Clinicians’ experience of providing heroin-assisted treatment: Key rewards and challenges

Background: Heroin-assisted treatment (HAT) is an evidence-based treatment for people with opioid use disorder who have not benefitted sufficiently from traditional opioid agonist treatment. HAT involves supervised self-administration of medical-grade heroin in designated clinics. While qualitative studies of patients’ experience of this treatment are crucial for understanding HAT’s impact, far less attention has been given to the experiences of those providing HAT. Scholars have called for more research on injectable opioid agonist treatment, such as HAT, and the involvement of healthcare professionals and nurses, as these treatment programs often are nurse-led and limited research exists on their role as “gatekeepers” to the services they provide. This study investigates clinicians’ experience of providing heroin-assisted treatment (HAT) to patients in Norway.

Methods: Qualitative in-depth interviews were conducted with 31 clinicians, four and fourteen months after the first HAT clinics were opened in Norway’s two largest cities: Oslo and Bergen. By conducting an inductive thematic analysis of interview data, we identified what clinicians experienced and perceived as the main rewards and challenges of providing this treatment.

Results: Analysis identified four aspects of providing HAT which clinicians experienced as particularly rewarding, and four aspects of treatment provision which were challenging. These rewarding aspects were the provision of holistic and patient-centered care; the observed harm reduction outcomes; the realization that the clinics ran smoother than expected; as well as positive clinic milieu and patient-clinician relations. The most challenging aspects of providing HAT were the negotiation of dosages and related risks of overdosing; the enforcement of rules and handling of individual patients’ frustration; the difficulties of initiating recovery beyond medication; and the staffing limitations which restricted treatment provision. However, the clinicians pointed out that these rewards and challenges of providing HAT could vary across different subgroups of patients. Some challenges were, for example, more pressing for the most unstable patients. 

Conclusions: This study presents the first findings on the clinicians' experience with the provision of HAT in Norway. It contributes also important knowledge about the clinical experiences with   HAT of which there is scarce evidence internationally. Results make evident that the research participants, quite unequivocally, experienced that the treatment was beneficial for their patients. This was an important part of what they saw as rewarding with the provision of HAT. Providing HAR was simultaneously filled with challenges, particularly related to securing a medically safe treatment for patients. However, the interviewed clinicians were more uncertain about the treatment’s utility for a smaller subgroup consisting of the most “unstable” patients.