Does recovery-oriented treatment prompt heroin users prematurely into detoxification and abstinence programmes? Qualitative study

Patient Activation of Persons With Opioid Use Disorder in Intensive Outpatient Treatment

BACKGROUND

High patient activation is associated with a variety of positive health outcomes. Although increasing patient activation in persons with opioid use disorder (OUD) in intensive outpatient treatment (IOT) programs may increase engagement and improve outcomes, little is known about how patient activation is manifested in these programs.

AIMS

To describe types of instances in which persons play an active role in their IOT or show self-determination in their recovery generally (patient activation) and types of instances in which they play a passive role in their IOT or have recovery directed by others (patient nonactivation).

METHODS

A qualitative descriptive study using data from a larger grounded theory study was conducted. Interviews were completed with 14 persons with OUD who attended an IOT program within a large health care system in the Midwest. Content analysis was used to create a typology of instances of patient activation or nonactivation in participants' IOT experiences.

RESULTS

Six types of instances were identified: (1) making and enacting one's own treatment decisions, (2) actively collaborating with staff, (3) self-determining one's disclosure in groups, (4) making a commitment to treatment, (5) taking responsibility for one's recovery, and (6) taking actions to avoid return to use.

CONCLUSIONS

Patient activation is multidimensional and plays a salient role in IOT experiences. IOT staff should engage patients as active participants in their treatment and encourage mutual goal-setting and shared-decision but should be aware that some approaches used too early in treatment may impede recovery.

Should I Stay or Should I Go? A Qualitative Exploration of Stigma and Other Factors Influencing Opioid Agonist Treatment Journeys

(1) The harm-reduction benefits of opioid agonist treatment (OAT) are well-established; however, the UK government's emphasis on "recovery" may be contributing to a high proportion of people leaving treatment and low retention rates. We wanted to develop a rich and nuanced understanding of the factors that might influence the treatment journeys of people who use OAT. (2) We explored factors at each level of the socioecological system and considered the ways these interact to influence treatment journeys in OAT. We carried out semi-structured interviews with people who use OAT (n = 12) and service providers (n = 13) and analysed data using reflexive thematic analysis. (3) We developed three themes representing participant perceptions of treatment journeys in OAT. These were: (1) The System is Broken; (2) Power Struggles; and (3) Filling the Void. (4) Conclusions: The data suggest that prioritisation of treatment retention is important to preserve the harm-reduction benefits of OAT. Stigma is a systemic issue which presents multiple barriers to people who use OAT living fulfilling lives. There is an urgent need to develop targeted interventions to address stigma towards people who use OAT.

Community-based residential treatment for alcohol and substance use problems: A realist review

Research and reviews to date suggest that community-based residential treatments for substance use disorders (SUDs) have mixed effectiveness, with some studies finding positive outcomes while others finding no differences between intervention arms, including inpatient, outpatient, and control groups. In order to understand these mixed findings, reviews have underscored the importance of outlining the active treatment components of residential treatment, as well as treatment mechanisms and outcomes. Further, there is very little research on the underlying theories explaining how and for whom residential treatments are effective. The purpose of the present realist synthesis was to address this gap in the literature by exploring how, why, for whom, and in what circumstances, community-based residential treatments are effective. Following the RAMESES Publication Standards, a search was undertaken for articles examining community-based residential treatments in PsycINFO and PubMed from anytime to January 2020. The search generated 28 articles that met inclusion criteria and were extracted for relevant information. Results of the realist synthesis identified six Context-Mechanism-Outcome (CMO) configurations. Contextual factors that generated subsequent mechanisms and outcomes included substance-related problem severity, psychiatric comorbidities, diverse populations, pre-treatment relationships, lack of structure and lack of coping strategies. These CMO configurations provide important information for clinicians, treatment centres and policy makers, including the specific programme components that need to be offered in treatment to facilitate positive treatment outcomes.

'Not at all what I had expected': Discontinuing treatment with extended-release naltrexone (XR-NTX): A qualitative study

BACKGROUND

Extended-release naltrexone (XR-NTX), an opioid antagonist, has demonstrated equal treatment outcomes, in terms of safety, opioid use, and retention, to the recommended OMT medication buprenorphine. However, premature discontinuation of XR-NTX treatment is still common and poorly understood. Research on patient experiences of XR-NTX treatment is limited. We sought to explore participants' experiences with discontinuation of treatment with XR-NTX, particularly motivation for XR-NTX, experiences of initiation and treatment, and rationale for leaving treatment.

METHODS

We conducted qualitative, semi-structured interviews with participants from a clinical trial of XR-NTX. The study participants (N = 13) included seven women and six men with opioid dependence, who had received a minimum of one and maximum of four injections of XR-NTX. The study team analyzed transcribed interviews, employing thematic analysis with a critical realist approach.

FINDINGS

The research team identified three themes, and we present them as a chronological narrative: theme 1: Entering treatment - I thought I knew what I was going into; theme 2: Life with XR-NTX - I had something in me that I didn't want; and theme 3: Leaving treatment - I want to go somewhere in life. Patients' unfulfilled expectations of how XR-NTX would lead to a better life were central to decisions about discontinuation, including unexpected physical, emotional, or mental reactions as well as a lack of expected effects, notably some described an opioid effect from buprenorphine. A few participants ended treatment because they had reached their treatment goal, but most expressed disappointment about not achieving this goal. Some also expressed renewed acceptance of OMT. The participants' motivation for abstinence from illegal substances generally remained.

CONCLUSION

Our findings emphasize that a dynamic understanding of discontinuation of treatment is necessary to achieve a long-term approach to recovery: the field should understand discontinuation as a feature of typical treatment trajectories, and discontinuation can be followed by re-initiation of treatment.

Enablers and hindrances for longer-term abstinence in opioid dependent individuals receiving treatment with extended-release naltrexone: A Norwegian longitudinal recovery trial (NaltRec study)

Opioid-dependence is a comprehensive, relapsing disorder with negative individual, - family, - and societal consequences. Recovery is difficult to achieve. Research has shown reduced substance use and improved health- and psychosocial factors with extended-release naltrexone (XR-NTX) treatment. Pharmacological treatment should include psychosocial interventions to improve longer-term recovery. This study explores how voluntary monthly treatment with extended-release naltrexone hydrochloride (Vivitrol®) will influence longer-term recovery, health and psychosocial relationships in opioid-dependent patients. Close relatives' experiences and societal costs will be assessed. This Norwegian naturalistic, multicenter, open-label study includes 150 opioiddependent patients. Patients are assessed every four weeks for 24 weeks, with 28 weeks optional follow-up treatment-period, and at three, six and 12 months posttreatment. Controls are opioid-dependent patients enrolled in Opioid Maintenance Treatment programs (n = 150). Data on recovery will be collected from participants, close relatives, and community health service providers. Genetic analyses of major signaling pathways and national registries on prescriptions and health care use will be analyzed. Recruitment period is September 2018 to September 2020. The assessment of medical, psychological, relational and societal factors may provide novel in-depth knowledge on the complexity of personal recovery-processes. The results are expected to have impact on priorities in treatment and follow-up for opioid dependent patients.

Adapting treatment length to opioid-dependent individuals' needs and preferences: A 2-year follow-up to a 1-year study of extended-release naltrexone

BACKGROUND AND AIM

Extended-release naltrexone (XR-NTX) is an underused treatment option for opioid dependence, today only available in a few countries in the world. Although effective, safe and feasible in short-term treatment, long-term data are scarce and there is no recommendation for required treatment length. The aims of the study were to determine the perceived need of long-term XR-NTX treatment and to examine long-term treatment outcomes.

DESIGN

In this prospective cohort study, following a parent 1-year study of XR-NTX, participants received treatment with XR-NTX at their own discretion for a maximum of 104 weeks.

SETTING

Five urban, outpatient addiction clinics in Norway.

PARTICIPANTS

Opioid-dependent adults 18-60 years old (n=50) already participating in the parent study.

INTERVENTION

XR-NTX administrated as intra-muscular injections (380 mg) every 4 weeks.

MEASUREMENTS

Time in the study, use of opioids and other illicit substances, opioid craving, and treatment satisfaction reported every 4 weeks.

FINDINGS

Among 58 participants who completed the 1-year parent study, 50 chose to continue the treatment with XR-NTX. Median prolonged treatment time was 44.0 weeks (95% CI: 25.5-62.5), ranging from 8 to 104 weeks. Most participants (35, 70%) reported no relapse to opioid use during treatment while a subgroup (15, 30%) reported relapses to opioids during the study. Scores for mean treatment satisfaction and recommending treatment to others were very high (>9) and mean opioid craving score was very low (<1) on a scale ranging from 0 to 10.

CONCLUSIONS

Extended-release naltrexone (XR-NTX) was well tolerated in long-term treatment of opioid dependent individuals in Norway already in XR-NTX treatment. On average, the participants chose to continue treatment for almost 1 year beyond the initial 9 to 12 months of treatment. Participants reported high treatment satisfaction and 70% showed no relapse to opioids during the treatment period.

A Longitudinal Qualitative Analysis of the Lived Experience of the Recovery Process in Opioid-Dependent Patients Post-Detoxification

The aim of the study was to gain an in-depth understanding of opioid-dependent patients' lived experiences post-detoxification.

METHOD

The study employed a naturalistic, observational longitudinal design, involving baseline screening and tracking of patients post-detoxification, with follow-up interviews at three, six, and nine months to observe specific processes of interest. This in-depth investigation of patients at four points was new within an Irish context and novel throughout the literature.

FINDINGS

Recovery was seen as a process that was not always linear, and lapse and relapse were viewed as part of this process. Patients had great insight into "risk factors for relapse," information and knowledge gained over several years and many treatment episodes. Furthermore, the findings illustrate the role insight plays in any learning and growth experience and the emphasis that is placed upon it within the treatment journey; insight is a fundamental underpinning to any real growth and development. The current article argues that insight merits a more explicit role in the model of recovery capital.

Mindfulness-Based Relapse Prevention for Methadone Maintenance: A Feasibility Trial

OBJECTIVES

As rates of opiate misuse rise in the United States, so do significant associated health and financial consequences to afflicted individuals, their families, and society at large. Methadone maintenance therapy (MMT) is one evidence-based approach to treating opiate addiction, yet supplemental psychosocial treatment to support this approach is lacking. Mindfulness-based relapse prevention (MBRP) has shown to be efficacious in various substance use populations, but has yet to be assessed with MMT clients.

DESIGN

The current mixed methods study was designed to inform protocol adaptation for MMT clients and to evaluate the feasibility, acceptability, and preliminary efficacy of MBRP for this population.

SUBJECTS

The sample consisted of adults (N = 15) recruited from a methadone clinic to participate in a 6-week MBRP course.

OUTCOME MEASURES

Data from focus groups and course satisfaction surveys supported feasibility and acceptability of the intervention. Self-report outcome measures included depression, anxiety, craving, symptoms of post-traumatic stress, and experiential avoidance, and were assessed at baseline and postcourse.

RESULTS

Mean scores on all primary outcomes changed in the expected direction at postcourse, and baseline to postcourse changes in depression, craving, and trauma symptoms reached statistical significance.

CONCLUSIONS

Results from this initial pilot trial support feasibility and acceptability, and provide preliminary data on outcomes for future trials of mindfulness-based approaches within the MMT community.

Acceptability of Extended-Release Naltrexone by Heroin-Dependent Patients and Addiction Treatment Providers in the Netherlands

BACKGROUND

Extended-release naltrexone (XRNT) was developed to overcome poor treatment compliance with oral naltrexone in alcohol and opioid-dependent patients. XRNT injections are registered in the United States and Russia, but not in The Netherlands. However, XRNT can be obtained for individual patients, but it is expensive and not reimbursed by the health insurance.

OBJECTIVES

This study evaluates the support for abstinence oriented treatment among heroin-dependent patients and the acceptability of XRNT injections by heroin-dependent patients and treatment providers in The Netherlands.

METHODS

A sample of 261 patients in methadone maintenance treatment or heroin assisted treatment and a sample of 188 addiction treatment providers completed specially designed questionnaires.

RESULTS

The current study shows that many patients in opioid maintenance treatment (58%) report a desire to become abstinent from opioids and that 83% of the patients with a desire for abstinence are interested in XRNT. The majority of treatment providers (81%) are willing to support the prescription of XRNT injections in opioid-dependent patients to prevent relapse after detoxification.

CONCLUSIONS

The current practice of automatic and indefinite continuation of opioid substitution should therefore be reconsidered. However, XRNT injections are very expensive and currently not reimbursed by the health insurance agencies in The Netherlands and thus not really available to most patients.

NPS and the methadone queue: Spillages of space and time

BACKGROUND

Between 2008 and 2013, powder-stimulants sold by 'head shops' as novel psychoactive substances (NPS) or 'legal highs' have displaced heroin among groups of injecting substance users in Bucharest, Romania. Rising HIV-infection rates and other medical or social harms have been reported to follow this trend.

METHODS

The study builds on two sets of original (N=30) and existing (N=20) interview data and on observations collected mainly at the site of a methadone substitution treatment facility.

RESULTS

By disentangling the space-time continuum of the methadone queue, this paper argues that injecting drug users' (IDUs) passage from opiates to amphetamine-type stimulants (ATS) can be understood as 'spillages' of space and time. IDUs thus 'spill' out of the disciplinary flows of methadone treatment in two ways. The first is that of space and materiality. Drawing on actor-network theory (ANT), ATS/NPS appear embedded in reconfigured practices and rituals of injecting use. Such spillages see the pleasure-seeking self being fluidised in forming connections with, or spilling into, nonhuman actants such as substances, settings or objects. The second dimension of spilling is that of time. In this sense, heroin use is a 'cryogenic strategy' of inhabiting history and facing the transition to the market society that Romanian opiate injectors spill out of, not able to appropriate choice and legitimate consumption. The phenomenological qualities of stimulants that seem to accelerate lived time and generalise desire thus present them with an opportunity to alleviate a form of what a post-communist moral imaginary of transition frames as debilitating nostalgia.

CONCLUSION

ATS/NPS are revealed as fluid entities that do not only shape risk conditions but also alter shared meanings and contextual configurations of bodies, substances and disciplinary regimes in unpredictable ways.

“Once you’ve been there, you’re always recovering”: exploring experiences, outcomes, and benefits of substance misuse recovery

Purpose

– Recovery is a central component of UK substance misuse policy, however, relatively little is known about the views and meanings of recovery by those experiencing it. The purpose of this paper is to explore these factors, and understand how service user experiences align to current understandings of “recovery capital”.

Design/methodology/approach

– This paper draws on qualitative interviews with 32 individuals from six UK recovery communities, including those commissioned by a statutory service (n=8) and a peer-led recovery community (n=24).

Findings

– Meanings of recovery differed between people in abstinence-based communities and those not; however, all had consistent views on their own recovery outcomes and the benefits they believed recovery brought. All viewed recovery as a process; a continuous journey with no end-point. Internal motivation, peer support, social networks and daily structure were integral to supporting individuals achieve and maintain recovery. Key benefits of recovery reflected recovery capital and included positive relationships, sense of belonging, increased self-worth and confidence, employment and education.

Research limitations/implications

– This research shows that recovery experiences and outcomes are not centred entirely on the individual but are wider, more holistic. Maintaining recovery involves being connected to themselves and to the wider environment: family, friends, peers and society. Although the recovery capital model has many elements that were discussed by the participants of this research, the discourse they used does not align with the model. To validly measure and quantify recovery outcomes, individuals need to identify with the measures themselves.

Practical implications

– From policy and commissioning perspectives, these findings suggest benefits of recovery that were viewed by participants as indicators of success: demonstrate elements which support recovery; and highlight key social value outcomes which people attribute to recovery.

Social implications

– These “softer”, qualitative benefits should be considered by policy-makers, commissioners, statutory and non-statutory services in order to evidence outcomes. However, it should also be recognised that a temporally static approach to assessing recovery may be in contradiction to the meaning and perspectives held by those in recovery communities who conceptualise it as a long term and ongoing process.

Originality/value

– This paper adds to understandings of experiences and meanings of recovery, with a particular focus on the measurement of outcomes and their meanings, and the role of abstention and continued drug use within the recovery process.

Salutogenesis: Contextualising place and space in the policies and politics of recovery from drug dependence

This commentary seeks to make a contribution to applied and academic debates concerning recovery from drug dependence. This involves a discussion of various commonalities relating to the places and spaces of substance use/treatment; the identification of various tensions relating to 'structure and agency' in current service provision and the way in which environmentally disparate settings may be synthesised to establish enabling environments of recovery. At the centre of this discussion is Aaron Antonovsky's (1984) model of 'salutogenesis' (and 'salutogenic environments') and how this conceptual framework may be considered and/or applied in the field of recovery from dependent substance use. Whereas public health, clinical intervention and epidemiology each attempt to identify the underlying causation of illness and ill health, salutogenesis is an agency-led concept that seeks to identify the factors and mechanisms that foster good health and the principles of 'keeping well'. It is suggested that a salutogenic approach to recovery options would draw upon the guiding principles of the framework towards advancing, individual level, recovery capital. These principles being (i) the development of social/cultural capital within socially-constructed environments; in which (ii) individual action (or agency) seeks to (iii) manage ill health; recognise the challenges underlying illness and identify the resources that are available to improve health. The author suggests that opportunities for a more 'salutogenic approach' to recovery may be noted within a grassroots model burgeoning throughout parts of the UK (and known as Recovery Cafés). This design is in stark contrast to the State's more structurally-focused treatment options that may not fully appreciate the influence of agency (and the role of place) in attempts to garner recovery capital. In order to demonstrate the academic and applied value of the proposed salutogenic framework to the issue of recovery from dependence (including the centrality of space and place in debate surrounding substance use/treatment), the author draws upon empirical research as well as theoretical and hypothetical frameworks from the discipline of sociology to illustrate throughout.

Effect of extended-release naltrexone on striatal dopamine transporter availability, depression and anhedonia in heroin-dependent patients

RATIONALE

Extended-release naltrexone (XRNT), an opioid receptor antagonist, is successfully used in the treatment of opioid dependence. However, naltrexone treatment of opioid-dependent patients may reduce striatal dopamine transporter (DAT) availability and cause depression and anhedonia.

OBJECTIVES

The aim of this study is to investigate changes in striatal DAT availability and symptoms of depression (Beck Depression Inventory (BDI)) and anhedonia (Snaith Hamilton Pleasure Scale (SHAPS)) before and during XRNT treatment.

METHODS

At baseline, ten detoxified heroin-dependent patients and 11 matched healthy controls underwent [(123)I]FP-CIT single photon emission computed tomography (SPECT) imaging to assess striatal DAT binding. Patients underwent a second SPECT scan 2 weeks after an intramuscular injection with XRNT.

RESULTS

At baseline, the mean binding potential (BPND) in the putamen was at a trend level lower and the mean BDI score was significantly higher in heroin patients (n = 10) than in controls (n = 11) (3.45 ± 0.88 vs. 3.80 ± 0.61, p = 0.067, d = -0.48 and 12.75 ± 7.40 vs. 5.20 ± 4.83, p = 0.019, d = 1.24, respectively). Post hoc analyses in subgroups with negative urine analyses for opioids and cocaine showed significantly lower baseline putamen BPND in heroin patients (n = 8) than controls (n = 10) (3.19 ± 0.43 vs. 3.80 ± 0.64, p = 0.049, d = -1.03). XRNT treatment in heroin patients was not significantly associated with changes in striatal DAT availability (p = 0.348, d = 0.48), but the mean BDI score after XRNT treatment was significantly lower than before treatment (7.75 ± 7.21 vs. 12.75 ± 7.40, p = 0.004, d = -0.68).

CONCLUSIONS

The results of this study suggest that XRNT treatment does not reduce striatal DAT availability and has no significant effect on anhedonia, but is associated with a significant reduction of depressive symptoms.

Enhancing motivation within a rapid opioid substitution treatment feasibility RCT: a nested qualitative study

Background

Opioid substitution treatment (OST) has multiple benefits for heroin injectors and is an evidence-based major component of international treatment. The current qualitative study sought to explore participants’ attitudes to and reasons for participating in a feasibility randomised trial in primary care offering ‘same day’ OST (methadone) for injecting heroin users compared to usual care.

Methods

Twenty injecting heroin users (8 intervention and 12 controls; 16 males and 4 females) were interviewed; purposive sampling was used to select a maximum variation sample from those who agreed; and analysis used thematic methods.

Results

Motivation to join the trial included the need to secure treatment set against some ambivalence due to previous negative experiences of trying to obtain OST. Positive effects of securing methadone via the trial, included self-reported improvements in health and self-care; reduction in crime, stress and drug use. Completing the baseline questionnaires at recruitment appeared to enhance motivation for treatment for all participants. For some control participants, this motivation seemed to increase a sense of self-efficacy and cognitive dissonance generated was resolved by seeking treatment from their GP. Self-determination theory suggests that behaviour change may have been initiated during the recruitment appointment, resulting in an increased determination to seek treatment amongst control participants.

Conclusions

Taking part in the ‘script in a day’ trial enabled participants in the intervention arm to gain same-day access to methadone and reduce their drug use. For those in the control arm, completing the baseline questionnaires at recruitment appeared to create cognitive dissonance between their current health state and own aspirations, so increasing motivation for treatment. Over 50% obtained and were still in receipt of OST (methadone or buprenorphine) at the 3 month follow-up. We suggest that a regular ‘health evaluation’ for injecting heroin users not in treatment, paired with low-barrier access to treatment, may be a way of exploring this and encouraging more into obtaining OST more quickly and at the best time for them. This intervention should be delivered without pressure for change.

Clinical trial registration

This trial is registered with International Standard Randomised Controlled Trial Number Register: SCript In a Day for injecting drug users: feasibility trial: ISRCTN16846554.