinary network of people who work in different capacities and locations. All of these individuals could have contact with clients/patients which may, in turn, have significant impact on treatment outcomes. A program, therefore, could include some or all of the following:
Linkages with other community-based supports including:
Outreach and Advocacy
To deliver treatment effectively - and to maximize an interdisciplinary approach -methadone maintenance treatment programs need adequate human resources and low staff turnover (Kreek; Centre for Substance Abuse Treatment, as cited in NIDA, 1995, 1-43). There should be sufficient numbers of qualified and trained team members (either on-site or linked through strong systems of referral) to deliver the program. The roles and responsibilities of various team members should be clearly articulated, and these descriptions should be a tool for building cohesion and fostering respect and recognition for the contributions of all team members.
Research indicates that a commitment to abstinence-oriented treatment among program team members is associated with being an obstacle to providing effective treatment (Bell et al., as cited in Bell, 1998a, 170). This suggests that team members' attitudes to methadone maintenance treatment - and to the people receiving it - are likely to be an important factor in program effectiveness. Consequently, it is important that team members be open to a variety of different treatment approaches (see Section 4.3: A Maintenance Orientation). In addition, team members need to have respect for clients'/patients' diversity of experiences and goals; a motivational style of interaction; and sensitivity to issues related to gender, culture, age, and other factors.
Team members also need to possess a particular knowledge, experience, ability and personal suitability to deliver methadone maintenance treatment effectively and with integrity. (See also Section 6.5: Adequate Ongoing Training)
Higher levels of trust and confidence between team members and clients/patients is associated with longer retention in treatment (Ball and Ross, as cited in Lowinson et al., 1997, 412). This suggests that the quality of the relationships between team members and clients/patients may have a significant influence on a variety of potential treatment outcomes. Both clients/patients and team members alike are likely to benefit from having healthy interpersonal relationships and a supportive atmosphere within the program. (See also Section 4.7: Client/Patient Involvement)
Given that the attitudes of the program team, and the quality of their relationships with clients/patients, will influence treatment outcome, providing adequate and appropriate training for all team members is key to improving treatment outcomes. Well-trained staff are an influential factor in client/patient retention (Ball and Ross, as cited in Lowinson et al., 1997, 412).
Some of the critical areas that should be addressed include:
Although the link between program environment and program effectiveness has not been extensively researched, the evidence suggests that an environment that supports trusting and confidential relationships between team members and clients/patients - and a program environment that is characterized by high team morale and low team turnover - can have a positive influence on client/patient retention (Ball and Ross, as cited in Lowinson et al., 1997, 412).
A well-organized, structured program should be based on:
Programs need to take appropriate steps to ensure that clients/patients and all team members are protected from harassment, victimization and stigmatization. The program rules and expectations about behaviour need to be clear. The enforcement of the rules should be fair and consistent to establish safe limits within which the program can operate.
Team members should be appropriately trained to handle anger and conflict.
Attention should also be paid to the safety of the location of the program, and to issues of personal security within and in the vicinity of the program.
Daily attendance for methadone dosing at a clinic or community-based pharmacy may offer some advantages, usually in the early part of treatment. For example, daily attendance may offer a structured daily routine that is an alternative to drug-seeking activities. Daily contact with team members can help establish a positive ongoing therapeutic relationship. A structured routine may make treatment safer by minimizing the risk of diversion, and ensuring a stable amount of methadone is taken on a regular schedule.
Routines, however, should be flexible. Prolonged periods of daily attendance may not be appropriate for all clients/patients. Over time, clients/patients may benefit from other approaches including flexibility concerning take-home doses.Footnote 38 Once the dose requirements are established and the dose is stabilized, daily attendance should not be a rigid requirement that interferes with other positive outcomes of treatment including employment, education, and other types of positive social involvement.
Programs should have an organized approach to record keeping that emphasizes the value of program data for treatment, research, evaluation and administration purposes.
The information collection and record keeping process should be based on appropriate protocols, which clarify the information items to be collected. There should be ethical guidelines in place to ensure confidentiality is protected.
Clients/patients should have access to information about the program from the outset. Other relevant information should also be shared with clients/patients at appropriate points throughout treatment.
Contrary to stereotyped images of "drug addicts," people who are dependent on opioids are a highly diverse group of men and women, in different age groups, with varying socioeconomic circumstances, involved in different types of relationships and family situations, from diverse cultural backgrounds, and with unique life circumstances. Clients/patients may live in urban, rural or remote areas of the country, and they may have other physical or mental health problems in addition to dependence on opioids. Clients'/patients' specific needs will depend on these and other factors. Some the groups of client/patients that may experience specific barriers and have unique needs include:
Information about the needs of some of these groups is more readily available than it is for others. The following sections highlight some of the key considerations for each group, where information is available.
Multiple substance use is very common among people who are dependent on opioids - practitioners delivering methadone maintenance treatment will almost certainly deal with this issue. Cocaine and crack use is very common, and clients/patients may use as many as four or five psychoactive substances including cocaine, crack, benzodiazepines, marijuana, alcohol, tobacco or other substances (Brooner et al.; Nirenberg et al., as cited in Stitzer and Chutuape, 1999, 87). There is evidence that opioid use (but also the use of cocaine, marijuana and alcohol) decreases during methadone maintenance treatment (National Consensus Panel on Effective Medical Treatment of Opiate Addiction, 1998, 1939; NIDA, 1995, 4-15).
Retention in treatment - including, for example, retaining clients/patients who use cocaine while receiving methadone maintenance treatment - can help to reduce the harm associated with continued drug use. Although MMT is used to treat opioid dependence specifically, if clients/patients take advantage of the services provided by the program they may be more likely to change their lifestyle, avoid drug-using friends and, consequently, also decrease or stop other drug use.
Where clients/patients have substance use problems, in addition to opioid dependence, a range of clinical responses can be used in combination with methadone maintenance treatment. For more information on effective substance use treatment approaches, readers are also encouraged to consult Health Canada's report on best practices in substance abuse treatment and rehabilitation (Health Canada, 1999a), as well as other forthcoming publications from Health Canada on specific areas of substance abuse treatment and rehabilitation.
Focus on reducing rather than eliminating other substance use:
Although stereotypes of drug users suggest that all people who are dependent on opioids are injection drug users, this is not the case - many people are dependent on opioids which are taken orally rather than injected, while others may snort or smoke opioids such as heroin. Methadone maintenance treatment is considered an appropriate treatment option for all people who meet the DSM-IV criteria for dependence on opioids regardless of the route of administration.
Education and awareness:
Barriers that may limit women's access to treatment include, among others:
As a result of the barriers they face in accessing treatment, when they do actually enter treatment, women who are dependent on opioids tend to have poorer overall functioning and more medical, psychological, social, family, legal and economic problems than men.
Comprehensive services for women should address gender-related concerns in many different areas including:
Medical care and women who are dependent on opioids
While all individuals entering treatment should be screened for medical needs, female clients/patients tend to have more severe medical problems than their male counterparts. In addition to the injection-drug use related medical problems noted in Section 4.6.1 above, they are at increased risk of reproductive problems, gynecological conditions and STDs. Compared to men who use drugs, women who use drugs have a higher risk of infection with HIV. For example, there is a higher risk of HIV infection because the virus is more easily transmitted from men to women during sexual intercourse, women are more likely to finance their drug use by having unprotected sex with men, and women more often have sexual partners who engage in high risk behaviours (McCaul and Svikis, as cited in Jones, Velex, McCaul and Svikis, 1999, 254). Women are also at high risk for exposure to HCV and other blood-borne pathogens (Health Canada, 2000a, 18). This means, women receiving methadone maintenance treatment may need medical care that includes:
Psychological, social and relationship issues
According to the literature reviewed by Jones et al, (1999, 253-254), compared to women who do not use substances, women who use substances are more likely to have a family history of alcohol or drug dependence, tend to have higher rates of childhood sexual abuse and are more likely to have relationships with men who have substance use problems and to experience violence at the hands of their partners. They are at increased risk for affective disorders, attempted suicide, low self-esteem, anxiety and depression. They may have high psychological distress, unresolved sexual issues and difficulties in relationships and social functioning. They may have experienced social isolation and loneliness, have difficulties socializing, and have smaller support networks and fewer friends or romantic relationships. They are more likely to be separated or divorced, to be passive in their relationships, and to lack confidence in their communication skills.
Treatment for women should include women-only groups to address issues of depression and anxiety, physical, sexual and psychological abuse, sexuality, loss, and to enhance self-efficacy.
Women may also need access to other substance use treatment, parenting skills, communication skills, conflict resolution, and help in developing a support network.
Economic and legal needs
Treatment should take into account the vulnerable economic and legal status of women who are dependent on opioids. According to the literature reviewed by Jones et al. (1999, 254-255), they may have poorer occupational functioning; they may be economically dependent on men; they may be involved in prostitution or exchanging sex for drugs, food, shelter. They may have low job skills and little vocational training. They may have a history of involvement with the criminal justice system.
Some of the strategies to help women improve their economic and legal situation may include, for example, establishing effective linkages with programs that can provide:
Given the many barriers to treatment that women face, there are many forms of support that could facilitate their access to and retention in treatment. Some of the areas that should be addressed include, among others:
To improve treatment for women clients/patients, programs should provide:
Pregnant women who are dependent on opioids experience inadequate nutrition and rest, poor access to obstetrical care, and exposure to fluctuating blood levels of opioids and other drugs, as well as contaminants and infections related to injection drug use. They are at high risk for a range of obstetrical problems (Jones et al., 1999, 260).
Methadone maintenance treatment is considered the standard of care for women who are pregnant and dependent on opioids. The potential benefits include:
Methadone maintenance treatment during pregnancy is an opportunity to provide medical and:
Methadone and Neonates
As mentioned in Section 5.3: Adequate Individualized Dosage, dosage levels during pregnancy should be determined by the individual woman's need. There is no compelling evidence that reducing a woman's methadone dose helps to reduce the severity or likelihood of neonatal abstinence syndrome (Kaltenbach et al., 1998, 147-148).
After the baby is born, appropriate care of the infant includes:
Given that research reviewed by several national organizations has shown that youth, particularly street-involved youth, are at high risk of contracting HIV, HCV or other blood-borne pathogens as a result of injection drug use and needle sharing (Canadian Centre on Substance Abuse and Centre for Addictions and Mental Health, 1999, 175-176; Health Canada, 2000a, 1,6; Canadian HIV/AIDS Legal Network, 1999,11), there is a need for much more information and research on MMT and youth, particularly street-involved youthFootnote 42. According to a leading practitioner in this area, methadone is not indicated as a first line therapy for adolescents with opioid dependence, as there are currently no evidence-based guidelines for use with this population. There may, however, be individual adolescents for whom methadone may be a reasonable optionFootnote 43. Recommendations for the management of adolescents (under the age of 18) who are dependent on opioids include:
More information and research on MMT and the needs of homeless people is needed.
In rural or remote communities, people who are dependent on opioids may have either no or limited access to methadone maintenance treatment. Potential obstacles include a lack of local physicians authorized to prescribe methadone; a lack of community pharmacists to dispense methadone; a lack of substance use treatment services; a lack of anonymity in local service settings; and difficulties obtaining or covering the cost of transportation to services located elsewhere.
Providing adequate services in rural and remote areas is a challenge for all of health care, and for substance use treatment in general. In the case of methadone, however, there can be some specific complications, including, among other issues, how to adequately initiate treatment with appropriate levels of assessment and monitoring; how to dispense methadone; and how to monitor the use of other drugs during treatment.
Depending on the resources available in the community, it may be difficult to provide a comprehensive approach to treatment, with linkages to the full range of services and supports that clients/patients may need. Practitioners may also lack access to information and supports.
Increasing access to methadone maintenance treatment in rural or remote communities is an important issue - there is anecdotal evidence that some clients/patients are not being started on methadone if they intend to return to a community where they will not be able to access treatment services.
While there is little or no literature available on MMT and First Nations and Inuit clients/patients, there has been a great deal of research on the issue of access to appropriate health care services for First Nations and Inuit communities. Injection drug use and high risks of infection with HIV, HCV and other blood-borne pathogens is an issue of growing concern (Canadian HIV/AIDS Legal Network, 1999, 1; Health Canada, 2000a, 1). Aboriginal people are over-represented among the population of people who use injection drugs in inner cities and among the clientele of needle exchange programs and counselling/referral sites (Health Canada, 1999b, 3). A growing proportion of AIDS cases among Aboriginal people are the result of injection drug use - injection drug use is the primary risk factor for Aboriginal women (Health Canada, 1999d, 2). Although some preliminary issues related to methadone maintenance treatment have been identified (below), there is a need for ongoing consultation with First Nations (on and off-reserve) and Inuit communities about the need for and approaches to methadone maintenance treatment.
Given the high prevalence of the hepatitis C virus (HCV) among injection drug users in CanadaFootnote 46 - and the extreme infectiousness of HCVFootnote 47 - many individuals who present for methadone maintenance treatment will either be HCV-positive when they enter treatment, or will become HCV-positive while in treatment. MMT programs should be prepared to identify evaluate, monitor, support and consider available treatment options for these individuals. For example, vaccination against hepatitis A may help prevent HCV-positive clients/patients acquiring an additional infection that could increase the risk of hepatic failure and death (Vento et al., as cited in Novick, 2000, 443).
Individuals with stable chronic liver disease can safely continue to receive methadone maintenance treatment for many years (Novick, 2000, 439), although caution must be exercised in some specific circumstances. In some cases, treatment for HCV infection can be provided in tandem with methadone dosing. Linkages with specialized clinicians in the community may also be required.
Treatment for HCV infection is an evolving area, and providers should become familiar with a number of pertinent issues, such as treatment effectiveness, side effects, eligibility constraints, contraindications, and variations in the availability of health coverage for treatment. Providers should also be aware that promising new treatments are expected to be available in the near future.Footnote 48
Given the prevalence of HIV infection among injection drug users, people who enter methadone maintenance treatment may either be HIV-positive on entry into treatment, or they may acquire HIV during the course of treatment if they continue to engage in high-risk behaviours. In particular, women who are dependent on drugs are at greater risk of acquiring HIV infection than their male counterparts (McCaul and Svikis, as cited in Jones et al., 1999, 252-253).
An important aspect of providing medical care to clients/patients in methadone treatment programs will include providing the necessary care and support for people who are living with HIV/AIDS. Among other potential benefits of MMT, stabilization on methadone may make it easier for people who are dependent on opioids and HIV-positive to comply with HIV treatment regimens.
Providers need to be knowledgeable about treatment for clients/patients who are HIV-positive. For example, practitioners providing methadone maintenance treatment should be aware of specific risks for people who are living with HIV/AIDS, such as:
Access to MMT treatment for people living with, or at risk of acquiring, HIV:
The prevalence of mental health disorders is very high among people who are dependent on opioids. Common conditions include major depression, dysthymic disorder, anti-social personality disorder and other personality disorders, anxiety disorder, attention-deficit-hyperactivity disorder. The following table provides information from an extensive review of the literature by King and Brooner (1999).
Differences between men and women with respect to prevalence of mental health disorders are the same as for those in the general population. In addition, women who are dependent on opioids experience more anxiety disorders and depressive disorders than men who are dependent on opioids. For example, men are more likely to be diagnosed with problems such as antisocial personality disorder, while women appear to have much higher levels of psychopathology, based on global measures (Ward, Mattick and Hall, 1998f, 432).
Clients/patients with mental health disorders are at increased risk for other substance use during and after treatment, and for risk behaviours, such as needle sharing (King and Brooner, 1999, 162; Brooner et al.; Brooner et al.; Gillet et al., as cited in Abbott, Moore, Weller and Delaney, 1998, 35). Identifying and providing treatment for mental health disorders can help improve methadone maintenance treatment outcomes, including retention (King and Brooner, 1999, 152).
Methadone maintenance programs are a key opportunity to identify and provide treatment for mental health disorders among clients/patients. Programs may be able to provide:
Table 1: Prevalence of co-morbid mental health disorders (based on King and Brooner, 1999, 144-146)
Prevalence of Mood Disorders
Prevalence of Anxiety Disorders
Prevalence of Personality Disorders
Prevalence of Other Mental Health Disorders
Assessment of mental health disorders should be based on standardized tools. Clinical evaluation should be based on the standard diagnostic criteria contained in the DSM-IV.
In order to diagnose and treat independent mental health disorders, the presence of symptoms that stem from other medical conditions or from the use of other substances should be ruled out. For example, use of some substances - including methadone, marijuana, caffeine, nicotine, alcohol, cocaine, benzodiazepines, and other sedatives/hypnotics - may either cause symptoms which present as depression, or else interfere with the management of a mood disorder. To rule out substance-induced disorders, there is a need for skilled assessment that should take into account how symptoms respond to increases or decreases in drug use, or periods of abstinence (King and Brooner, 1999, 154).
Given the high numbers of clients/patients who experience mental health disorders, programs should be prepared to deal with the problems - for clients/patients and for team members - that can be associated with these disorders including:
Access to treatment:
In recent years, several national level reports have focussed attention on the issue of drug use in correctional facilities in Canada - including the over-representation of injection drug users among offender populations; the prevalence of drug injecting and needle sharing during incarceration; and risks of transmission of HIV, HCV and other blood-borne pathogens (Canadian HIV/AIDS Legal Network and Canadian AIDS Society, 1996; Canadian Centre on Substance Abuse and Canadian Public Health Association, 1997; Canadian HIV/AIDS Legal Network, 1999).Footnote 50
Internationally, and in Canada, access to methadone maintenance treatment for offenders who are dependent on opioids has been identified as a key harm reduction strategy, and many methadone-related recommendations have been made to reduce the harm related to drug use in correctional facilities.
Experts suggest that there are a number of different points at which methadone maintenance treatment should be provided to offenders including:
It is important that corrections-based methadone maintenance treatment programs are responsive to the needs of both men and women offenders, are combined with psycho-social interventions that target criminogenic needs, conform to evidenced-based principles of effective correctional treatment, and draw on the standards of methadone maintenance treatment in community-based programs. Rigorous evaluations of corrections-based MMT programs are also needed (Dolan et al., 1998, 386).
Increase access to MMT within correctional systems:
Continuity of care:
Research and evaluation of methadone maintenance treatment - and particularly research and evaluation in the Canadian context - is essential to:
More research on methadone maintenance treatment is needed in many different areas. For example, some treatment goals have not received as much research attention as others including the role of MMT in the:
There is also a need for more research on the cost-benefits and cost-effectiveness of methadone maintenance treatment.
Evaluation of MMT programs is an extremely important tool for determining the extent to which programs meet their objectives and the needs of clients/patients; improving program delivery; and comparing the effectiveness of different types of treatment delivery models.
Client/patient involvement, through the use of inclusive, participatory research techniques should be considered.
A systematic approach to evaluation - and to ensuring that results are published and disseminated - requires the commitment of those delivering treatment, the involvement of clients/patients, and the support of policy makers.
For purposes of this document, a methadone maintenance treatment "program" encompasses the full continuum of treatment delivery modes and communities - from physicians in private practice who prescribe methadone to patients, to multi-service centres that provide a range of services and supports including methadone maintenance treatment, other substance use treatment and rehabilitation services, mental health services, and medical services.
Several provinces have created, or are in the process of creating, their own guidelines. In these jurisdictions, the provincial guidelines are intended to replace the national guidelines.
Due to the wide range of practitioners and sectors involved in delivering MMT in Canada, this document uses the term "client/patient" rather than either "client" or "patient".
In addition to the original literature search for the period 1995-1999, a selection of key 2000 publications were reviewed. The evidence from the published literature is summarized in the literature review report (see Health Canada, 2002a). References to the evidence presented in the literature are also included throughout this document. There is now almost forty years of accumulated research knowledge and treatment literature concerning MMT. This report relies, in large part, on reviews of the evidence provided in comprehensive, state-of the-art texts edited by others, particularly Ward, Mattick and Hall (1998e), Strain and Stitzer (1999), and Lowinson, Payte, Salsitz, Joseph, Marion and Dole (1997). Although not all of the primary sources cited in these and other texts are mentioned in this document, readers are encouraged to consult these materials.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.
The documents reviewed for this report primarily focussed on injection of opioids - primarily heroin injecting. Some clients/patients who receive methadone maintenance treatment are dependent on opioids that are taken in other forms, e.g. opioids such as morphine or hydromorphone which are taken orally. Others may smoke or snort heroin. Although no estimate of the number of people who are dependent on opioids administered through non-injection routes was identified for this review, there is some information available regarding prescription opioid use: the 1996-97 National Population Health Survey found that 4.7% of Canadians aged 15 years or older reported using an opioid analgesic (codeine, Demerol ®or morphine) in the month preceeding the survey (Canadian Centre on Substance Abuse and Centre for Addiction and Mental Health, 1999, 117).
Injection drug users are at risk, regardless of the substance being injected. These figures include people who inject opioids and/or other drugs such as cocaine. According to research by Poulin et al. (as cited in Canadian HIV/AIDS Legal Network, 1999, 10), there are very high rates of injectable cocaine use in Vancouver, Toronto and Montreal.
According to research reviewed by Fischer and Rehm (1997, 368), Canada has a rate of 111 methadone treatment spots per million people, a rate which is lower than Australia (1,020), Switzerland (2,000), Belgium (1,000), Germany(247) and the US (442). In mid-1996, there were about 3,250 people receiving methadone treatment in Canada.
There is no single definition of what the term "harm reduction" means. This document relies on the following description: "Harm reduction strategies seek to reduce the likelihood that drug users will contract or spread HIV infection, hepatitis C, and other infections, overdose on drugs of unknown potency or purity, or otherwise harm themselves or other members of the public. Such an approach attempts to reduce the specific harms associated with drug use without requiring abstinence from all drug use. Harm reduction strategies are based on a hierarchy of goals, and stress short-term, achievable, pragmatic objectives rather than long-term idealistic goals" (Nadelmann; Des Jarlais et al., Canadian Centre on Substance Abuse; Des Jarlais and Friedman, as cited in Canadian HIV/AIDS Legal Network, 1999, 43). Harm reduction is also described as a public health philosophy that "recognizes that a pragmatic, non-judgmental approach, especially in dealing with addictions, is a more effective way to minimize the harm done by drug use than a model that insists on abstinence as a prior condition of treatment." (de Burger,as cited in Canadian HIV/AIDS Legal Network, 1999, 44).
The survey results indicate that methadone maintenance treatment is particularly prevalent in British Columbia. In addition, respondents from Newfoundland, PEI, and New Brunswick indicated a limited need for treatment for opioid dependence. Respondents from NWT and Yukon reported increases in opioid dependence and a need for new programs (Health Canada, 1999c, 20). Ontario and several other provinces are working to expand methadone maintenance treatment services and license and train physicians to provide treatment for people who have been stabilized on methadone (Brands et al., 2000).
The search of the Canadian Centre on Substance Abuse Treatment Database identified a range of methadone programs.
Including "low threshold" programs which have limited entry criteria.
The effectiveness of MMT as a primary prevention strategy for preventing the transmission of HCV and other blood-borne pathogens requires further research. The National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction (1998, 1940) found that MMT reduces the transmission of "many infections, including HIV and hepatitis B and C." While acknowledging the potential for MMT to play a role in reducing transmission of the hepatitis C virus (HCV), Ward, Mattick and Hall (1998g, 68-69) argue that most people who present for MMT will have already been exposed to HCV, which reduces the likelihood that MMT can be an effective means of primary prevention for those individuals. The results of the consultation process for this project suggest that there may be differences in urban and rural settings. Individuals in rural areas may present for treatment before they have contracted HCV, a situation that may relate to either lower prevalence in those communities, or to higher use of oral opioids. In circumstances where individuals who present for treatment have not been exposed to HCV, and become abstinent from all substance use during treatment, MMT may be a key strategy for prevention (Novick, 2000, 440). As discussed later in this document, people who present for MMT should be evaluated for HCV infection, and should receive appropriate care, monitoring and support. Available treatment options should be considered as part of a comprehensive approach.
In the U.S., treatment fees have been found to have an adverse effect on retention (Maddux et al., as cited in NIDA, 1995, I-39).
According to research reviewed by NIDA (1995, 4-29) two of the program characteristics associated with treatment success are: "providing comprehensive services" and "integrating medical, counseling and administrative services."
This does not mean that limited service programs are ineffective.
According to NIDA (1995, 1-43, citing McLellan et al.): "At 24 weeks, methadone alone resulted in minimal improvements; methadone plus counselling resulted in significant improvements over methadone alone; and enhanced methadone services, including a broad range of psychosocial services plus methadone, had the best outcomes of all."
For more information about comorbid medical conditions, please see Fingerhood (1999).
Readers are encouraged to consult Brands and Janecek (2000) for a detailed chapter on drug interactions. They (Brands and Janecek, 2000, 99) note that: "The risk of interactions need not preclude the use of any medications that can interact with methadone, except those that are contraindicated. However, patients must be monitored more closely and doses may have to be adjusted as appropriate." See also Gourevitch and Friedland (2000) for a detailed article on interactions between methadone and medications used to treat HIV infections.
For comprehensive information about effective substance use treatment approaches, see Health Canada (1999a).
According to a study by McLellan et al. (as described in NIDA, 1995, 4-30), patients were assigned to three types treatment programs: methadone with no counselling; methadone plus counselling; and methadone plus counselling and other psychosocial treatment. The patients receiving the most comprehensive services had the highest rate of negative urine toxicology screens for opioids after 24 weeks.
For a discussion of counselling, please see Mattick, Ward and Hall (1998).
Definitions of ancillary services vary depending on the research study, but Ward et al. (1998b, 324) use the term to refer to "services provided by methadone maintenance programs other than the dispensing of methadone," such as medical treatment, counselling and job training. In this document, medical services and counselling are discussed separately.
According to a study by Bell et al. (as cited in Ward, Mattick and Hall al., 1998a, 193) , the main consequences for individuals not admitted to treatment were a delay of 16 months in their entry into treatment, and their exposure in the interim to the risk of imprisonment and death.
In some programs, liver function tests are also done monthly for all those who test positive for hepatitis C so that referrals to a specialist can be made quickly if there is a problem.
Please note: Practitioners who wish to prescribe methadone will require more detailed information than is provided in this section, e.g. information on topics such as initial starting dosage, methadone half-life, time to peak plasma level, dosage increase in first week, dosage range, lethal dosage, dosage increases over time, monitoring dosage level, overdoses, side effects, drug interactions and other safety issues. This information can be obtained by consulting existing federal guidelines (Health and Welfare Canada, 1992), or provincial guidelines where these exist. Additional resources include Brands and Brands (1998), Brands and Janecek (2000), and Brands, Kahan, Selby and Wilson (2000).
According to Hartel; Hartel; and Kreek (as cited in NIDA, 1995, I-36) high doses of methadone prescribed over long periods of time did not have a toxic effect, and resulted in only minimal side effects among adults who were maintained in treatment for up to 14 years, and for adolescents treated for up to 5 years.
Adequate dose is an influential factor in client/patient retention, according to research by Ball and Ross (as cited in Lowinson et al., 1997, 412).
For a detailed overview and exploration of these issues, readers are encouraged to consult Brands and Janecek (2000).
See also Brands et al. (2000, 244-245) for more information on pain management in individuals receiving methadone maintenance treatment.
Current federal guidelines (Health and Welfare Canada, 1992) and existing provincial guidelines include specific requirements for urine toxicology screening.
See Ward, Mattick and Hall (1998i) for an extensive discussion of this literature on the advantages and disadvantages of the use of urinalysis.
Ward et al. (1998i) (citing Grevert and Weinberg; Goldstein and Judson; Havassy and Hall, 1998, 251) conclude that "there is little to be gained by using urinalysis to monitor drug use, if the main purpose of the procedure is to deter patients from using illicit drugs...on the basis of the available evidence, it has to be concluded that there is no compelling evidence that the absence of urinalysis leads to an increase in illicit drug use."
In reviews conducted by Stitzer et al. (as cited in Ward et al., 1998i, 253) the use of take-home methadone as a reward has been extensively evaluated and demonstrated as effective in reducing illicit drug use.
See Ward et al.(1998c) for a more detailed discussion of their suggestions concerning this transition.
See also Bell (1998b) for a detailed discussion of staff training in methadone maintenance treatment programs.
Flexible take-home doses are an influential factor in client/patient retention according to research by Ball and Ross, (as cited in Lowinson et al., 1997, 412).
For more information on effective approaches to providing treatment for women with substance use problems, please see Health Canada (2001a).
According to the National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction (1998, 1939), women who are HIV-positive and are receiving MMT are more likely to be treated with the help of medication in order to reduce the rate of transmission of HIV infection to their infants.
For more information on methadone maintenance treatment and neonates, please see Brands et al. (2000, 239-240).
Readers are encouraged to consult Health Canada's publication on youth and substance abuse (Health Canada, 2001b)
This document is not intended to provide readers with sufficient information to prescribe or dispense methadone to patients under the age of 18. Readers must consult their respective regulatory body as well as the federal guidelines (Health and Welfare Canada, 1992) and existing provincial guidelines for further information on prescribing methadone to this population.
Adolescent women may have hypotension which would require close monitoring of symptomatic hypotension, particularly orthostatic hypotension.
Dr. Karen Leslie, Staff Paediatrician, Division of Adolescent Medicine, Hospital for Sick Children. Assistant Professor in Paediatrics, The University of Toronto, personal communication, March 2001.
Among individuals who inject drugs, the rate of infection with the hepatitis C virus is very high. International estimates range from 50% to 100% (Finch, as cited in Health Canada, 2000a, 1). In Canada, 70% of all prevalent HCV infections are related to injection drug use (LCDC, as cited in Health Canada, 2000a, 6).
HCV is 10 to 15 times more infectious through blood contact than HIV (Heintges and Wands, as cited in Health Canada, 2000a, 1).
Examples of two recent articles in this area include Hagan and Des Jarlais, 2000 and Novick, 2000.
For more information about potential interactions between methadone and drugs used to treat HIV/AIDS, readers are encouraged to consult, Brands and Janecek (2000), and Gourevitch and Friedland (2000).
In a Quebec correctional facility, for example, 38% of women offenders reported injecting drugs before being incarcerated, and half of those had shared needles. Of those who had injected previously, 11% reported injecting drugs during incarceration, with 92% of those sharing needles. Among the men offenders in the study, 26% reported injecting drugs before incarceration, and half of those had shared needles. Of those who had injected previously, 2% reported injecting drugs while incarcerated, with most of those (92%) having shared needles (Dufour et al., as cited in Health Canada, 2000c,2).