Saskatoon's Programme.

1. General Information

Saskatoon is a stable midwestern prairie community, now of 200,000, about 250 miles (400K) north of the US border; and about 150 miles (250K) north of Regina, the Provincial capital city. The Province is mostly agricultural; Saskatoon is a supply town and University centre with a strong agriculture department. The city is slowly growing at the expense of the rural communities as they thin out.

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2. Saskatoon Methadone Clinics.

In the seventies Saskatoon had a single clinic run under the auspices of SADAC and the old 1972 Federal withdrawal protocol, until the programme ran out of patients. In 1995 a psychiatrist started a small programme but fairly abruptly cancelled it after about 12 months. This did not please the patients, some of whom had returned to Saskatoon because a new programme had started, and were now stranded.

The current programme started Feb 1997 after encouragement from the Provincial College of Physicians and Surgeons, Saskatoon City Police, and Addiction Services. Initially this was a pilot programme, to find out whether there was demand for a permanent clinic, and also to study the techniques for running a clinic integrated into general practice, the clinic rapidly grew and is still increasing. About 300 have been screened; some never did start Methadone, others quit early on, others have become stable and then weaned off, and the majority, about 200, continue on maintenance with the initial physician; Two other doctors have joined to do sessional methadone work

These patients are absorbed into a busy general medical and surgical practice run by a solo GP / surgeon with 35 years general experience; at the outset this was thought to be better than a separate "Addiction Clinic" setup. The clinic was started with no prior information available, no Protocol on hand, no guidelines for assessment and management etc; other than our initial physician's experience with Methadone from the old programme abandoned 20 years previously.

Methadone material is not generally available, and it took time to acquire literature and direct experience with patients from which to base and develope adequate medical knowledge. Many changes were necessary, including training staff to handle these patients, developing information kits for staff and patients, intake screening procedures, medical assessment, diagnostic and prescribing techniques, repeat visit assessments and frequencies, dose adjustments, urinalysis problems, long term goals for the programme itself and for the patients, etc.

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3. Patient Access to the Saskatoon Programme

Access is wide open but does need some screening to ensure that patients who do not require Methadone are not inappropriately started on it. Initial patients were referred by the authorities; most these days are referred from street people; as the programme has become more established, courts and colleagues are referring more patients.

Methadone, as we prescribe and dispense it, is inconvenient, initially requiring daily visits to the drugstore; and becomes a nuisance over the long haul; early on this is an advantage, discouraging those not really committed to the programme.

Before starting patients on Methadone we need evidence of dependency and addiction; and reports from other professionals, doctors, addiction services, gaols, probation and / or parole staff, hospitals, etc, for which we have again developed special release forms which the patient signs at the first visit.

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4. Staff Information Kit.

Our office has regular staff only; no-one specially trained in dependency or addiction. This may well have been an advantage, allowing us to develope our own approach, largely as we got more experience over time. We have receptionists, typists and a licensed Lab Tech, and XRay facility.

Special information sheets were developed to orientate our staff. Dependency medicine is complicated by social attitudes which we all share, and by a lack of orientation material for professionals. The material we produced proved useful for teaching other physicians and their staffs.

In 1998, 12 months after we began the clinic, the Provincial Addiction Service attached one if its staff to our program on a full time basis for support work. This has proved invaluable, and has made possible the assessment and development of a counselling guideline

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5. Patient Information Kit.

Patients are not well informed about Methadone, and often have skewed notions about the drug; they ask many questions. Over time the bulk of these have been put into an info kit which covers :

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6. Patient Assessment.

Components include :

The Opiate Dependency Categories are :

Other problems influencing treatment include :

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7. Medical Management Plan.

This varies with the need :

1. Dependent for/on analgesia alone, probably do not need Methadone, but in some situations it works better than morphine or heroin, or can be more convenient and is certainly cheaper. Dependent but not addicted; no compulsion; patients do not escalate doses.

2. Dependent for/on withdrawal and craving alone. Most patients are in this group. Dependent and tend to become addicted with poor control and escalated doses. Should benefit from Methadone.

3. Dependent on both components, analgesia and the withdrawal and craving (dopesickness) elements. Dependent and tend to become addicted. Should benefit from Methadone.

Four options are available to opiate dependents :

Most patients start on option 2, and sort themselves into options 3 or 4 over time.

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8. Prescribing Techniques.

Based on several concepts :

A low starter dose is given once daily for some days to ensure no respiratory or other problems; most have no trouble with this. Then rapid increases to the minimal blocking dose, then increasing more slowly until there is no craving for opiates. Withdrawal generally gets blocked first; craving takes longer, and some crave the needle and activities rather than the drug. Needle craving is much harder to suppress. Sensitivity to Methadone varies considerably as with all drugs. The range is 30 to 110 mg in general, most cases settling at 70 to 90 mg daily to block both withdrawal and craving.

All dependent patients get withdrawal if not given opiates while starting Methadone. If they are not prescribed they will be bought on the street. In this clinic we prescribe them. Clinical trials are needed in this area. To date (3 years) we have had no problems with this approach.

Duration of treament varies. In general 6 - 12 weeks to chemical stability, then no less than 12 months on steady dose, during which time they get other issues sorted out and begin to lead straight lives, and many can then slowly come off Methadone; if this can't be achieved then Methadone Maintenance may be their only therapeutic option, lasting as long as needed. There are some who do not find Methadone helps at all; since it is the only drug available in its class, these people return to the street; there have been very few like this in our clinic. Even those who leave their programmes keep in touch with us and most return in time.

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9. Other Support Structures. Several categories :

Physical and Mental health immediate illnesses are assessed in our office and handled as necessary. Some situations require that problems get treated before Methadone is started. Patients agree that we can refer to other specialists as required.

Environmental components like housing, personal contact group, transport problems, and financial status are all deeply connected. Often very poor situations. Finances usually dreadful. Some sort of social support struture is always needed and we include it in the initial assessment and get those agencies involved as early as possible to facilitate medical management, otherwise the patient will not do well in our experience. Lack of transport can be a major and simple drawback to running a Meth programme - inability to get to clinic appointments or daily visits to the drugstore; these need sorting out before starting treatment.

Legal issues, pending or unresolved, including the prospect of going to gaol, may defer treatment. Gaol personel could be much more pro-active in this; they can fairly easily identify many of these potential patients and could equally easily initiate therapy which we could then continue when the patient is released. Quite commonly the sequence is legislation before medication. Their help could be invaluable.

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10. Saskatoon Data.

Started Feb 1997 with 5 patients in a pilot study, integrated into a general practice clinic with no separation of patients. Initial instruction was to help these five people get off the street and out of criminal activities. All had requested treatment for some long time before the clinic started.

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