Addiction Prevention and Treatment Services

Methadone Evaluation Questionnaire

DEMOGRAPHICS
Date: _______________
1. Gender: (check one)

Male Female

2. Date of Birth ______ /______ /______ (dd/mm/yy)

3. Marital Status married single divorced
widowed common law
4. How many months have you been a client in the Addiction Prevention & Treatment Services
methadone program? _____________
5. Which town/city do you currently reside in? ___________________
6. Highest education level reached: (check one)
less than elementary some high school
elementary completed high school completed
some junior high school some post-secondary
junior high school completed post-secondary completed
DRUG USE / HIGH RISK BEHAVIOURS
7. Are you currently still using drugs OTHER than methadone? (check one)
Yes No .if NO skip to question 14 and continue.
8. Type of primary drug used? (check one ONLY)
dilaudid morphine heroin cocaine
other, specify _____________
9. Frequency of use of primary drug of choice per week? ____________
10. Type of secondary drug used, if any? (check one ONLY)
dilaudid morphine heroin cocaine
benzodiazepine THC alcohol
other, specify ______________

11. Frequency of use of secondary drug of choice per week? ___________

12. Do you currently use needles? (check one) Yes No
13. If so, how many needles do you currently use per week? ____________
14. Have you shared needles since participating in the APTS Methadone
program? (check one) Yes No
15. Would you consider your drug use and high-risk behaviours have been
reduced since admission to the APTS methadone program?
(check one) Yes No
HOUSING
16. Are you homeless? (check one) Yes No
17. Do you have adequate housing? (check one)

Yes No

18. Have you changed residences since admission to the APTS methadone
program? (check one) Yes No
19. If you have changed residence since admission, how many times? _____
20. Would you consider your housing condition has improved since
admission? (check one) Yes No
EMPLOYMENT STATUS
21. Please circle which employment status currently applies to you (circle one)
full-time employment
part-time employment
seasonal employment
homemaker
student
disabled
retired
unemployed
22. Would you consider your employment status has improved since
admission? (check one)
Yes No
CRIMINAL CONVICTIONS
23. Have you had any new criminal convictions since admission?
(check one) Yes No
24. If you have had new criminal convictions since admission, how many?
__________

25. Would you consider there has been a decrease in your criminal behaviour
since admission? (check one) Yes No
FAMILY
26. Do you have family support? (check one) Yes No
27. Would you consider your family support has increased since admission?
(check one) Yes No

Open Forum Questions and Responses

1. Now that you are on methadone, what would help you the most?
Longer carry privileges
Recruit physicians to smaller communities
Employment education/ Counselling (i.e. resume preparation,
interview training)
Better accessibility to community physicians/counsellors
Tough to get into detox due to bed shortage
Continued support from APTS
ID card
Client manual
2. To date, what has been your experience with the quality of care youve
received from APTS?
Wonderful staff
Accommodations not as bad as other detox units
Staff care and work for more than a pay cheque
Staff encouragement and support help retain client participation
in program
Encouraged to make own decisions
A-1!
All positive
Help was accessible
Counsellors are very kind
I believe the care has been specifically designed for who I am
and where I am at in my program
I feel open to communicate with all members from APTS
Always understanding my situation
Excellent
3. What do you think new Methadone clients need to know to make the
transition to the community?
This is not a cure. It is a way to deal with life on lifes terms.
More information on methadone the drug.
More support needed
Change only happens if you want it and the program will work if you
work it
Keep in touch with the program, continue to go to meetings and working
the program
4. What do you think would lead you back to drug use?
Being around users
Right now, to be off methadone
No programs
Required to leave the program
Wrong frame of mind, negative thinking
Being off the program
Prolonged periods of high stress

5. What had APTS done to assist you to improve your life?

Made me accountable
Opening a new kind of life
Renewed my faith in people
Encouraging people to be honest with themselves and others
Improving self-esteem
Rescuing me from a more serious illness/disease
Reducing stress
Just being there, to talk, lean on, go to for advice and know that youre
not just a number
Informed me of ways to stay clean
Helped to get me off and keep me off drugs, helping me to realize I was
worth it
6. What could we do better?
Need more staff and sponsors
Help in relocation
Bringing in speakers that have been successful on the program
More community outreach programs
Increases in dosage should not lead to delays in releasing to the
Community Phase of the program.
Have education workshops for pharmacists
Program designed to jobs and getting people more independent
Have Picture ID
More information when first starting the program
Nothing just keep it up!
7. What do you think about the appeal procedure?
No problem to meet with the Committee as a whole
Good Process
People given a fair shot as long as they remain interested in the program
Like to speak on own behalf
Perhaps need smaller appeals committees.