Transcript presentation - Canadian Public Health Association

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