Barriers to progressing through a methadone maintenance treatment programme: perspectives of the clients in the Mid-West of Ireland’s drug and alcohol services

Abstract

BackgroundThe ‘perfect’ journey through an Irish Methadone Maintenance Treatment Programme (MMTP) would have a client engage appropriately with all relevant services available to them, inclusive of psychiatry, counselling, out-reach support, nursing and psychology. Concurrently, a client would ideally adhere to their prescribed methadone-dosing regimen, until a client is stabilised allowing them to function optimally. At this point, a client should transfer to the GP community setting. Unfortunately, this fails to occur. To date, very few studies have specifically investigated the reasons why a cohort of clients remain ‘trapped’ in the high risk, specialist clinical setting.MethodsQualitative detailed semi-structured interviews were undertaken with 17 clients of one of Ireland’s Health Service Executive (HSE) Drug and Alcohol Services, entitled ‘HSE Mid-West Limerick Drug and Alcohol Service’. Each client had a severe Opioid Use Disorder (OUD) and clients had spent on average 7.5 years engaging with the MMTP.ResultsParticipants’ life journey prior to an OUD included Adverse Childhood Experiences (ACEs) and early exposure to illicit drug use. Shared life events resulting in their initiating and sustaining an OUD involved continuous hardship into adulthood, mental illness and concurrent benzodiazepine use disorder, often resulting in harrowing accounts of participants’ loneliness and lack of life purpose. Their living environments, an erroneous understanding of their illness and poor communication with allied health professionals further perpetuated their OUD. Positive factors influencing periods of abstinence were familial incentives and a belief in the efficacy of methadone. Clients own suggestions for improving their journeys included employing a multi-sectorial approach to managing OUD and educating themselves and others on opioid agonist treatments. If clients were not progressing appropriately, they themselves suggested enforcing a ‘time-limit’ on clients to engage with the programme or indeed for their treatment to be postponed.ConclusionsTo optimise the functioning of the MMTP, three tasks need to be fulfilled: 1) Reduce the incidences of ACEs, 2) Diagnose and treat clients with a dual diagnosis 3) Educate clients, their families, the public and allied health care professionals on all aspects of OUD. A cross- departmental, inter-governmental approach is needed to address opioid misuse as a societal issue as a whole.

Factors influencing recovery in opioid substitution treatment: a systematic review and thematic synthesis

“…[INSERT OST medications should be delivered in tandem with psychosocial support, however treatment services may not be providing the type of support that service users need during detox, placing more emphasis on stopping drug use than resolving underlying issues (24-28)" "I do feel that the services tend to treat the symptoms not the cause hugely" The included studies show that, although abstinence is not a goal for all services users, with 'on-top' use of heroin relatively common (20,26,(29)(30)(31). As described above, many welcome the stability provided by OST to be able to stop using heroin and regain a sense of normality and routine (21,23,24,29,(31)(32)(33). However, the next steps towards 'recovery', and for some, abstinence, are more challenging.…”

“…The keyworker role may provide unique challenges for both service users and staff, with staff having to perform multiple roles including 'gatekeeper' of medications and 'monitor' of treatment adherence (42). This may result in service users feeling the need to withhold information in order to secure their medications (21,25,28,34,(42)(43)(44)(45)(46). The 'monitoring' aspect of the role (for instance, performing drug testing) appeared to be a particular barrier to building trust in client-staff relationships (42):…”

“…Whilst actively avoiding their drug using networks, they do not yet feel integrated into wider society (25,27). This leaves individuals feeling isolated and lonely (20,21,25,37,43), which in turn results in increased vulnerability to relapse:…”

“…Stigma is a cross-cutting concept that permeated all levels of the SEM and was referred to either directly or indirectly in 22 of the 37 included studies. The studies showed that service users are vulnerable to experiencing stigma from a wide range of sources including from pharmacy staff and other customers when collecting OST medications (44,(47)(48)(49)(50); the GP surgery and other healthcare settings (21,43,45,50,51); from their family and friends (25); from the wider community (25,27,29,41,43,45) and from the government (27,50).…”

“…Repeatedly experiencing stigma results in service users fearing judgement from others, which can directly lead to premature detox from OST to avoid further scrutiny (29). This may leave service users vulnerable to relapse and overdose and may prevent them from seeking help from professionals for other health issues (21,43,51). Experiencing stigma can lead to feelings of shame and result in self-stigma -the lowering of one's expectations of self and motivation to change (25,30,50).…”