Drug Users' Views of Prescribed Methadone

The legal regulation of drugs and role of government: Perspectives from people who use drugs

BACKGROUND

The legalization and regulation of currently illicit drugs has come to the forefront of drug policy debates in recent years, particularly in the context of cannabis legalization and the opioid crisis in North America. However, sufficient granularity on the various aspects of a legally regulated drug supply is missing from these debates. Further, the voices and opinions of people who use drugs have generally been absent from drug law reform deliberations. This study aimed to examine the views of people who use drugs and who are deeply impacted by drug policies to understand the perceived impacts and role of government under a legalized-regulated market.

METHODS

Four focus groups were held with people who use drugs in Sydney, Australia.

RESULTS

Most participants supported various models of legalization, although the perspectives on these models were diverse. Overriding these views was skepticism over the government's role in regulating a legal market, as well as concern for the personal agency of people who use drugs under a medically regulated drug supply model. Some participants discussed potential harms (e.g. increases in use and initiation), but emphasized the benefits (e.g. increases in quality and safety) from legal reform.

DISCUSSION

While there was support for legal models of drug supply regulation, findings have major implications in terms of how governments and medical systems may perpetuate the oppression of people who use drugs through regulation, and urge future drug policy deliberations to include broader perspectives from the affected community.

Implants and depot injections for treating opioid dependence: Qualitative study of people who use or have used heroin

BACKGROUND

Long-acting opioid pharmacotherapy (OPT) is presumed to offer benefits over more conventional OPT formulations. This paper analyzes the views and experiences of people who use or have used heroin in order to explore two novel systems for delivering long-acting OPT: implants and depot injections. New materialism theorizing is used to interpret and frame the findings.

METHODS

Qualitative data were generated via seven focus groups conducted during 2017 in London, UK. Participants (n = 44; 28 men and 16 women; ages 33-66 years) had all received OPT. Focus group discussions covered real and potential OPT delivery systems. All participant data relating to implants and depot injections were coded using MAXQDA software and analysed inductively via Iterative Categorisation.

FINDINGS

Participants discussed implants and depot injections in terms of interacting physical, psychological and social factors: dose stability; OPT administration; stopping treatment; co-presence of an antagonist; breaking rituals and habits; reduced choice and control; feeling normal; information needs; getting on with everyday life; and social interaction. Participants identified both benefits and concerns, and variable needs and preferences, with respect to each delivery system.

CONCLUSIONS

Implants and depot injections are not 'fixed' medications that can be administered to people to achieve pre-determined treatment aims. Rather, they are complex 'assemblages' with uncertain outcomes. Furthermore, they are themselves part of wider interactive 'assemblages'. Drug developers and treatment providers need to understand this complexity in order to target long-acting OPT at people most likely to benefit from it, and to reduce any unintended negative consequences.

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.

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

BACKGROUND/AIM

To inform understanding of the experience of long-term opiate maintenance and identify barriers to recovery.

METHODS

A qualitative systematic review.

RESULTS

14 studies in 17 papers, mainly from the USA (65%), met inclusion criteria, involving 1,088 participants. Studies focused on methadone prescribing. Participants reported stability; however, many disliked methadone. Barriers to full recovery were primarily 'inward focused'.

CONCLUSION

This is the first review of qualitative literature on long-term maintenance, finding that universal service improvements could be made to address reported barriers to recovery, including involving ex-users as positive role models, and increasing access to psychological support. Treatment policies combining harm minimisation and abstinence-orientated approaches may best support individualised recovery.

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

AIMS

(i) To consider whether or not recovery-oriented treatment might be prompting heroin users prematurely into detoxification and abstinence programmes; (ii) to explore the findings with reference to Foucauldian theory.

METHODS

Longitudinal qualitative data comprising 57 audio-recorded interviews, which captured heroin users' views and experiences of treatment duration. Participants included 30 heroin users (15 men; 15 women) starting a new episode of treatment, of whom 27 (14 men; 13 women) were re-interviewed after 3 months. Recruitment occurred in community drug services, pharmacies and residential treatment settings in Southern England, UK. Transcribed data were systematically coded and analysed inductively.

FINDINGS

All participants wanted to be free from heroin and prescribed substitute drugs. Individuals were often impatient with the detoxing process and some reduced dosages of substitute medication faster than prescribers recommended, occasioning cross addiction and relapse. Previously unsuccessful rapid detoxifications induced slower recovery attempts. Participation in residential rehabilitation facilitated client realisation that recovery required time and effort.

CONCLUSIONS

Recovery-oriented treatment can prompt heroin users prematurely into detoxification and abstinence programmes with negative consequences. The desire to detoxify quickly can be interpreted through Foucault's concepts of 'self-governance' and 'resistance;' heroin users' participation in decision-making processes reflects notions of 'agency;' and clients' willingness to adopt longer approaches to recovery following past negative detoxification experiences and exposure to residential rehabilitation confirms their commitment to be 'well.' The experiential knowledge of heroin users who have personally attempted recovery is a crucial resource for both those contemplating their own recovery and those advocating recovery-oriented services.

Clients' perceptions of opioid substitution treatment: an input to improving the quality of treatment

Despite the emphasis on providing high quality mental health and addiction treatment, there has been relatively little consideration given to examining clients' perceptions of addiction treatment (consumer satisfaction) as a quality improvement strategy. The present article reports on a survey of a representative sample of 93 clients receiving opioid substitution treatment (OST). Employed participants reported higher treatment satisfaction and a pattern of positive associations was found between satisfaction and general health, mental health, social functioning, lower methadone doses, and participants' ratings of their treatment progress. Lower satisfaction was associated with higher frequency of benzodiazepine use, and, for women, longer treatment duration. Māori participants rated their treatment progress as lower than that of non-Māori. Results strongly endorse recording participants' comments to provide a deeper understanding of survey item ratings. The study findings highlight the need for a research focus on the roles of mental health and other registered nurses who work with people receiving OST in specialist service and primary care settings, and endorse a partnership approach to future research in this area. The pattern of findings arising from this study suggests key strategies for improving the flexibility and client responsiveness of OST.

A good quality of life under the influence of methadone: a qualitative study among opiate-dependent individuals

BACKGROUND

Attention from researchers and health care workers to the quality of life (QoL) of opiate users is growing, but most studies are quantitative, giving limited attention to the consumer's perspective. No information is available on how opiate-dependent individuals themselves perceive QoL and what they see as the important components that contribute to a good QoL.

OBJECTIVES

This qualitative study aims to expand our knowledge concerning opiate-dependent individuals' perceptions of a good QoL and the impact of methadone on components of a good QoL.

METHODS

In-depth interviews were conducted with 25 opiate-dependent individuals aged between 26 and 46 years old who started a methadone maintenance treatment at least 5 years ago. Purposive sampling was used to recruit participants with different socio-demographic characteristics and drug use profiles. The interviews were audio-tape recorded, transcribed verbatim and analysed thematically.

RESULTS

Thematic analyses revealed five key themes contributing to a good QoL for opiate-dependent individuals: (1) having social relationships, (2) holding an occupation, (3) feeling good about one's self, (4) being independent and (5) having a meaningful life. Opiate-dependent individuals valued methadone's ability to help them function normally, overcome their psychological problems and dependence on illicit opiates, and support them in achieving certain life goals. On the other hand, stigmatisation, discrimination, dependence on methadone and the drug's paralysing effects on their emotions were mentioned as common negative consequences.

CONCLUSIONS

The findings of this study highlight the importance of supporting opiate-dependent individuals in their daily life by means of practical, social and environmental support (alongside pharmacological treatment) in order to improve their QoL. This study further illustrates the ambivalent influence of methadone on opiate-dependent individuals' QoL, and demonstrates how something commonly perceived as a 'good' can also be a 'bad' for some people. Efforts should be made to limit the negative consequences of methadone on opiate-dependent individuals' QoL, while increasing its potential benefits.

Drug misuse treatment services in Scotland: predicting outcomes

OBJECTIVE

To investigate which aspects of treatment satisfaction are the best predictors of improved health, improved mental health and achievement of abstinence in drug misuse treatment services.

DESIGN

Data were collected as part of the Drug Outcome Research in Scotland study, a prospective cohort study designed to evaluate drug misuse treatment provided in Scotland. Data were collected using a structured interview. Participants were recruited between 1 October 2001 and 30 June 2002. Follow-up interviews were carried out approximately 8 months later. Logistic regression analysis is used to explore client satisfaction with treatment on outcomes, using the Treatment Perceptions Questionnaire (discussed in Marsden et al., Assessing client satisfaction with treatment for substance use problems and the development of the Treatment Perceptions Questionnaire (TPQ). Addict Res 2000;8:455-70).

SETTING

Prison, residential and community facilities.

PARTICIPANTS

A total of 841 drug users starting a new episode of drug treatment in Scotland in 2000-01.

INTERVENTIONS

Methadone, substitute drugs other than methadone, residential rehabilitation, residential detoxification and non-clinical.

MAIN OUTCOME MEASURES

Reported improvements in physical health, mental health and abstinence.

RESULTS

Client satisfaction predicted positive outcomes, independent of treatment setting. Predicting abstinence and improved physical and mental health were the items: 'I have received the help that I was looking for' and 'The staff have helped to motivate me to sort out my problems'.

CONCLUSIONS

Feeling that treatment is appropriate, finding staff motivating, and having enough time to sort out problems are important aspects of satisfaction with treatment among users of drug treatment services who achieved positive treatment outcomes. Services should seek to provide more individualized services based on understanding of individual client needs. This may require longer treatment periods and greater client involvement.

Eyes wide shut?--A conceptual and empirical critique of methadone maintenance treatment

BACKGROUND

Methadone maintenance treatment (MMT) has been the 'gold standard' pharmacotherapy treatment for illicit opioid dependence for over 30 years. It has been widely evaluated, and is generally claimed to be 'effective'.

METHODS

The objective of this paper is to review the rationale of MMT as an intervention for a biomedical disorder with primary social objectives as well as the methodological quality and evidence of MMT outcome research. Data sources included opioid dependence treatment practice, review and outcome research literature (1965-2001) in the form of peer-reviewed articles, books, monographs and reports that are preeminently cited and reviewed international studies on MMT. RESULTS/DATA SYNTHESIS: Rigorous and appropriate evaluation (i.e., RCTs, intent-to-treat, patient-centered) methods in MMT evaluations are rare. Evidence of MMT's effectiveness on primary treatment objectives is mixed and appears to be largely partial and short-term. Positive outcomes may be the result of selection effects of compliant patients and loss in proportion when more rigorous standards of analysis are applied.

CONCLUSIONS

The quality of existing MMT research, and evidence for its general effectiveness are limited. Key concepts of self-medication and psychiatric comorbidity are largely ignored in MMT treatment and research frameworks, although they may serve to explain MMT's limited treatment success. Emerging new opioid pharmacotherapies require the fundamental review of the existing MMT paradigm as well as the application of rigorous and appropriate evaluation methods for future treatment.

Users' experiences of heroin and methadone treatment

The present study, conducted in 2003, Melbourne, Australia, examined and compared how different personal and social resources related to participants' use of both heroin and methadone, as well as their experiences of stigma and program regulation, and their evaluation of methadone treatment. In-depth interviews were conducted with 10 participants (five men, five women) aged between 25 and 42. Participants who had diverse personal and social circumstances were purposefully sought. Findings showed that users with "non-addict" or "functional" self-concepts had more resources and supportive social relationships that assisted them to develop realistic treatment expectations, avoid the stigma associated with methadone, and focus on the benefits of the treatment. Conversely, "conflicted" users with limited resources, few social connections, and negative self-concept saw methadone as an addiction, and as a highly stigmatizing and disempowering intervention. Social policies that differentiate users and address ways of improving users' personal and social resources are now needed.

A risk-benefit analysis of methadone maintenance treatment

Methadone maintenance treatment for heroin (diamorphine) addiction has been extensively researched. There is consistent evidence that while in treatment, heroin addicts are at a lower risk of death, are less involved in crime, and feel and function better than while using heroin. Despite the research evidence supporting methadone treatment, there remains widespread public scepticism about this form of treatment. This scepticism is frequently expressed in terms of the perceived risks of methadone treatment. The perceived risk that methadone treatment may maintain people in an addicted lifestyle is not supported by research literature. The risks of treatment include an increased risk of death during induction into treatment, and risks of diversion of drugs to the black market. For some patients, adverse effects of methadone pose a problem and the availability of new pharmacotherapies may provide useful options for these patients. Risks can be reduced and benefits increased by directing greater attention to the quality of treatment.

Methadone, methadone treatment and non-fatal overdose

This paper provides a mainly qualitative investigation of the role of methadone and methadone treatment in non-fatal illicit drug overdose. During 1997 and 1998, semi-structured interviews were conducted with 33 individuals in six hospital accident and emergency departments in two Scottish cities. The research identified four overdose situations related to methadone/methadone treatment. These were: (1) topping up a legitimate methadone prescription; (2) abusing another's methadone prescription; (3) preferring illegal drugs to prescribed methadone; and (4) failing to obtain prescribed methadone. The implications of these findings for methadone treatment policy and practice are discussed.