The experience of long-term opiate maintenance treatment and reported barriers to recovery: a qualitative systematic review

Caregivers' Attitudes Toward Treatment Length for Persons in Swedish Opioid Agonist Treatment. A Qualitative Interview Study

Although opioid agonist treatment (OAT) has several beneficial effects, the issue of optimal treatment length remains unresolved. It is plausible that caregivers' attitudes toward treatment length are of importance to whether, how and when tapering off will take place. In this study, we investigated caregivers' attitudes toward treatment length by interviewing 15 caregivers from a variety of professions working in seven OAT treatment programs in Sweden. Data were analyzed using applied thematic analysis. The participants were generally hesitant concerning the idea of tapering off. Few of them had experiences of patients tapering off successfully. Many of them never brought up the subject unless the patient did so her-/himself. Only younger, socially stable patients were perceived to be suitable for tapering off. Participants also expressed a need among staff for education and ethical discussions on treatment length. A person-centered focus may be promoted by recurrently discussing treatment goals and by co-operating with patients to map the recovery capital of those interested in tapering. To further support caregivers in developing person-centered care, more knowledge of opioid use disorder and professional and interprofessional discussions of caregivers' own attitudes and beliefs are paramount.

Waiting for inpatient detoxification: A qualitative analysis of patient experiences

BACKGROUND

There is limited provision of inpatient detoxification relative to other treatments for alcohol and other drug (AOD) use. This means people often need to wait prior to detoxifying. However, waiting for healthcare is generally perceived as negative and stressful. This paper aims to understand patients' experiences of waiting for inpatient AOD detoxification to ascertain whether and how service-level policies and practices might be improved.

METHODS

Semi-structured telephone interviews were conducted with 32 people (20 males, 12 females; aged 25-67 years) who were waiting for inpatient detoxification. Data collection was part of a wider evaluation of a policy initiative started in 2021 to increase detoxification service capacity in England, UK. Interviews were professionally transcribed and data on waiting experiences were coded using qualitative software. Analyses were informed by new materialist thinking and undertaken via Iterative Categorisation.

RESULTS

We found that waiting was constituted through five dimensions: i. duration; ii. support; iii. information; iv. preparations; and v. emotions. These five dimensions were multi-faceted and operated in and through wider interacting social, material, and affective forces (e.g., professional judgements, formal and informal relationships, the availability of beds and funding, bureaucratic procedures, the utility and relevance of information, and participants' diverse feelings, including desperation for treatment). Not all accounts of waiting were negative. The experience was complex, non-uniform and variable over time. Moreover, it affected how people felt and how they behaved.

CONCLUSIONS

Changes to service-level policies and practices can potentially minimise the stress of waiting for inpatient AOD detoxification. The negative impact of waiting may be reduced if professionals more consistently engage patients in a wider range of constructive pre-treatment activities, offer regular 'check-ins' to mitigate any anxiety, explain changes in wait duration to help with planning and demonstrate fairness, and facilitate contact between those waiting to lessen feelings of isolation.

A legal dispute resolution intervention for patients with substance use disorders: a study protocol for a randomized controlled trial

BACKGROUND

Substance use disorders (SUDs) represent major public health concerns and are linked to enhanced risk of legal consequences. Unresolved legal issues may prevent individuals with SUD from completing treatment. Interventions aimed at improving SUD treatment outcomes are limited. Filling that gap, this randomized controlled trial (RCT) tests the ability of a technology-assisted intervention to increase SUD treatment completion rates and improve post-treatment health, economic, justice-system, and housing outcomes.

METHODS

A randomized controlled trial with a two-year administrative follow-up period will be conducted. Eight hundred Medicaid eligible and uninsured adults receiving SUD treatment will be recruited at community-based non-profit health care clinics in Southeast, Michigan, USA. Using an algorithm embedded in a community-based case management system, we randomly assign all eligible adults to one of two groups. The treatment/intervention group will receive hands-on assistance with a technology aimed at resolving unaddressed legal issues and the control group receives no treatment. Upon enrollment into the intervention, both treatment (n = 400) and control groups (n = 400) retain traditional options to resolve unaddressed legal issues, such as hiring an attorney, but only the treatment group is targeted the technology and offered personalized assistance in navigating the online legal platform. To develop baseline and historical contexts for participants, we collect life course history reports from all participants and intend to link those in each group to administrative data sources. In addition to the randomized controlled trial (RCT), we used an exploratory sequential mixed methods and participatory-based design to develop, test, and administer our life course history instruments to all participants. The primary objective is to test whether targeting no-cost online legal resources to those experiencing SUD improves their long-term recovery and decreases negative health, economic, justice-system, and housing outcomes.

DISCUSSION

Findings from this RCT will improve our understanding of the acute socio-legal needs faced by those experiencing SUD and provide recommendations to help target resources toward the areas that best support long-term recovery. The public health impact includes making publicly available a deidentified, longitudinal dataset of uninsured and Medicaid eligible clients in treatment for SUD. Data include an overrepresentation of understudied groups including African American and American Indian Alaska Native persons documented to experience heightened risk for SUD-related premature mortality and justice-system involvement. Within these data, several intended outcome measures can inform the health policy landscape: (1) health, including substance use, disability, mental health diagnosis, and mortality; (2) financial health, including employment, earnings, public assistance receipt, and financial obligations to the state; (3) justice-system involvement, including civil and criminal legal system encounters; (4) housing, including homelessness, household composition, and homeownership.

TRIAL REGISTRATION

Retrospectively registered # NCT05665179 on December 27, 2022.

Patients’ Perspectives on Coming Off Opioid Agonist Treatment: A Qualitative Study

Aims:

Opioid agonist treatment (OAT) programs are life-saving, as they reduce opioid use, overdoses, and criminal activities. Disadvantages reported with long-term OAT include side effects of the medication, especially on cognitive ability and sexual function, which may discourage potential participants. Many of those who participate in OAT have a desire to come off treatment. The aims of this study were to explore patients’ thoughts about coming off OAT and to investigate their perceptions of what support they would need in order to realize a planned withdrawal from OAT.

Methods:

A qualitative interview study with semi-structured interviews, using applied thematic analysis. Persons with experiences of participating in OAT were invited from Swedish programs and a private Facebook community.

Results:

Fifteen persons, with a mean of 9.6 (±6.4) years of treatment experience, were included. The participants underlined the need for a patient-centered focus within the treatment. They wanted to be regarded as capable of deciding if, when, and how a planned ending was to take place. They also called for staff to be supportive in making such decisions. Participants recommended staff to be sensitive to the needs of the specific patient and to have strategies for coming off OAT that could be adjusted for the single person.

Conclusions:

OAT programs need to be continually updated and adapted to the persons who can benefit from them. Applying a person-centered, holistic perspective would enhance the quality of the treatment by emanating from individual goals. Regulatory guidelines need to take into account research on patient experiences and perspectives on coming off.

Barriers and Facilitators to Substance Use Disorder Treatment: An Overview of Systematic Reviews

objective:

This investigation explored the barriers and facilitators to substance use disorder (SUD) treatment in the integrated paradigm.

methods:

A search technique for barriers and facilitators of SUD treatment was applied to the PubMed and Web of Science databases to identify relevant systematic reviews. The eligibility criteria included systematic review (SR) or SR plus meta-analysis (MA) articles published before the end of 2021, human research, and the English language. Each of the 12 relevant review articles met the inclusion criteria. AMSTAR was utilised to evaluate the methodological quality of the systematic reviews.

results:

Two authors analysed 12 SR/SR-MA articles to identify barriers or facilitators of SUD treatment. The cumulative summary results of these 12 evaluations revealed that barriers and facilitators may be classified into 3 levels: individual, social and structural. By analysing these review papers, 37 structural barriers, 21 individual barriers and 19 social barriers were uncovered, along with 15 structural facilitators, 9 social facilitators and 3 individual facilitators.

conclusions:

The majority of barriers indicated in the review articles included in this analysis are structural, as are the majority of facilitators. Consequently, the design of macro models for the treatment of substance use disorders may yield various outcomes and potentially affect society and individual levels.

A Grounded Theory Study: How Non-Treatment-Seeking Substance Users Make Sense of Their Behaviour “I Want To Be Me but I Don’t Know Who Me Is”

Despite the global impact of substance misuse, there are inadequate levels of specialist service provision and continued difficulties with treatment engagement. Within policy and research, there is substantial consideration of the importance of these factors. However, there is little empirical evidence of the views of non-treatment-seeking substance users, who make up the majority of the substance using population. The aim of this study was to understand how these individuals make sense of their behaviour and their reasons for not accessing treatment. A constructivist grounded theory approach was used to interview eight individuals who were currently using substances and not seeking help to stop. The analysis highlighted the importance of attachment to an identity associated with substance use, and relational variables such as connectedness to others, for treatment decisions for individuals who use substances. Understanding these influences, through trauma- and attachment-informed service provision, may reduce barriers to help-seeking and improve treatment uptake.

A multi-methods and longitudinal study of patients' perceptions in injectable opioid agonist treatment: Implications for advancing patient-centered methodologies in substance use research

BACKGROUND

Patients' perceptions are vital to the delivery and evaluation of substance use treatment. They are most frequently collected at one time-point and measured using patient satisfaction questionnaires or qualitative methodologies. Interestingly, the findings of these studies often diverge, as satisfaction scores tend to be highly positive, while qualitative findings suggest dissatisfaction and areas for improvement. This divergence limits current understandings of patients' perceptions and their potential change over time in treatment.

OBJECTIVE

This study explores the relationship between open-ended positive and negative perceptions of treatment and patient satisfaction scores over time.

METHODS

The RUTH (Research on the Utilization of Therapeutic Hydromorphone) prospective cohort study included 131 participants receiving injectable diacetylmorphine or hydromorphone in Canada's first injectable opioid agonist treatment (iOAT) program. The study collected the Client Satisfaction Questionnaire (CSQ-8) at eight time-points over an 18-month period. Following a multi-methods approach, the study complemented the CSQ-8 with open-ended positive and negative comments of iOAT. The research team analyzed these comments thematically at each time-point to develop positive and negative perception themes. We then used growth curve modeling to explore the relationship between positive and negative perception themes and patient satisfaction over time.

FINDINGS

Over the eight time-points, six positive and eight negative perception themes emerged, broadly reflecting structural (e.g., expansion of iOAT), process (e.g., schedules), relational (e.g., interactions with providers), and outcome-related (e.g., met/unmet needs) perceptions of iOAT. On average, participants reported high satisfaction (grand mean = 29.2 out of 32), and scores did not significantly change over time. However, we did find significant unexplained variation within participants in their satisfaction trajectories and between participants in their initial satisfaction scores. In conditional growth curve models, the theme "unfavorable interactions with providers" had the strongest independent effect on overall satisfaction trajectories.

CONCLUSIONS

This study provides an example of how open-ended comments can be integrated with patient satisfaction questionnaire data to gather a comprehensive and patient-centered evaluation of substance use treatment. Considering the iOAT context specifically, relational dynamics and daily treatment access were significant predictors of patient satisfaction over time and may be attributes of iOAT that require further investigation.

Barriers to accessing opioid substitution treatment for opioid use disorder: A systematic review from the client perspective

OBJECTIVES

To update the existing evidence to identify specific barriers to initiation of opioid substitution therapy (OST) for those with opioid use disorder (OUD).

METHODS

The review follows Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) guidelines. Six databases were initially searched in November 2019, with the search updated on 11 November 2020, for qualitative or quantitative studies reporting the barriers to initiating OST from the client with OUD perspective. Thematic analysis of the barriers to OST was undertaken to determine barrier themes and subthemes.

RESULTS

There were 37 studies included in the review; 18 were qualitative, 15 were quantitative and four were mixed methods. The barrier themes identified were stigma and fear, regulatory, logistical, attitudinal and social factors. Within these barrier themes 19 barrier subthemes were identified. The most reported OST barrier subthemes were negative treatment perceptions, cost, stigma and lack of flexibility.

CONCLUSION

This review discusses important barriers to OST and examines reported barriers from the client perspective. OST guidelines and programs would benefit by introducing programs that reduce stigma, increase treatment knowledge and health literacy, reduce treatment costs, increase treatment flexibility and allow for easier treatment access.

Are patients' goals in treatment associated with expected treatment outcomes? Findings from a mixed-methods study on outpatient pharmacological treatment for opioid use disorder

OBJECTIVES

Existing methods of measuring effectiveness of pharmacological treatment for opioid use disorder (OUD) are highly variable. Therefore, understanding patients' treatment goals is an integral part of patient-centred care. Our objective is to explore whether patients' treatment goals align with a frequently used clinical outcome, opioid abstinence.

DESIGN

Triangulation mixed-methods design.

SETTING AND PARTICIPANTS

We collected prospective data from 2030 participants who were receiving methadone or buprenorphine-naloxone treatment for a diagnosis of OUD in order to meet study inclusion criteria. Participants were recruited from 45 centrally-managed outpatient opioid agonist therapy clinics in Ontario, Canada. At study entry, we asked, 'What are your goals in treatment?' and used NVivo software to identify common themes.

PRIMARY OUTCOME MEASURE

Urine drug screens (UDS) were collected for 3 months post-study enrolment in order to identify abstinence versus ongoing opioid use (mean number of UDS over 3 months=12.6, SD=5.3). We used logistic regression to examine the association between treatment goals and opioid abstinence.

RESULTS

Participants had a mean age of 39.2 years (SD=10.7), 44% were women and median duration in treatment was 2.6 years (IQR 5.2). Six overarching goals were identified from patient responses, including 'stop or taper off of treatment' (68%), 'stay or get clean' (37%) and 'live a normal life' (14%). Participants reporting the goal 'stay or get clean' had lower odds of abstinence at 3 months than those who did not report this goal (OR=0.73, 95% CI 0.59 to 0.91, p=0.005). Although the majority of patients wanted to taper off or stop medication, this goal was not associated with opioid abstinence, nor were any of their other goals.

CONCLUSIONS

Patient goals in OUD treatment do not appear to be associated with programme measures of outcome (ie, abstinence from opioids). Future studies are needed to examine outcomes related to patient-reported treatment goals found in our study; pain management, employment, and stopping/tapering treatment should all be explored.

Effectiveness, safety and feasibility of extended-release naltrexone for opioid dependence: a 9-month follow-up to a 3-month randomized trial

BACKGROUND AND AIM

This is a follow-up study of a previously published randomized clinical trial conducted in Norway that compared extended-release naltrexone (XR-NTX) to buprenorphine-naloxone (BP-NLX) over 3 months. At the conclusion of the trial, participants were offered their choice of study medication for an additional 9 months. While BP-NLX was available at no cost through opioid maintenance treatment programmes, XR-NTX was available only through study participation, accounting for why almost all participants chose XR-NTX in the follow-up. The aim of this follow-up study was to compare differences in outcome between adults with opioid dependence continuing XR-NTX and those inducted on XR-NTX for a 9-month period, on measures of effectiveness, safety and feasibility.

DESIGN

In this prospective cohort study, participants were either continuing XR-NTX, changed from BP-NLX to XR-NTX or re-included into the study and inducted on XR-NTX treatment.

SETTING

Five urban, out-patient addiction clinics in Norway.

PARTICIPANTS

Opioid-dependent adults continuing (n = 54) or inducted on (n = 63) XR-NTX.

INTERVENTION

XR-NTX administrated as intramuscular injections (380 mg) every fourth week.

MEASUREMENTS

Data on retention, use of heroin and other illicit substances, opioid craving, treatment satisfaction, addiction-related problems and adverse events were reported every fourth week.

FINDINGS

Nine-month follow-up completion rates were 51.9% among participants continuing XR-NTX in the follow-up and 47.6% among those inducted on XR-NTX. Opioid abstinence rates were, respectively, 53.7 and 44.4%. No significant group differences were found in use of heroin and other opioids.

CONCLUSIONS

Opioid-dependent individuals who elect to switch from buprenorphine-naltrexone treatment after 3 months to extended-release naltrexone treatment for 9 months appear to experience similar treatment completion and abstinence rates and similar adverse event profiles to individuals who had been on extended-release naltrexone from the start of treatment.

Clonidine Increases the Likelihood That Abstinence Can Withstand Unstructured Time in Buprenorphine-maintained Outpatients

OBJECTIVE

In a clinical trial examining daily clonidine as an adjunct to buprenorphine treatment for opioid dependence, we found that clonidine increased opioid abstinence and decoupled stress from craving. From a personalized-medicine perspective, the next step is to identify people for whom clonidine would be beneficial. To that end, using data from the same clinical trial, we examined the associations of daily-life activities with treatment success.

METHODS

Outpatients (N = 118) received clonidine (0.3 mg/d) or placebo during 18 weeks of buprenorphine treatment. Participants carried a smartphone that randomly prompted them 4 times per day to report their moods and activities. Using generalized linear mixed models, we assessed the likelihoods of different types of daily activity as a function of clonidine versus placebo, days of longest continuous opioid abstinence, and their interaction.

RESULTS

Participants in the buprenorphine-only (buprenorphine plus placebo) control group who engaged in more responsibilities (work and child/elder care) had longer streaks of abstinence, whereas those who engaged in more unstructured-time activities had shorter streaks of abstinence. Conversely, for participants in the buprenorphine-plus-clonidine group, longer streaks of abstinence were associated with higher frequencies of activities associated with "unstructured" time.

CONCLUSIONS

The study replicates findings that engaging in responsibilities is related to positive treatment outcomes in standard opioid agonist therapy. The pattern of results also suggests that clonidine helped participants engage in unstructured-time activities with less risk of craving or use than they might otherwise have had.

Respiratory health screening for opiate misusers in a specialist community clinic: a mixed-methods pilot study, with integrated staff and service user feedback

OBJECTIVES

Increased rates of illicit drug inhalation are thought to expose opiate misusers (OMUs) to an enhanced risk of respiratory health problems. This pilot study aimed to determine the feasibility of undertaking respiratory screening of OMUs in a community clinic.

SETTING

Single-centre UK community substance misuse clinic.

PARTICIPANTS

All clinic attendees receiving treatment for opiate misuse were eligible to participate. 36 participants (mean age=37) were recruited over a 5-week period. The sample included 26 males and 10 females.

OUTCOME MEASURES

Spirometry without bronchodilation; health related quality of life EQ-5D-3L; Asthma Control Test; Mini Asthma Quality of Life; Clinical COPD Questionnaire and the Treatment Outcome Profile were used to assess the respiratory health of participants. Findings were discussed with staff and service users in 2 patient and public involvement events and feedback was analysed thematically.

RESULTS

34 participants reported that they had smoked heroin. 8 participants diagnosed with asthma, scored under 13 on the Asthma Control Test, suggesting poorly controlled asthma. Participants (n=28), without a diagnosis of asthma completed the Lung Function Questionnaire. Of these, 79% produced scores under 18, indicating symptoms associated with the development of chronic obstructive pulmonary disease. Spirometry showed 14% of all participants had forced expiratory volume in 1 s/forced vital capacity <0.7 (without bronchodilator), indicating potential obstructive lung disease. Feedback from service users and staff suggested a willingness and capacity to deliver respiratory health screening programmes. Insight towards the difficulties service users have in accessing services and the burden of respiratory health was also provided.

CONCLUSIONS

It is feasible to undertake respiratory health screening of OMUs in a community clinic. Larger screening studies are warranted to determine the prevalence of respiratory health problems in this population. Research regarding asthma medicines adherence and access to healthcare among OMUs is also required.

Efficacy of Cognitive Behavioral Therapy on Opiate Use and Retention in Methadone Maintenance Treatment in China: A Randomised Trial

Aims

Methadone maintenance treatment (MMT) is widely available in China; but, high rates of illicit opiate use and dropout are problematic. The aim of this study was to test whether cognitive behavioral therapy (CBT) in conjunction with MMT can improve treatment retention and reduce opiate use.

Method

A total of 240 opiate-dependent patients in community-based MMT clinics were randomly assigned to either weekly CBT plus standard MMT (CBT group, n=120) or standard MMT (control group, n=120) for 26 weeks. The primary outcomes were treatment retention and opiate-negative urine test results at 12 weeks and 26 weeks. The secondary outcomes were composite scores on the Addiction Severity Index (ASI) and total scores on the Perceived Stress Scale (PSS) at 12 weeks and 26 weeks.

Results

Compared to the control group in standard MMT, the CBT group had higher proportion of opiate-negative urine tests at both 12 weeks (59% vs. 69%, p<0.05) and 26 weeks (63% vs. 73%, p<0.05); however, the retention rates at 12 weeks (73.3% vs. 74.2%, p=0.88) and 26 weeks were not different (55.8% vs. 64.2%, p=0.19) between the two groups. At both 12 and 26 weeks, all of the ASI component scores and PSS total scores in the CBT group and control group decreased from baseline; but the CBT group exhibited more decreases in ASI employment scores at week 26 and more decrease in the PSS total score at week 12 and week 26.

Conclusions

CBT counselling is effective in reducing opiate use and improving employment function and in decreasing stress level for opiate-dependent patients in MMT in China.

Trial Registration

ClinicalTrials.gov NCT01144390

"Bureaucracy & Beliefs": Assessing the Barriers to Accessing Opioid Substitution Therapy by People Who Inject Drugs in Ukraine

AIMS

Opioid substitution therapy (OST) is an evidence-based HIV prevention strategy for people who inject drugs (PWIDs). Yet, only 2.7% of Ukraine's estimated 310,000 PWIDs receive it despite free treatment since 2004. The multi-level barriers to entering OST among opioid dependent PWIDs have not been examined in Ukraine.

METHODS

A multi-year mixed methods implementation science project included focus group discussions with 199 PWIDs in 5 major Ukrainian cities in 2013 covering drug treatment attitudes and beliefs and knowledge of and experiences with OST. Data were transcribed, translated into English and coded. Coded segments related to OST access, entry, knowledge, beliefs and attitudes were analyzed among 41 PWIDs who were eligible for but had never received OST.

FINDINGS

A number of programmatic and structural barriers were mentioned by participants as barriers to entry to OST, including compulsory drug user registration, waiting lists, and limited number of treatment slots. Participants also voiced strong negative attitudes and beliefs about OST, especially methadone. Their perceptions about methadone's side effects as well as the stigma of being a methadone client were expressed as obstacles to treatment.

CONCLUSIONS

Despite expressed interest in treatment, Ukrainian OST-naïve PWIDs evade OST for reasons that can be addressed through changes in program-level and governmental policies and social-marketing campaigns. Voiced OST barriers can effectively inform public health and policy directives related to HIV prevention and treatment in Ukraine to improve evidence-based treatment access and availability.

Exploring the Concepts of Abstinence and Recovery Through the Experiences of Long-Term Opiate Substitution Clients

BACKGROUND

This study aimed to explore the client experience of long-term opiate substitution treatment (OST).

METHODS

A qualitative grounded theory study set in a U.K. rural community drug treatment service.

RESULTS

Continuous OST enabled stability and a sense of "normality." Participants expressed relief at moving away from previous chaotic lifestyles and freedom from the persistent fear of opiate withdrawal. However, for some, being on a script made them feel withdrawn, lethargic, and unable to fully participate in mainstream society. Intrapersonal barriers (motivation and fear) were perceived as key barriers to abstinence.

CONCLUSIONS

Participants experienced long-term OST as a transition between illicit drug use and recovery. Recovery was seen as a process rather than a fixed goal, confirming that there is a need for services to negotiate individualized recovery goals, spanning harm minimization and abstinence-oriented treatment approaches.

Impact of methadone maintenance treatment on women offenders' post-release recidivism

Drug--including opioid--dependence is common in correctional populations, however little research exists on interventions for women offenders. Based on retrospective administrative data, we examined rates of return to custody (RTC) among three samples of Canadian federal women offenders with problematic opioid use (total n=137): (1) a group initiated on MMT during incarceration who continued MMT post-release (MMT-C; n=25); (2) a group initiated on MMT but who terminated treatment post-release (MMT-T; n=67), and (3) a non-MMT control group (MMT-N; n=45). Study groups were similar regarding socio-demographic, drug use and criminogenic indicators. Based on an unadjusted Cox proportional hazards model, the MMT-C group had a 65% lower risk of RTC than the MMT-N (reference) group (HR 0.35, CI 0.13-0.90); RTC risk was not different between the MMT-T and the reference group. Most RTCs were for technical revocations (e.g. violation of a legal condition of their release). Continuous MMT following release from corrections appears to be effective in reducing recidivism in women offenders with opioid problems; barriers to MMT in the study population should be better understood and ameliorated.