Community Development Troubleshooting Guide

Methadone Maintenance Treatment: A Community Planning Guide

This section deals with issues that may arise in your community along with some potential solutions to these problems.

Issues on this page:

1. Professionals and the public have concerns about bringing methadone maintenance treatment into the community.
2. There has been some difficulty obtaining information on opiate use and the potential demand for methadone treatment.
3. Recruiting physicians to become exempted has been very difficult.
4. Recruiting service providers to become involved in MMT has not been successful.
5. The local correctional facility does not allow incarcerated clients to continue with their treatment.
6. How can a group develop a methadone clinic or program with no new funding?
7. Our community is divided on the issue of "abstinence" versus "harm reduction" models of treatment.
8. Is the community able to meet the needs of all methadone patients including those who are unable to access MMT due to a lack of service providers? How are trends monitored and plans developed for future need?
9. The community has had a program for some time, but there are still a number of people who are critical of the model.
10. How are sensational incidents handled along with the negative media coverage that may follow?

1. Professionals and the public have concerns about bringing methadone maintenance treatment into the community.

One of the best and most effective ways to deal with this issue is through education. There are many people both professionals and members of the public who may not have a great deal of knowledge about the subject area. Some of these people may also possess inaccurate information. The community needs to understand that methadone is a research proven treatment option which has helped many people with opiate dependence problems. Some people may have deep rooted philosophical issues especially if their background focuses around abstinence-based models of treatment because in their opinion, methadone is a "drug". These individuals fail to recognize that methadone is a prescription medication. The goal with this group is get them to understand that individuals have a right to choose this option and MMT should be made accessible to potential clients.

People should be informed of the many benefits of methadone treatment not only for the individual, but the community. An excellent way to do this is through a cost-benefit analysis. It needs to be explained that untreated opiate users may be involved with a number of systems such as legal, court, corrections, and social assistance which can cost taxpayers enormous amounts of money. Some estimates put the cost on average at $49,000 per year per untreated user. On the other hand, it costs approximately $6,000 a year to maintain an individual on methadone maintenance treatment. Many of these people as a result of receiving methadone treatment are staying out of jail, going back to school or getting a job, supporting family members and developing positive relationships. The question that needs to be asked to the taxpayer is would you rather have someone using illegal substances, stealing to continue their habit, involved with the police and the courts, possibly ending up in the corrections system, social assistance programs providing income support to their dependents, and the spreading of HIV in the community versus being involved in a recognized treatment which helps the individual contribute in a positive way to society? As with any other issue, people need to be informed of the facts before making any judgements.

If the group decides to have information sessions to inform professionals and the public, there are speakers from such organizations as CAMH or the CPSO who can provide assistance. It is ideal to use people who have had experience in dealing with community groups since they have usually responded to the same types of issues and concerns in the past. The use of the media is recommended to assist in informing the public since it is not costly and has the potential to reach a large number of residents in the community.

2. There has been some difficulty obtaining information on opiate use and the potential demand for methadone treatment.

This can be a very difficult exercise because in all likelihood there is no piece of information from your community that states the number of opiate users and/or the number of potential methadone clients. There are several other angles that can be looked at in reference to a starting point. Firstly, if there is a needle exchange program in the area, this can be a good source of information. They will be able to provide statistics on the number of needles exchanged and the outreach workers may be able to provide some anecdotal evidence on the number of opiate users along with the number of potential methadone clients. Depending upon the extent of their outreach work, they may be getting requests from clients on the availability of methadone treatment. Some of the workers may be in contact with clients who are receiving methadone through a physician in another community. Other sources who could be called upon to provide this type of information include addiction treatment providers and the police. Another source of information is the College of Physicians and Surgeons of Ontario. Through their database, they can provide information on the number of patients from a particular city who are receiving MMT. This information itself can assist in showing that there is a definite need for this treatment in the community.

Another potential method is to estimate the number of methadone users based upon information from other countries. Research from countries such as Australia, Netherlands, Belgium and Switzerland suggest a range of 100-200 methadone patients per 100,000 population (8). There may be variance due to the availability of opiates in addition to the types of methadone treatment that are offered. This figure can provide the community with a base and can be adjusted in conjunction with local factors.

3. Recruiting physicians to become exempted has been very difficult.

Recruiting physicians is probably the most difficult aspect of the development of methadone treatment services. Since there are a number of areas of the province which are currently under serviced in terms of the number of family physicians, this presents even more challenges. Methadone patients may present with many more needs as compared to family practice clients and physicians who are already quite busy may not have the time to devote to this client group. It should also be stated that it would be ideal to have at least two physicians exempted in each community since they could spell each other off in instances off vacation time or illness.

Several techniques to explore include a physician's information night on methadone treatment, a presentation at a local physician's meeting or a hospital staff meeting and writing an article in the local medical society newsletter about the treatment model and the need for physicians. Another potential tactic is to contact physicians who have an interest in addictions or HIV issues since they are usually well aware of the needs of methadone clients. Working group members may want to explore the possibility with their own physician or ones they know of on a personal level. Consultation with the College of Physicians and Surgeons may also provide insight and possible names of physicians from the area who may be interested. Contact with the local CPSO physician representative should also be explored. A supportive working group comprised of agencies and professionals willing to provide an array of services for methadone clients may also encourage physicians to become involved in MMT.

A potential model which may assist in recruiting more physicians who are not interested in taking on unstablized patients due to time constraints is that of the tiered care approach. Some physicians may not have the time to work with patients when they first enter treatment, but may be interested in taking on stabilized ones. This model would free up more MMT slots for new patients as stabilized patients are transferred from a clinic to community-based family physicians.

As stated above, this can be a monumental task because of the intangibles, therefore the working group will have to be creative in the recruitment process. This is an important step because if recruitment is unsuccessful, there will be no service delivery or expansion in that community.

4. Recruiting service providers to become involved in MMT has not been successful.

As in the case of Issue #1, education about MMT and the needs of the community can be key elements in recruiting service providers. Some providers may not be aware of the need or may not have a clear picture as to how MMT services are delivered. All providers should be educated during the recruitment phase because far too often their decision to become involved is not based on factual information. With providers, it needs to be clearly identified what they are able to contribute to the model since the working group will want to ensure that the needs of the clients will be met. For example in the case of a pharmacy, it is important to have seven day service since all patients who start with the treatment will have to go there everyday to ingest their methadone. From a counselling perspective, some agencies may have policies that do not allow clients using methadone to participate in treatment. These policies may have been developed years ago and did not take into consideration a research-based treatment such as methadone maintenance.

Should there be difficulties in recruiting service providers, provincial bodies such as the Ontario College of Pharmacists (pharmacies), the Ontario Substance Abuse Bureau (addiction treatment agencies) and the College of Physicians and Surgeons of Ontario (physicians) should be consulted for advice and possible names of local providers who may be interested in becoming part of MMT service delivery.

5. The local correctional facility does not allow incarcerated clients to continue with their treatment.

A copy of the relevant guidelines (federal or provincial) for the institution should be reviewed to determine the actual policy and procedures for methadone maintenance treatment. This may be somewhat of a controversial issue since in some instances if there is a policy, it may not be followed at that facility for various reasons. In cases where the policy clearly allows for the continuation of methadone treatment for incarcerated clients, it may be beneficial for a member of the working group to contact the local facility to determine why the institution is not following through on its mandate. Should there be difficulties obtaining an answer or if there is a clear violation of the policy and the rights of the client, the group may want to contact a senior official within that particular department. This person may be unaware that the policy is not being carried out.

This type of issue should be handled in a very delicate manner because it can be one of a very political nature. The goal here is to get the facility on board and hopefully it can be achieved with as little difficulty as possible. In some cases, clients may want to take it to the next level and inform the media as to what is taking place. In most situations, this should be seen as a last resort should all other means fail to produce the desired result.

6. How can a group develop a methadone clinic or program with no new funding?

Unfortunately, in this current fiscal era, there is not a great deal of money for new programs. Therefore, communities have to be very creative and collaborative to make a new program work with very little or no funding. Some communities have pooled their resources to develop methadone programs. For example, agencies which have space can provide the location for a clinic type model. Professionals such as physicians, addiction counsellors, lab personnel, pharmacy staff and other support services can provide services for specified periods of time during clinic hours. In a number of situations, physicians may give a portion of their OHIP billing to the clinic to help provide funds for various administrative functions. One-time start-up money may be required to make renovations and various government bodies should be contacted since they may be able to provide assistance. Several communities including Kingston, London and Windsor have been successful in getting a program off the ground without any type of annual funding. It can be a difficult and arduous process, but by no means an impossible one.

7. Our community is divided on the issue of "abstinence" versus "harm reduction" models of treatment.

This is an issue which can tear the group apart if it is not handled in an effective way. Many professionals in the field of methadone treatment would argue that the two terms are very simplistic and help to create some of the dissension that exists. However, since many individuals do not possess an in-depth knowledge base on methadone treatment, they tend to focus on these two terms when describing models of treatment. One of the goals is to help move people to look beyond this dichotomy to a more encompassing description of the treatment.

Education can play a key role in getting people to understand that both aspects of methadone treatment are options that patients should have the ability to choose. In a perfect world, a community would be able to offer both types of treatment. The part that presents a problem is that some individuals in the community believe that methadone patients should not be using any substances while they are on methadone. Most would agree with this, but they fail to recognize that it is very difficult for people to stop using substances immediately and it may take some time before change occurs as a result of stabilization issues for the client. In addition, from a harm reduction perspective, it is seen that as long as a person is getting benefits from the treatment, they should be kept involved considering the potential negative factors associated with terminating the person from a program (e.g. return to opioid use, criminal activity, risk of HIV etc.). People need to understand that harm reduction does not condone substance use, but it tries to meet clients where they are at and work with them in helping to attain a healthy lifestyle. Overall, abstinence and harm reduction models have similar goals (e.g. improving the health of the client), but use different methods to achieve them. An important aspect to understand is no matter what side of the fence one is on, in the end, it should be the client's choice since they are the ones that are most affected by the treatment. A question that should be posed to people who do not agree with the harm reduction approach is " What is the best way to help clients who are having difficulty achieving complete abstinence"?

8. Is the community able to meet the needs of all methadone patients including those who are unable to access MMT due to a lack of service providers? How are trends monitored and plans developed for future need?

One way to monitor trends is to contact physicians to see if they have waiting lists. The CPSO should also be contacted since some patients may be travelling out-of-town for treatment. One has to be careful when analysing some of this information since some people prefer to travel outside their district since they have developed a rapport with a physician and do not want to make a change.

The working group should keep in close contact with methadone service providers to assist in identifying any service gaps in the model. A working group that meets on a consistent basis is a good way to prepare and plan for any trends that may occur in the future. Possible ways to reach out to opiate users who are potential methadone clients should be reviewed and discussed. It is important for the group to maintain a proactive rather than a reactive mode.

9. The community has had a program for some time, but there are still a number of people who are critical of the model.

Probably the best way to deal with the critics is to point out the benefits of the program. Evaluation information either from a statistical or anecdotal perspective can help in promoting the model and at least getting these people to acknowledge the benefits and its place in the local treatment continuum. Unfortunately, some people may never agree with MMT no matter what type of information is presented. However, it will be impossible for them to challenge the positive changes that clients have made as a result of methadone. The group may want to use the media to assist in informing the community about the results of an evaluation or at least profile the story of an individual (anonymously to ensure confidentiality) who has been able to make positive changes in their life as a result of methadone maintenance treatment.

10. How are sensational incidents handled along with the negative media coverage that may follow?

No matter how many precautions are taken, a group has very little control over incidents that may take place involving clients who are involved in methadone maintenance treatment. The group needs to be prepared to show the community that there are many positives involved and that an individual incident is not indicative of the entire population involved in the treatment model. As a result of any negative publicity, the working group may have to take a very defensive position because the average citizen may be highly critical especially if the media puts a negative spin on the situation. As can be imagined, it is not an easy situation and the working group should be encouraged to examine the problem together and come up with some potential solutions to address the concerns which may come out as a result of an incident.

Next>> Appendix - Methadone Fact Sheet

Methadone Maintenance Treatment: A Community Planning Guide

1. Preface
2. Introduction - How to Use the Guide
3. Methadone Maintenance Treatment - Rationale and Benefits
4. Methadone Maintenance Treatment - Service Components and Delivery Models
5. Critical Stages in the Development of Methadone Maintenance Treatment Services
   1. Identification and Verification of Need
   2. Establishment of a Community Working Group
   3. Methadone Maintenance Treatment Model Development
   4. Implementation
   5. Evaluation
6. Continuity of Care for Methadone Patients
7. Special Treatment Issues
8. Community Development Troubleshooting Guide
9. Appendix - Methadone Fact Sheet
10. References
11. Recommended Resources

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