Plausibility of patient-centred care in high-intensity methadone treatment: reflections of providers and patients

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.

"And this is the life jacket, the lifeline they've been wanting": Participant perspectives on navigating challenges and successes of prescribed safer supply

BACKGROUND

In 2021, 43% of drug toxicity deaths in Ontario were reported by public health units serving medium-sized urban and rural communities. Safer supply programs (SSPs) have been primarily established in large urban centres. Given this, the current study is based on an evaluation of a SSP based in a medium-sized urban centre with a large catchment area that includes rural and Indigenous communities. The aim of this research paper is to understand the challenges and successes of the nurse practitioner-led SSP from the perspective of program participants.

METHODS

Interpretive description was used to understand the experiences of 14 participants accessing a SSP. Each participant was interviewed using a semi-structured approach, and 13 of the interviewees also completed surveys accessed through Qualtrics. An iterative process using NVivo software was used to code interviews, and a constant comparative data analysis approach was used to refine and categorize codes to themes.

FINDINGS

Three overarching themes were the result of this analysis: feeling better, renewed hope, and safety. These three themes capture the experiences of participants in the SSP, including both the challenges and successes they faced.

CONCLUSION

The findings and subsequent discussion focus on both the key best practices of the program, and areas for future development and improvement. Despite barriers to services, prescribed SSPs are improving the lives of people who use drugs, and the current outcomes align with reports and evaluations from other SSPs across Canada.

Patient and Provider Perspectives on Processes of Engagement in Outpatient Treatment for Opioid Use Disorder: A Scoping Review

Effective treatment for opioid use disorder (OUD) is available, but patient engagement is central to achieving care outcomes. We conducted a scoping review to describe patient and provider-reported strategies that may contribute to patient engagement in outpatient OUD care delivery. We searched PubMed and Scopus for articles reporting patient and/or provider experiences with outpatient OUD care delivery. Analysis included: (1) describing specific engagement strategies, (2) mapping strategies to patient-centered care domains, and (3) identifying themes that characterize the relationship between engagement and patient-centered care. Of 3,222 articles screened, 30 articles met inclusion criteria. Analysis identified 14 actionable strategies that facilitate patient engagement and map to all patient-centered care domains. Seven themes emerged that characterize interpersonal approaches to OUD care engagement. Interpersonal interactions between patients and providers play a pivotal role in encouraging engagement throughout OUD treatment. Future research is needed to further evaluate promising engagement strategies.

Nurse managers' perceptions of patient-centred care and its influence on quality nursing care and nurse job satisfaction: Empirical research qualitative

AIM

To explore nurse managers' perceptions of patient-centered care (PCC), its influence on quality nursing care, nurse job satisfaction, and to provide baseline data for a context-driven PCC model.

DESIGN

The study utilized a qualitative, phenomenological design, employing individual in-depth interviews to collect data on nurse managers' PCC perceptions until data saturation.

METHODS

Sampling involved purposive selection of Northern Ghana, random selection of the tertiary hospital cluster with the three participating hospitals, and purposive sampling of the nine nurse managers. Data analysis employed thematic analysis based on a six-phase framework. Methodological trustworthiness was ensured through various strategies including prolonged engagement, supervisor discussions and crosschecking with interviewees.

RESULTS

Three main themes emerged from the study including nurse managers' conceptualization of PCC, perceived patient-centred practices and its influence on nursing quality and job satisfaction. The findings emphasized the patient's individuality, cultural values, holistic care, the importance of strong nurse-patient relationships and a patient-centric environment. The nurse managers perceived PCC as positively influencing quality nursing care and nurse job satisfaction. The findings offer nuanced insights into nurse managers' perspectives on patient-centeredness and highlight areas for improvement.

Patient reported goals for medications for opioid use disorder: A theory of proximal goal attainment

Background

There exist substantial patient barriers to accessing medications for opioid use disorder (MOUD), including travel distance, stigma, and availability of MOUD providers. Yet, despite these barriers, there exists a subset of patients who possess the requisite motivation to seek and remain adherent to treatment.

Objective

To explore patient-derived goals in MOUD treatment-adherent patients.

Methods

This study used in-depth interviews with patients receiving methadone who were enrolled in opioid treatment programs (OTPs) across Tennessee. Participants were recruited from 12 different OTPs to participate in telephonic semi-structured interviews to a point of saturation. Participants had to be adherent to treatment, in treatment for 6 months or greater, and English speaking. Analysis occurred inductively using a constructivist approach to Grounded Theory.

Results

In total, 17 patient interviews were conducted in the spring of 2021. Participants described goal setting across three general stages of treatment: (1) addressing acute physical and emotional needs upon treatment entry, (2) development of supportive structure and routine to develop healthy skills facilitated by treatment team, and (3) identifying and pursuing future-focused goals not directly linked to treatment. A Proximal Goals in MOUD Framework is introduced.

Conclusion

In this qualitative study on patient reported goals in MOUD it was found that goals are transitory and relative to the stage of treatment. Further research is needed to better understand goal evolution over the course of treatment and its impact on treatment retention.

The mobilization of nurse-client therapeutic relationships in injectable opioid agonist treatment: Autonomy, advocacy and action

INTRODUCTION

Injectable opioid agonist treatment (iOAT) is an evidence-based treatment that serves an important minority of people with opioid use disorder who require specialized care. Unique to iOAT care is the consistency with which clients access treatment (up to three times daily), a condition that creates repeated opportunities for health care engagement. To date, no study has examined therapeutic relationships in this life saving, nurse-led treatment that can have lasting implications in the equitable delivery of other forms of addictions care.

METHODS

This study used grounded theory to generate a dynamic framework for therapeutic relationship building in iOAT. Researchers collected semi-structured interviews from registered nurses working in iOAT sites (n=24) form January 2020 through June 2022. The study analyzed collected data through a constant comparative analysis; explored through open, axial, and selective coding; and assessed in a conditional relationship matrix. The team reviewed key findings with stakeholders through formalized processes of engagement to confirm saturation of coding categories. Throughout data collection and analysis, researchers integrated feedback from additional knowledge users and member checking. Reported findings adhered to the COREQ1 standardized checklist.

RESULTS

We identified five interrelated categories that created a distinct culture of care for iOAT nurses: Ways of Knowing, Personal Investment, Leveraging Empathy, Finding Flexibility, and Collaborating to Overcome. Through creating a safe, nonjudgmental environment, nurses establish therapeutic relationships that build trust to identify client needs outside of medication administration. In turn, nurses participate in team-based problem solving to advocate for client needs. If nurses cannot find flexibility within and outside of the health care system to improve client engagement, tensions can arise and therapeutic relationships can be strained.

CONCLUSIONS

Therapeutic relationships are an integral part of building and maintaining trust with a population that has been precariously involved with other forms of health care. Nurses make a substantial effort to create a safe and nonjudgmental environment to manifest a culture of care that bridges client needs and program access. Without the expansion of access to iOAT programs and their embedded services, nurses are limited in their ability to provide individualized care for clients with diverse needs.

Changes in daily dose in open-label compared to double-blind: The role of clients' expectations in injectable opioid agonist treatment

Introduction

Though double-blind studies have indicated that hydromorphone and diacetylmorphine produce similar effects when administered through injectable opioid agonist treatment (iOAT) programs, participant preference may influence some aspects of medication dispensation such as dose.

Methods

 This is a retrospective longitudinal analysis. Participants (n = 131) were previously enrolled in a double-blind clinical trial for iOAT who continued to receive treatment in an open-label follow up study. Data included medication dispensation records from 2012 to 2020. Using linear regression and paired t-tests, average daily dose totals of hydromorphone and diacetylmorphine were examined comparatively between double-blind and open-label periods. A subgroup analysis explored dose difference by preference using the proxy, blinding guess, a variable used to facilitate the measurement of treatment masking during the clinical trial by asking which medication the participant thought they received.

Results

During the open-label period, participants prescribed diacetylmorphine received 49.5 mg less than during the double-blind period (95% CI -12.6,-86.4). Participants receiving hydromorphone did not see a significant dose decrease. Participants who guessed they received hydromorphone during the clinical trial, but learned they were on diacetylmorphine during the open-label period, saw a decrease in total daily dose of 78.3 mg less (95% CI -134.3,-22.4) during the open-label period.

Conclusion

If client preference is considered in the treatment of chronic opioid use disorder, clients may be able to better moderate their dose to suit their individual needs. Together with their healthcare providers, clients can participate in their treatment trajectories collaboratively to optimize client outcomes and promote person-centered treatment options.

'This is hardcore': a qualitative study exploring service users' experiences of Heroin-Assisted Treatment (HAT) in Middlesbrough, England

BACKGROUND

Heroin-Assisted Treatment (HAT) is well evidenced internationally to improve health and social outcomes for people dependent on opioids who have not been helped by traditional treatment options. Despite this evidence base, England has been slow to implement HAT. The first service outside of a trial setting opened in 2019, providing twice-daily supervised injections of medical-grade heroin (diamorphine) to a select sample of high-risk heroin users in Middlesbrough. This paper explores their experiences, including the negotiation of the strict regularly controls required of a novel intervention in the UK context.

METHODS

We conducted in-depth interviews with service providers and users of the Middlesbrough HAT service between September and November 2021. Data from each group were thematically analysed and reported separately. This paper details the experiences of the twelve heroin dependent men and women accessing HAT.

RESULTS

Participants' accounts of HAT treatment evidenced a tension between the regulatory constraints and uncertainty of treatment provision, and the positive outcomes experienced through supportive service provision and an injectable treatment option. Limited confidence was held in treatment efficacy, longevity of funding, and personal capacity for treatment success. This was counteracted by a strong motivation to cease engagement with the illicit drug market. While attendance requirements placed restrictions on daily activities, participants also experienced benefits from strong, supportive bonds built with the service providers through their continued engagement.

CONCLUSIONS

The Middlesbrough HAT programme provided benefits to a high-risk population of opioid dependent people who were unable or disinclined to participate in conventional opioid substitution treatments. The findings in this paper highlight the potential for service modifications to further enhance engagement. The closure of this programme in 2022 prohibits this opportunity for the Middlesbrough community, but holds potential to inform advocacy and innovation for future HAT interventions in England.

More than just 'free heroin': Caring whilst navigating constraint in the delivery of diamorphine assisted treatment

BACKGROUND

In 2020, drug related deaths in the United Kingdom (UK) reached the highest rate in over 25 years, with hospitalisations and deaths particularly impacting people who use illicit opioids such as heroin. Treatment systems are increasingly required to be innovative to engage the most vulnerable at risk from premature morbidity and mortality. Heroin Assisted Treatment (HAT) is an alternative treatment modality for people for whom more traditional forms of opioid substitution therapy, such as methadone, have been ineffective. Middlesbrough, a town in the North-East England, was home to the first service in the UK to implement HAT outside of a clinical trial setting which closed for operation in November 2022.

METHODS

Qualitative in-depth interviews with patients and health care providers (n =17) involved in the delivery of HAT were undertaken during 2021. This paper focuses on the health care provider interviews, the majority of which took place remotely. Interviews were audio recorded and thematically analysed.

RESULTS

Health care providers navigated multiple layers of constraint during HAT implementation and delivery. We explore this in relation to three themes: 1) Negotiating risk and safety within treatment 2) More than a prescription: care beyond diamorphine 3) Internal and external delivery barriers and impact on treatment acceptability, identity and longevity. Negotiating and managing risks of polysubstance use was a complex task. Benefits regarding access to holistic care, improved therapeutic and social relationships were recognised by practitioners. The rigorous delivery schedule was the biggest barrier to engagement. Outside the treatment room, socio-structural factors posed additional challenges.

CONCLUSION

Despite some operational complexities, health care providers viewed HAT as an effective method of engaging a high risk population with drug treatment services, with holistic benefits for clients over and above the treatment of opioid dependency. Findings will inform advocacy and innovation for future HAT interventions in England.

'As for dignity and respect…. me bollix': A human rights-based exploration of service user narratives in Irish methadone maintenance treatment

INTRODUCTION

This paper explores the narratives of service users of contemporary methadone maintenance treatment services (MMT) in the Republic of Ireland to obtain their perspectives in the context of them negotiating their right to health METHODS: Participants were recruited and interviewed by a former service user of MMT services. In-depth qualitative interviews were conducted with 40 current and recent users of MMT services RESULTS: Participants overwhelmingly reported a reduced sense of personal agency because of their experiences in MMT treatment. Participants observed that their perceptions of treatment were forged by a sense of reduced autonomy, coercive and disrespectful approaches from healthcare workers. Within a system which the participants considered to be failing, the services that they accessed were predicated on a process of reward and punishment, where best practice was often ignored by practitioners, all of which resulted in adverse consequences for service users DISCUSSION: The findings indicate that there is a significant 'chasm' between human rights, policy and best practice and how these are operationalised within the structures and practices of Irish MMT services. The treatment of service users, based on human rights principles such as equality, respect, autonomy, empowerment and personal choice remains aspirational and is unlikely to be fulfilled without addressing more systemic challenges such as funding, training of staff, service culture, governance and independent oversight of MMT services.

Bridge clinic implementation of "72-hour rule" methadone for opioid withdrawal management: Impact on opioid treatment program linkage and retention in care

BACKGROUND

Methadone for opioid use disorder (OUD) treatment is restricted to licensed opioid treatment programs (OTPs) with substantial barriers to entry. Underutilized regulations allow non-OTP providers to administer methadone for opioid withdrawal for up to 72 h while arranging ongoing care. Our low-barrier bridge clinic implemented a new pathway to treat opioid withdrawal and facilitate OTP linkage utilizing the "72-hour rule."

METHODS

Patients presenting to a hospital-based bridge clinic were evaluated for OUD, opioid withdrawal, and treatment goals. Eligible patients were offered methadone opioid withdrawal management with rapid OTP referral. OTPs accepted patients as direct admissions. We described bridge clinic patients who received at least one dose of methadone between March-August 2021 and key clinical outcomes including OTP referral completion within 72 h. For the subset of patients referred to our two primary OTP partners, we described OTP linkage (i.e., attended at least one OTP visit within one month) and OTP retention at one month.

RESULTS

Methadone was administered during 150 episodes of care for 142 unique patients, the majority of whom were male (73%), white (67%), and used fentanyl (85%). In 92% of episodes (138/150), a plan for ongoing care was in place within 72 h. Among 121 referrals to two primary OTP partners, 87% (105/121) linked and 58% (70/121) were retained at one month.

CONCLUSIONS

Methadone administration for opioid withdrawal with direct OTP admission under the "72-hour rule" is feasible in an outpatient bridge clinic and resulted in high OTP linkage and 1-month retention rates. This model has the potential to improve methadone access.

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.