Expanding MMT in Ontario: The Rise and Fall of Primary Care OBOT

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Expanding MMT in Ontario The Rise and Fall(?)
of Primary Care OBOT

• Douglas Gourlay, MD, FRCPC, FASAM
• Centre for Addiction and Mental Health
• Toronto, Ontario Canada

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Oh, Canada!

• Population roughly 1/10 that of USA
• 32,207,113 (2003)
• 10 provinces (1 territory)
• Ontario
• Canadas largest and most populated province
• 12,536,031 (2001)
• Toronto
• 2,482,000 / 5,600,000 GTA

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Methadone in Canada

• Methadone is a prohibited substance in Canada
• Exemptions are granted for
• Pain Management
• Summary application to Office of Controlled
  Substances
• Treatment of Opioid Addiction
• Through highly structured, well defined system
• 8 hours formal added training with guidelines
• 2 full days of approved preceptorship
• Provincial quality assurance oversight

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History of MMT in Ontario

• In 1996, Addiction Research Foundation (now CAMH)
  was only MMT program in Ontario
• 300 clients 200 wait list
• Fast track entry via pregnancy or HIV ve status
• Clients dying on the wait list
• Expansion of services limited to Urban setting
• Rural delivery did not occur

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Office-Based Agonist Treatment

• Premise
• MMT could be safely delivered by primary care
  MDs with limited added training
• Only more complex cases needed the resources of
  tertiary comprehensive programs
• Initial set of guidelines released to allow
  community-based MDs to offer MMT to a small
  number of patients (lt30 patients)
• College of Physicians and Surgeons Ontario (CPSO)
  plan for quality assurance audits to ensure
  guideline compliance

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OBOT 1996

• Relatively small number of practitioners took up
  the challenge
• Most treated a few of their own patients
• A few became full-time methadone doctors
• Pockets of practices gt100 patients
• Larger practices tended to do poorly in QA audits
• Initial regulatory audits were not popular

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Audit Results 1998

• 121 audits conducted first year
• Vast majority of practices were found to be
  adequate or better
• Some self-directed CME recommended
• 5 were found to have severe deficiencies which
  led to legal challenges to CPSO decision to
  revoke exemptions
• This effectively drove marginal doctors further
  from the control of the CPSO
• Coroners Office became aware of increased adverse
  events associated with MMT (over 1997 to mid 1998)

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Methadone Assessments
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CPSO Initiatives

• Guideline revisions
• Reframing Audit Process to Peer Assessment
  Model
• Stimulated chart recall approach
• Transparent assessment tool was introduced
• Most practitioners saw this as primarily CME not
  oversight not adversarial
• Coroner noted fall in Methadone-related deaths

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Why drop in death rate?

• When ever any treatment increases in
  availability, there is a transient increase in
  adverse events (AE) associated with that
  treatment until 3 groups gain experience
• Prescribers
• Patients
• Public

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Methadone in Ontarioas of October 28, 2004
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The Commercial Group Practice

• 2 groups began to establish clinics in various
  cities around Ontario
• Clearly for-profit
• Excessive Urine Drug Testing (fee-driven)
• Clinic competition became overt, even hostile
• Liberal take-home doses
• Numbers of patients increased dramatically
• Adverse events increased
• College became aware that current guidelines did
  not fit the commercial practice setting

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When the system goes wrong

• One commercial group became identified as a
  problem practice
• Located in several cities
• Reputation for liberal take-home doses
• Coroner alerted CPSO to marked increase in
  Methadone overdose deaths from this area
• In one community, 19 deaths in 2 years
• CPSO took rare step to suspend 11 practitioners
  pending further investigation

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The Coroners Inquest

• In Ontario, the coroner must
• Determine manner and cause of death AND
• Where possible, make recommendations how to avoid
  such deaths in the future
• Enable interested parties to seek standing before
  the court during an inquest
• Next week, we begin an Inquest looking into 4
  representative cases
• Likely most serious threat to OBOT MMT in Ontario
  to date

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Coroner's Inquest

• Four cases
• Accidental death in opioid naïve person
• Trafficked Methadone
• Induction death
• Too rapid dose escalation
• Induction death
• Excessive take-home doses given early
• Late program death
• Drug-drug interaction

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Questions

• What problems can occur when commercial
  enterprises expand methadone services in a given
  area
• What type of oversight needs to be put in place
  to reduce risk associated with this type of
  expansion
• How can a primary care OBOT program coexist with
  commercial expansion of MMT?