Methadone clinics face new scrutiny
Scores of Ontario doctors are billing the province hundreds of thousands of dollars each to treat people addicted to opioids, according to a new study into what one critic calls the province’s burgeoning network of “McMethadone” clinics.
The top 10 per cent of methadone prescribers — 57 doctors — billed an average of $648,352 each in 2014, researchers found. Together they were looking after half the methadone population.
Each had, on average, 435 methadone patients with public drug coverage. Each billed for an average of 97 patients daily (71 of them on methadone) and each had patients return every four or five days, on average, to provide a urine sample.
According to the authors, there’s no evidence that, after the first few weeks or months of treatment, “routine, ongoing weekly office visits and urine drug screens are associated with reduced substance use.”
If anything, the opposite may be true, they said.
“Ontario’s treatment retention rate is low — 50 per cent. That means that after one year, 50 per cent of the patients drop out of methadone treatment,” said Dr. Meldon Kahan, medical director of the Substance Use Service at Women’s College Hospital in Toronto, and a co-author of the new study.
Kahan said the clinics are meeting a need — “I will say that, on a whole, it’s better that they’re there than having nothing there” — but he said more primary-care doctors and nurse practitioners in the community should offer opioid treatment as part of their practices.
In Ontario, the number of people on methadone has skyrocketed, from 3,000 in 1996 to more than 40,000 in 2016. Dozens of private, forprofit clinics have sprung up since the province introduced financial incentives several years ago to improve access to treatment.
“While these clinics have helped thousands of people who use opioids,” Kahan and his co-authors write in the journal, Drug & Alcohol Dependency, “they have also generated controversy regarding their high patient volumes and frequent (urine drug screening) billings.”
“I refer to it as the McMethadone model,” said Benedikt Fischer, a scientist at Ontario’s Centre for Addiction and Mental Health who wasn’t involved in the study.
“A lot of the principles are the same, which is basically mass volume-oriented methadone provision,” he said. “These clinics are set up as business enterprises.”
Ontario has the highest rate of prescription opioid use in the country. About one in every 170 deaths is
ON A WHOLE, IT’S BETTER THAT THEY’RE THERE THAN HAVING NOTHING THERE.
now related to opioids.
The province recently cut in half the fee paid to doctors for urine drug tests, from $29 to $15. Whether that will make a difference in the fees billed to the province isn’t clear, said the study’s senior author, Tara Gomes, a scientist at St. Michael’s Hospital and the Institute of Clinical Evaluative Sciences.
Dr. David Marsh is chief medical director of Canadian Addiction Treatment Centres, which runs 70 methadone clinics across Ontario. He said 10 per cent of the 40 doctors who work with the chain “would fit the criteria” for a high-volume methadone prescriber, adding a small number of doctors carry a heavy number of patients.
However, Marsh said that typically half of what’s billed goes to overhead. Clinics have to remain open 365 days a year, he added.
Marsh said urine tests are usually required twice a week in the first several months of treatment, then once a week thereafter, and that testing is driven “by clinical best practice.”
He said his clinics are trying to partner with agencies that provide primary care, mental-health care and addiction counselling.
“I think the entire system has room for improvement,” he said. “But I believe that the organization I work with is focused on delivering the best quality care possible.”