Provision of methadone treatment in primary care medical practices: review of the Scottish experience and implications for US policy (see comments)

摘要

CONTEXT: Under new proposed regulations, US physicians outside of traditional methadone clinics could prescribe methadone to patients with opioid dependence. No large-scale evaluations of US programs in which methadone maintenance is provided by primary care physicians are available, but primary care physicians in Scotland have participated in such programs on a large scale. OBJECTIVE: To review the history, operation, and outcome data on the efficacy and safety of 2 Scottish primary care-based opioid agonist treatment programs to derive lessons for the US context. DESIGN AND SETTING: Naturalistic study of programs in Edinburgh and Glasgow, Scotland, with data obtained through site visits and interviews conducted in 1996 and 1998, as well as from published reports and retrospective analysis of electronic databases. MAIN OUTCOME MEASURES: Proportions of injection drug users who were enrolled in the methadone maintenance programs, average methadone doses in the programs, and methadone-related deaths. RESULTS: A total of 60% to 80% of injection drug users in Edinburgh and 41% to 73% of those in Glasgow were enrolled in methadone maintenance in 1998-1999. Dose levels are consistent with US recommendations (for Edinburgh in 1998, 61 mg; for Glasgow in 1994-1996, 54 mg). The Glasgow program required supervised consumption of methadone in community pharmacies for the first year and experienced significantly fewer methadone-related deaths than Edinburgh in 1997 (17 vs 30 deaths; P<.0001). Programs in both Edinburgh and Glasgow provided support to primary care physicians and achieved levels of general practitioner participation of 59% (1998) and 30% (1999), respectively. CONCLUSIONS: The Scottish experience indicates that prescription of methadone in office-based settings can expand access to an important treatment modality. Primary care physicians safely prescribed methadone for maintenance treatment when provided with adequate support. Diversion of methadone was minimized by requiring supervised consumption in community pharmacies.