Access to their own drugs': Navigating the drawbacks and benefits of injectable hydromorphone and diacetylmorphine treatment in Vancouver, BC
Amidst a sustained drug poisoning crisis, there is growing recognition in Canada and the US to expand use of injectable hydromorphone (HDM) and diacetylmorphine (DAM) for people diagnosed with opioid use disorder. While injectable HDM/DAM is an intensive treatment with demonstrated effectiveness in reducing drug use-related risks, it is also highly medicalized and involves ongoing surveillance, which can create barriers to treatment engagement. This study examined how clients navigate the operational components of this high-intensity treatment. Fifty-two participants were recruited for qualitative interviews during two waves of data collection between 2018-2019, including baseline (n=52) and follow-up interviews (n=19). Eligible participants were enrolled in injectable HDM/DAM treatment from four programs in Vancouver, Canada. Data included both individual interviews and >50 hours of field observations. Interview transcripts and field notes were analyzed thematically and guided by the theoretical concepts of risk and enabling environments, with attention to structural vulnerability.
Among clients, the benefits and drawbacks of receiving injectable HDM/DAM were influenced by the structural vulnerabilities shaping their everyday lives, such as unstable housing. Restrictive dosing policies, intensive time commitment, and the location and physical environment of treatment clinics functioned as drawbacks that negatively impacted participant engagement with this treatment. Such drawbacks were balanced against positive relationships with staff, access to health and social services, the potential to reduce overdose risk, and the possibility of moving beyond precarious employment conditions associated with obtaining illicit opioids.
Client experiences highlight how injectable HDM/DAM is navigated within the social context of structural vulnerabilities in everyday life. Adaptations to current treatment models could mitigate barriers and should focus on: building client autonomy; integrating this treatment into the continuum of care; and ensuring program flexibility to respond to clients’ needs. Findings also point to the need for broader structural interventions (e.g., housing) in order to improve treatment implementation.