OST futures: integrating the user’s experience into person-centred care

Background

The efficacy of opiate substitution treatment (OST) in substantially reducing illicit heroin use, opioid overdose deaths and HIV infection, and in improving the quality of life of people who are opioid dependent, is well evidenced internationally (ACMD, 2015; Mattick, Breen, Kimber & Davoli, 2009; National Treatment Agency, 2012). However, contextual conditions influence intervention outcomes (Tilley, 1998), including the risk environments (Rhodes, 2004; O’Gorman, 2016) that structure treatment delivery.

This study explores the experiences and perspectives of people receiving methadone maintenance treatment (MMT) in the abstinence-focussed environment of a Recovery-Oriented System of Care (ROSC) in Scotland. The study aims to inform future drug treatment policy and practice by capturing how context influences treatment experience and outcomes, and shapes the views of people undergoing MMT towards their treatment.

Methods

Qualitative semi-structured interviews were chosen to gather in-depth data on people’s experiences of MMT. Nineteen participants (10 females and 9 males) who had received MMT for two years or more were recruited from a number of services in Glasgow, Scotland. The interview schedule was co-produced with people with lived and living experience of methadone and recovery. Interviews were recorded, fully transcribed and coded for emergent themes. A content and thematic analysis of the data was conducted using NVivo to compare and contrast the research participants’ experinces and perspectives.

Results

All participants reported seeking improved health and relationships; being ‘normal’; and being ‘abstinent’ from drug use as their treatment outcome goals. Abstinence included cessation of MMT despite participants reporting and acknowledging its positive impact on their health and well-being. Participants expressed feelings of disempowerment as a result of having little input into their care plan, particularly in relation to dose management and the travails of attending daily supervised methadone consumption. However, further in-depth questioning by the interviewer revealed that the participants’ views of MMT were shaped by their experience of stigma within drug treatment services. This stigma resulted from their care providers and ‘abstinent’ peers’ disapproval of their long-term participation in MMT. Their designated ‘unclean’ status affected, for example, their access to ancillary services such as mental health and trauma support and group talk therapies. As a result, their broader mental health and social needs remained unaddressed.

Conclusions

The results suggest a level of cognitive dissonance among the study participants in relation to their contradictory experience of MMT. On the one hand they appreciated its role in improving their health and well-being and managing their substance use; on the other hand, they experienced stigma, exclusion and isolation within the ROSC drug treatment services as a result of their ongoing MMT. The study’s results highlight how the efficacy of long-term MMT may be compromised within the abstinence expectation context of a Recovery-Oriented System of Care and indicate the need for person-centred care and integrated service provision to address needs.