Victorian survey of methadone patients - not all good.

Ezard N, Lintzeris N, Odgers P, Koutroulis G, Muhleisen P, Stowe A, Lanagan A. An evaluation of community methadone services in Victoria, Australia: results of a client survey. Drug and Alcohol Review (1999) 18:417-423


Dear Colleagues,

This study reveals some interesting and important findings regarding the treatment of heroin dependency patients in Victoria, Australia where most patients attend pharmacies for their dosing with licensed GPs prescribing. It is a credit to the authorities that there has been such an expansion of treatment services to meet the increasing numbers of dependent citizens. It is especially important to document the functioning of methadone dispensing in community pharmacies since this is where most of the expansion of such treatment is occurring around the globe.

However, while changes will have occurred since 1995/6, the authors' positive conclusions still need to be tempered with some reservations about the limitations of current treatment delivery.

As in other states, there is a perception by Victorian dependency patients that pharmacy dosing sometimes lacks confidentiality (46% said it was 'too public') and that there is some discrimination in others being served first (42%). Dosing hours and location (only 66% satisfied) were also problems, especially when looking for work (53% said it 'interfered').

The authors state: "Results of the study were generally encouraging. The majority of clients surveyed stated they were satisfied with their relationship with their prescriber and their pharmacist, and with the methadone programme overall. Overall, our survey indicates that the Victorian community-based methadone service is in general an acceptable model of methadone service delivery for clients in the metropolitan area."

The survey of 195 patients would seem to indicate otherwise, revealing worrying deficiencies with treatment delivery as well as responses to that treatment. Only 72% were satisfied with their treatment and over a third stated that they would not have commenced treatment if they had know more about it, quoting 'hassles' amongst other problems.

Although the average duration of treatment was over 2 years, 40% of patients had received no take-away or dispensed doses at the time of the interview. Only 10% received 2 such doses weekly, and they were more likely to be female. The reason for this uniquely rigid regimen is not given.

The mean dose was 41mg (mode 30mg) with only 15% receiving 60mg or more. Almost half of the patients (44%) were still using heroin regularly by self-report.

These outcomes are consistent with the literature which yields a consensus that doses of methadone should normally be in the range 60mg to 120mg daily with only a small proportion of cases needing less or more than these levels. Hence up to 85% of Victorian patients may have been receiving inadequate doses in 1995/6.

Dr Vincent P. Dole wrote "With adequate dosage of methadone, taken daily, heroin use should be completely eliminated in 95% of all patients." He also recommended a minimum blood methadone level of 0.2mg/l to prevent cravings in such patients.

The lack of dispensed doses in this study is unparalleled in the world to my knowledge and is not based on sound scientific grounds. Like inadequate dosing, it is known to be associated with a significantly lower retention rates (Rhoades 1998). Dispensed doses for the Sabbath are given in many areas and reports have shown no differences from strict 7-day pick-ups (Gelkopf 1999).

comments by Andrew Byrne ..

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Dr Andrew Byrne,

General Practitioner, Drug and Alcohol,

75 Redfern Street,

Redfern,

New South Wales, 2016,

Australia

Tel (61 - 2) 9319 5524 Fax 9318 0631

Email ajbyrne@ozemail.com.au

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author of: "Methadone in the Treatment of

Narcotic Addiction" and "Addict in the Family"