Physician questions "outrageous" care provided by private methadone clinics in a context of opioid crisis

While a city in Northern Ontario fights an opioid overdose mortality rate twice as high as the provincial average, doctors are sounding the alarm about private methadone clinics who, they say, are making huge profits on the backs of addicted patients.

In Thunder Bay, Ontario, hundreds, if not thousands, of patients visit high-volume drug treatment centers for regular doses of methadone or suboxone. Both are medications for what is called opioid replacement therapy, used to suppress cravings and the horrific symptoms of withdrawal from other opioids such as fentanyl, oxycodone or alcohol. 39; heroin.

There was more than 8,000 apparent deaths due to an opioid overdose in Canada since 2016 – and even though all of Ontario has not been hit as hard as BC. In Alberta, Thunder Bay had a death rate twice as high (18 per 100,000) as the provincial average (8.9 per 100,000) in 2017.

But it is also a city where many people seek help through methadone or suboxone treatment, creating an environment conducive to private clinics. According to a report released by the Thunder Bay District Health Unit and Thunder Bay's Addiction Strategy, "one in 50 … has been prescribed an opioid to treat a condition related to the use of substances in 2016 ".

Many experts agree that suboxone and methadone play a vital role in the treatment of opioid addiction – but claim that a therapeutic relationship with a trusted health care provider, which is going to beyond the simple dispensing of drugs, is important.

The board & # 39; must arrive & # 39;

Dr. Corinna Chung, Thunder Bay family physician specializing in addiction treatment, said methadone and suboxone were a starting point for giving users "respite" so they could then attack. to the problems that led to addiction. place, free of debilitating cravings.

"Usually, once they take a stable dose of methadone [or] suboxon, they can continue to counsel, return to school, or re-establish relationships that have often been damaged by opioid use. "

But most patients who attend high-volume methadone and suboxone treatment clinics do not receive this level of care, said Dr. Meldon Kahan, medical director of the addiction department at Women's College Hospital. from Toronto and former co-chair of a methadone treatment. Advisory Panel for the Government of Ontario.

"We know that these patients, most of them, actually have significant concomitant mental disorders, such as anxiety, post-traumatic stress disorder, mood disorders" Kahan said. "They often have other disorders related to the use of substances such as cocaine and alcohol, and they have needs in primary care, they do not meet any of these needs." [in many high-volume clinics]. "

The business of addiction

One company, the Substance Abuse Treatment Centers in Canada (formerly known as Substance Abuse Treatment Centers in Ontario), has more than 70 clinics across the province, hosting a total of approximately 15,000 patients a year. Four of them are located in Thunder Bay.

Patients sometimes consult a doctor in person in these clinics, but appointments are often made on television screens with a person who may be hundreds of miles away. Doctors monitor doses of methadone or suboxone administered to their patients, tell them about their progress and issue prescriptions. Patients also submit urine samples to determine whether or not they are taking another medication.

The appointments and urine tests of these doctors are billed to OHIP (the provincial government's insurance provider). Many clinics also earn money through partnerships with pharmacies, which charge for preparation fees for methadone and suboxone.

All this is a lot of money, said Kahan.

He estimates that each patient in a high-volume methadone clinic pays an average of a few thousand dollars a year. The fact that a US company, Baymark Health Services, based in Texas, bought CATC earlier this year shows how profitable they are, he said.

"It's really just a shameful system," said Kahan, pointing out that these clinics have a patient retention rate of 50% or less – a rate that he considers unacceptable.

This is dangerous, he said, because when patients stop taking methadone or suboxone, they are more likely to illegally reuse opioids, putting them at high risk of overdose.

According to Kahan, many high-volume clinics charge high overhead costs to physicians, which may encourage them to see more patients in order to generate more revenue.

Although Kahan stated that some doctors working in clinics "do a great job" and spend enough time with their patients to meet their needs, this is not the case most of the time.

"It's not so terrible for doctors to make money, but it's quite deplorable to have a model of care that does not serve patients or the public." in general."

For-profit clinics are poorly understood, according to society

But Dr. David Marsh, Chief Medical Director of the Addiction Treatment Centers of Canada (CATC) and Professor of Addictions at the Northern Ontario School of Medicine, said that his company's focus is profit does not compromise the care provided to patients.

"Our goal is to provide the best quality of care possible – it is not a matter of profit-seeking – it is simply a matter of making sure to charge enough to cover the costs." Clinic management costs, "said Marsh at CBC News.

Clinic doctors charge their time to OHIP, like any other medical specialty in the province, and it's up to them to determine how many patients to see each day and how long each person takes, he said.

"There are misunderstandings, I think, people think that because we are funded by the payment at the act, we are under pressure to see as many patients as possible in order to make money. I can assure you that this is not the case at CATC., "He said.

Many doctors, including Chung and Kahan, argue that the best way to help patients with opioid addiction is to integrate treatment with primary care. For example, family physicians and nurse practitioners would prescribe methadone or suboxone to their patients as part of their overall health care. not just treat their addictions.

"This [methadone or suboxone] is part of the treatment of the person. The person has other parts of his body that must also be treated, "Chung said.

"I think here we are trying to be a little more holistic in our care of these patients – taking care of that person as a whole, not just taking care of their methadone or their suboxone. " [needs], "said Dr. Laurie Kibiuk, Chung's medical practice partner.

"Many of these people have been trying for years to go to a family doctor and they often fail, so we often end up practicing family medicine because no one else does it."

"Suboptimal care"

The very fact that many people do not have access to primary care means that high-volume clinics respond to a significant need, said Marsh.

"I think we need options for patients.At the present time, in case of epidemic of opioid overdoses, we need to expand access to treatment of every possible way, "he said.

"I would be very happy if many family physicians in the province started prescribing methadone and suboxone and we have different treatment settings for patients, depending on their needs."

Kahan, however, said that even when patients find it difficult to find a family doctor, fast-access drug treatment clinics – two of which were recently opened in Thunder Bay – would receive much better care than "suboptimal care". "delivered in high volume clinics.

Rapid access clinics allow patients to come without an appointment. They can not only get prescriptions for methadone or suboxone but also benefit from advice and help finding other services.

The Ontario Ministry of Health has funded fast-access drug treatment clinics in several communities across the province in response to the opioid crisis.