Pubdate: Tue, 01 Feb 2005
Source: Canadian Medical Association Journal (Canada)
Copyright: 2005 Canadian Medical Association
Contact:  http://www.cmaj.ca/
Details: http://www.mapinc.org/media/754
Author: Barbara Sibbald, CMAJ
Bookmark: http://www.mapinc.org/find?136 (Methadone)
Bookmark: http://www.mapinc.org/rehab.htm (Treatment)

TIGHTEN ONTARIO'S METHADONE PROGRAM STATES INQUEST

Ontario's methadone maintenance program needs additional funding and more 
precise treatment guidelines for physicians, a coroner's jury has concluded 
after investigating 4 deaths related to the program.

The Office of the Chief Coroner's month-long November inquest found that 
physicians treating patients in methadone maintenance deviated from current 
guidelines by allowing patients an excessive number of "carries" (take-home 
methadone) and not following guidelines for initiating patients into therapy.

The jury's 46 recommendations also identified systemic problems, including 
stagnant funding despite a growing number of patients and a lack of access 
to information about the number of deaths specifically related to methadone 
maintenance.

Since 1996, when provincial colleges of physicians and surgeons took over 
methadone maintenance from Health Canada, Ontario's program has grown to 11 
147 registered clients and 182 trained physicians (from 474 patients and 40 
physicians). Initially designed for people addicted to heroin, the program 
now serves more people addicted to prescription opiates.

Despite the escalating number of clients, the percentage of 
methadone-related deaths since 2000 has remained about the same: 0.7% (37 
deaths) in 2000 and 0.85% (79 deaths) in 2003. "We'd like to take credit 
for that," said Wade Hillier, who administers the program for the Ontario 
College of Physicians and Surgeons.

Dr. Mark Latowsky, a former member of the College's expert committee on 
methadone maintenance, says "We've done a good job expanding," but 
increasing patient loads have presented problems. "It's left up to the 
practitioner to deal with these complex patients, and most are 
inexperienced," says Latowsky. "There's not a lot of support."

The inquest was called due to concerns about methadone-related deaths in 
some cities between 2000 and 2003. During that time there were 20 such 
deaths in Oshawa, 10 in Windsor and 34 in Hamilton. The coroner selected 4 
methadone maintenance-related deaths representing various aspects of the 
problem, said Dr. William J. Lucas, the regional supervising coroner who 
presided over the inquest.

"We're not critical of the merits of methadone maintenance, but let's 
tighten it up because people should not be dying on the program or in the 
community," said Lucas. Here are the 4 Oshawa-area cases:

Diverted carries: Craig Beers, 17, was not in the program but died July 13, 
2003 of an overdose of methadone that he obtained from a program client. 
Lucas said a "significant source" of methadone in the community comes from 
programs, but how much is diverted is unknown.

Although the coroner's office knows from autopsy reports whether a person 
died of methadone overdose, it doesn't know whether the methadone came from 
the maintenance program, was prescribed for pain or was obtained illegally.

"We need to know which [deaths] are related to MMT," said Dr. Jim Cairns, 
deputy chief coroner of investigations. That information would provide "a 
better statistical analysis leading to program tweaking. We're trying to 
prevent deaths."

Before 2000, the College identified any deceased individuals in treatment 
to the coroner's office, to allow tracking of the number of patients in the 
program who overdosed. Since 2000, that information has been deemed 
private. The jury recommended changes to privacy legislation and that the 
coroner's office pursue a legal challenge to obtain the data.

Excessive carries: Steven Pidgeon, 48, was enrolled in the program for 3 
years but continued to use a variety of other medications. He died on July 
16, 2003. An autopsy revealed "markedly elevated" levels of methadone as 
well as oxycodone and diphenhydramine in his blood. Pidgeon was sometimes 
allowed up to 17 carries due to travel distances to the clinic.

Pidgeon's doctor deviated from program guidelines, which state that only 
clinically stable clients should get carries, and should receive no more 
than 6 at a time. In practice, doctors provide them "much more liberally," 
said Lucas. The jury recommended that no one using opiates, benzodiazepine 
or illicit substances be given carries.

Initiation risks: David Stevenson, 28, had recently returned to the program 
when he died of an overdose on Nov. 12, 2002. The inquest found that due to 
a prescription error, Stevenson received an excessive dose of methadone. 
The jury recommended "more stringent and precise guidelines during the 
initiation phase."

Dr. Graeme Cunningham, the former chair of the College's methadone 
governance committee and director of the Homewood Addiction Centre in 
Guelph, said updated College guidelines (coming Mar. 31) reflect this concern.

Lucas said it is "not uncommon" for doctors to exceed the recommended 
initiation dose. Latowsky finds this unacceptable. "I can't think of any 
circumstances where deviation [from this guideline] would be justified. 
Certain aspects of the guidelines should be more like standards."

The jury also recommended more education for physicians and reassessment 
every 3 years, rather than only at the end of their first year.

Cunningham believes physicians also need broader training in addiction. 
"It's like teaching doctors about diabetes, but only talking about 
insulin," he said. "Doctors are naive and in some cases enabling. It's a 
huge problem."

Lack of integration: Judith Jenkins, 42, had been in treatment for 10 
months when she died Sept. 21, 2003, of "combined drug toxicity." Jenkins 
was also seeing a psychiatrist, who was unaware that she was taking 
methadone and prescribed other drugs, including diazepam.

"The left hand didn't know what the right was doing," says Lucas.

The jury recommended random urine screening throughout treatment.

Many of these recommendations will require increased funding. The budget 
has remained stagnant for 3 years at $225 000 annually, while the number of 
clients has nearly doubled, says Hillier. "Funding has to be addressed."

Practitioners are often left to manage "on their own," says Latowsky. 
"There's no money for case management, rehabilitation, psychiatric care, 
etc. If more services were available, generally these people would do better."

The jury recommended that funding be based on the number of clients.

The College will study all 36 recommendations pertaining to its management 
of the program, but Latowsky is worried that neither the College nor the 
province will act on the recommendations. "As long as there's a perception 
of a safe program and reasonable recommendations, then everyone's happy -- 
though nothing may happen. It's much harder to have recommendations 
followed through with real action."
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MAP posted-by: Terry Liittschwager