Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario M5T 3M7, Canada.
Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario M5T 3M7, Canada.
Int J Drug Policy. 2013 Nov;24(6):e51-6. doi: 10.1016/j.drugpo.2013.05.005. Epub 2013 Jun 3.
Low threshold methadone maintenance (MMT) was developed for clients who do not have abstinence as a treatment goal. We explored how MMT programs in Canada defined low threshold and the challenges they faced.
Using semi-structured interviews, we collected data from clients (n=46), nurses/counsellors (n=15) and physicians (n=9) at three low threshold MMT programs. All participants were asked to define low threshold MMT and describe how it was implemented in practice. Interviews were taped, transcribed, verified and analysed using an iterative thematic coding technique.
Low threshold MMT was defined by an explicit rejection of abstinence from opiates and other drugs as an over-arching treatment goal. In the absence of guidelines defining a set of practices as low threshold, programs implemented practices they believed would reduce barriers to admission and help retention. There was not always agreement between professional groups or across the programs regarding these practices. For physicians, there was a tension between accepting poly-drug use during treatment as a means to improve retention, with an obligation to do more good than harm for their patients. Missed prescribing appointments generated few to severe consequences and revealed differential focus on reducing barriers versus encouraging client 'ownership' of treatment. Differences of opinion regarding appropriate urine drug testing practices revealed power dynamics between medical and non-medical staff.
Our findings show that there are potentially more ways to reduce barriers to MMT than those presented in the current literature. Our findings are important given the growing number of people with opiate dependence across the world and calls to increase access to MMT. To fully develop the low threshold model, it will be important to evaluate what policies and practices can achieve the goals of reducing barriers to admission and improving retention in treatment.
低门槛美沙酮维持治疗（MMT）是为那些不以戒除毒瘾为治疗目标的患者而开发的。我们探讨了加拿大的 MMT 项目如何定义低门槛以及他们面临的挑战。
使用半结构式访谈，我们从三个低门槛 MMT 项目的客户（n=46）、护士/辅导员（n=15）和医生（n=9）收集数据。所有参与者都被要求定义低门槛 MMT，并描述它在实践中是如何实施的。访谈进行了录音、转录、验证和分析，采用迭代主题编码技术。
低门槛 MMT 被明确拒绝将戒除阿片类药物和其他药物作为总体治疗目标。在没有定义一套实践为低门槛的指导方针的情况下，项目实施了他们认为会减少入院障碍并有助于保留的实践。在这些实践方面，专业团体之间或项目之间并不总是达成一致。对于医生来说，在治疗过程中接受多药使用以提高保留率是有压力的，他们有义务为患者做更多的好事而不是坏事。错过处方预约产生的后果很少到很严重，并且显示出对减少障碍与鼓励客户“拥有”治疗之间的不同重点。关于适当尿液药物测试实践的意见分歧揭示了医疗和非医疗人员之间的权力动态。
我们的研究结果表明，与当前文献中提出的方法相比，降低 MMT 障碍的方法可能更多。鉴于全世界阿片类药物依赖者的数量不断增加，以及增加 MMT 机会的呼吁，我们的研究结果很重要。为了充分发展低门槛模式，评估哪些政策和实践可以实现减少入院障碍和提高治疗保留率的目标将非常重要。
