Ontario study raises red flags over methadone distribution

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More than half of the methadone distributed in Ontario is prescribed by just 57 doctors, most of whom work in high-volume clinics that provide assembly-line medical care to the burgeoning number of patients struggling with opioid addictions, a new study says.

The authors of a report published on Wednesday in the journal Drug and Alcohol Dependence say their findings are proof of an open secret in addictions medicine: that past financial incentives from the Ontario government helped to concentrate treatment in chains of clinics where opioid-dependent patients can access methadone, but little else in the way of counselling or physician support.

"These are not simple patients. The idea that methadone alone is going to treat them is preposterous," said Meldon Kahan, medical director of the substance use service at Women's College Hospital in Toronto and one of the authors of the new paper. "Most of them have underlying issues like anxiety, depression, post-traumatic stress disorder and social difficulties. They need a lot of support."

The way methadone is doled out in Ontario and across Canada has come under increasing scrutiny as demand for addiction treatment has skyrocketed alongside an opioid-abuse epidemic rooted in the over-prescribing of powerful painkillers such as oxycodone, hydromorphone and fentanyl.

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By analyzing de-identified physicians' billing information, researchers at the Institute for Clinical Evaluative Sciences in Toronto discovered that the top 10 per cent of methadone prescribers billed for an average of nearly $650,000 in services related to methadone in 2014, 45 per cent of which was for reading urine screening tests.

That is nearly twice the average gross annual billings for Ontario physicians. (Billings do not equal take-home pay for doctors, who often draw on that money to pay rent, staff salaries and other expenses.)

The 57 highest-volume methadone prescribers billed for an average of 97 unique patients per working day, although about half of those billings were for interpreting the results of urine tests, which do not require a face-to-face visit with a doctor.

The authors expressed concern that this volume of work leaves the doctors little time to do any kind of counselling.

The high-volume methadone doctors – who skewed much older than the average physician and tended to work in urban areas – prescribed approximately 56 per cent of all the methadone provided to patients who qualify for the Ontario Drug Benefit program, meaning many patients could be left in the lurch if a single doctor retires or quits the methadone business, said Tara Gomes, a scientist at the Li Ka Shing Knowledge Institute at Toronto's St. Michael's Hospital and the senior author of the paper.

"As the province tries to ramp up addiction treatment, we need to think about how we can make [methadone treatment] more evenly distributed among a larger number of prescribers in the province," she said.

Methadone is an opioid that people who are already addicted to prescription opioids or heroin take daily to manage their withdrawal symptoms and cravings without getting high or risking an overdose. A white powder usually dissolved in a fruit-flavoured drink, methadone has to be ingested in front of a pharmacist until a doctor deems the patient stable enough to take a few doses home.

In 2011, the province put in place financial incentives to persuade more doctors to prescribe methadone, one of which was a fee for reading urine drug tests. The tests help doctors determine whether their patients are taking other opioids that, combined with methadone, could lead to an overdose.

The frequency of the screening is another concern raised in the new study, which found that the high-volume prescribers were conducting an office visit and a urine test with methadone patients, on average, every four or five days. "How can you look after a family or work or go to school if you're spending twice a week waiting at the clinic?" Dr. Kahan said.

But David Marsh, medical director of the Ontario Addiction Treatment Centres (OATC,) one of the largest chains of methadone clinics in the province, said the authors of the study are overlooking the fact that – at his clinics, at least – clean weekly drug tests go hand-in-hand with approval for take-home doses of methadone.

"Coming once a week for a urine test, a dose and then carrying the other six doses home is much less disruptive than having to go [to the clinic] every day for observed dosing," Dr. Marsh said.

Dr. Marsh, who is also a dean at the Northern Ontario School of Medicine, said OATC employs 40 doctors across its 70 clinics; all but 10 work at the clinics part-time and practise other kinds of medicine. The study does not identify any of the high-volume prescribers by name or say where they work.

"We expect [our] physicians to offer the best quality of care possible within the funding that's available in the province," he said. "Each individual patient visit varies in length of time, depending on what your patient needs."

Last year, the Ontario government accepted the findings of a special advisory committee on methadone, co-chaired by Dr. Kahan.

The government has already adopted some of the committee's ideas, including making a safer alternative called buprenorphine/naloxone, or Suboxone, more easily available. (The study also examined Suboxone prescribing data from 2014, when the treatment was limited mainly to patients who failed methadone or could not access it.)

The province also halved the fee it pays for the urine tests in 2015 as part of wider cuts to doctors' fees. At the time, a physician who operated a chain of clinics said the cuts forced him to shut down two smaller clinics in Toronto because they were no longer financially viable.

The new study is based on data from 2014, before the cuts took effect.