International Journal of Drug Policy 24 (2013) e51–e56 Contents lists available at ScienceDirect International Journal of Drug Policy jo ur nal ho me p age: www.elsevier.com/locate/drugpo Research Paper What is low threshold methadone maintenance treatment? Carol Strike a,* , Margaret Millson a , Shaun Hopkins b , Christopher Smith c a Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario M5T 3M7, Canada b The Works, Toronto Public Health, 277 Victoria Street, Toronto, Ontario M5B 1W2, Canada c School of Humanities and Social Sciences, Faculty of Arts and Education, Deakin University, 221 Burwood Highway, Burwood, Victoria 3125, Australia a r t i c l e i n f o Article history: Received 30 November 2012 Received in revised form 18 April 2013 Accepted 8 May 2013 Keywords: Methadone maintenance Low threshold Program policies Harm reduction Canada a b s t r a c t 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 dur- ing 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. Conclusion: 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. © 2013 Elsevier B.V. All rights reserved. Introduction Methadone maintenance treatment (MMT) was designed by Dole and Nywsander (1965) to manage opioid dependence, which they characterized as a permanent metabolic deficiency. To block cravings and stabilize this deficiency, they advocated for long-term maintenance of the client and provision of ancillary services (Dole & Nywsander, 1965). As Ward, Mattick, and Hall (1998) note, MMT quickly became the most common treatment for opiate depend- ence. However, it underwent significant changes in the United States in terms of its goals, dosage and ancillary services and its focus on ‘maintenance’ was diminished (Ward et al., 1998). Whilst, Dole and Nywsander (1965) designed a program with long term * Corresponding author. Tel.: +1 416 978 6292; fax: +1 416 978 2087. E-mail address: carol.strike@utoronto.ca (C. Strike). goals, newer models have moved towards shorter duration of treat- ment and abstinence within a few years (Ward et al., 1998). However, in the 1980s the pendulum swung back towards a maintenance approach, with the introduction of a ‘low threshold’ MMT model. This emerged to reduce barriers to admission and retention in MMT amongst people for whom abstinence from all drugs was not their goal, but who might benefit in other ways from treatment (Klingemann, 1996). Two MMT policies in particular were identified as barriers: abstinence from all drugs as a condition of entry into treatment and abstinence from all drugs, including non-opioids, throughout the entire course of treatment. The first low threshold programs, such as ‘methadone by bus’ in Amster- dam, tried to remove these barriers. This program was designed for a group of mostly black heroin users who did not use services and experienced many health and social problems (Buning, Van Brussel, & Van Santen, 1990). The goal of methadone by bus was to stabilize opiate dependence, provide regular contact for clients, and address other health and social problems. Although not an original 0955-3959/$ – see front matter © 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.drugpo.2013.05.005