Patient and Physician Characteristics in Relation to Clinical Decision Making in Methadone Maintenance Treatment

Abstract

Delivery of methadone maintenance treatment (MMT) varies considerably between service providers, but the reasons for this are unclear. This two-phase study involved a controlled investigation of factors that influence clinical decision making by methadone-prescribing physicians in regard to three decision-making scenarios: (1) individuals seeking induction into MMT and existing patients seeking (2) replacement and (2) takeaway methadone doses. In phase 1, physicians (n = 17) rated the diagnostic merit of 87 patient factors for each scenario. Ratings suggested that decisions are influenced by a range of subjective and “nonmedical” patient factors (e.g., contact with drug subculture, appearance, employment status, social support, having children), in addition to more conventional information sources regarding patients' medical and treatment status (e.g., being pregnant, urinalysis evidence of opioid and poly drug use, signs of opioid withdrawal). Phase 2 (n = 296) investigated relationships between physician characteristics and responses to randomized-controlled case vignettes (decisions and confidence ratings) in which the amount and type of diagnostic and nondiagnostic patient information was controlled. Vignette responses were significantly related to physician characteristics (e.g., professional orientation, location, and experience) independent of the patient information provided. Delivery of MMT may vary due to the diversity of patient factors that influence decisions and variability between physicians in the way such information is used to form judgments. Training programs for methadone prescribers should account for these sources of potential variability in treatment management.

Keywords:

• clinical decision making
• methadone maintenance
• prescribing

Additional information

Notes on contributors

Timothy B. Mitchell

Timothy B. Mitchell, Ph.D., is currently undertaking postdoctoral research at the National Addiction Centre within the Institute of Psychiatry, King's College London. His primary research foci include the evaluation of novel pharmacological interventions for drug dependence, the psychopharmacological properties of opioids and other drugs of abuse, and processes of treatment delivery in substance abuse and mental health. He graduated with a Ph.D. in Medicine from the University of Adelaide in 2003, based on work evaluating slow-release morphine as a maintenance pharmacotherapy for opioid dependence, following earlier training in psychology at Flinders University of South Australia (BPsych Hons 1st Class).

Kyle R. Dyer

Kyle R. Dyer, Ph.D., is a Senior Lecturer within the School of Medicine & Pharmacology at the University of Western Australia, with joint status at Next Step Specialist Drug & Alcohol Services (W. A. Department of Health). Activities related to this position include the management of clinical research at Next Step, the provision of education and training within the University of Western Australia and for other health professionals, and supporting clinical practice via the provision of consultancy and patient treatment plans. Dr. Dyer also directs the East Perth Neuropsychological Clinic, which conducts thorough neurocognitive assessments of all patients entering drug-dependency treatment at Next Step and implements individualized treatment plans based on neurocognitive ability. Current research areas relate to the use of saliva for drug screening and therapeutic drug monitoring in drug dependency treatment, the diagnosis and management of Axis I disorders among drug-dependent individuals, and a recently commenced double-blind randomized controlled trial evaluating Mirtazapine for the management of methamphetamine withdrawal. He is currently a member of the Australian Psychological Society (APS) Drug Policy Working Group and a consultant for the Department of Justice (WA Government) Drug Testing and Pharmacotherapy Reference Groups.

Edmund R. Peay

Edmund R. Peay, Ph.D., has held academic status as a Senior Lecturer in the School of Psychology at Flinders University since his retirement from that School in 2000. Most recently his interests have centered on cognitive factors in health care delivery, including both doctor and patient decision making. He has had a long-standing involvement in the development of methodology in the fields of clustering, social networks, and geometrical models.