title: What is low threshold methadone maintenance treatment?
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario M5T 3M7, Canada. Electronic address: carol.strike@utoronto.ca.
authors.forename: Carol
authors.initials: C
authors.lastname: Strike
authors.affiliation: Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario M5T 3M7, Canada.
authors.forename: Margaret
authors.initials: M
authors.lastname: Millson
authors.affiliation: The Works, Toronto Public Health, 277 Victoria Street, Toronto, Ontario M5B 1W2, Canada.
authors.forename: Shaun
authors.initials: S
authors.lastname: Hopkins
authors.affiliation: School of Humanities and Social Sciences, Faculty of Arts and Education, Deakin University, 221 Burwood Highway, Burwood, Victoria 3125, Australia.
authors.forename: Christopher
authors.initials: C
authors.lastname: Smith
mesh_terms: D000701:Analgesics, Opioid / Q000008:administration & dosage*; D001291:Attitude of Health Personnel; D016739:Behavior, Addictive; D002170:Canada; D055030:Drug Users / Q000523:psychology; D040261:Harm Reduction; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006556:Heroin Dependence / Q000175:diagnosis / Q000188:drug therapy* / Q000523:psychology; D006801:Humans; D007407:Interviews as Topic; D055118:Medication Adherence; D008691:Methadone / Q000008:administration & dosage*; D058850:Opiate Substitution Treatment / Q000379:methods*; D016730:Program Development; D015397:Program Evaluation; D016320:Substance Abuse Treatment Centers; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid; D008691:Methadone
keywords: Canada; Harm reduction; Low threshold; Methadone maintenance; Program policies