Research Paper
Motivations to initiate injectable hydromorphone and diacetylmorphine treatment: A qualitative study of patient experiences in Vancouver, Canada

https://doi.org/10.1016/j.drugpo.2020.102930Get rights and content

Highlights

  • Experience and perception of ineffective alternative treatments shaped initiation.

  • Treatment initiation was contextualized by the overdose crisis.

  • Motivation to address physical risks (overdose, dope sickness and chronic pain).

  • Injectible HDM/DAM aligned with opioid use experiences and needs.

  • Desire to make changes to daily life and address broader opioid use goals.

Abstract

Background

Within the context of the ongoing overdose crisis and limitations of conventional opioid treatments, the scale-up of injectable hydromorphone (HDM) and diacetylmorphine (DAM) as evidenced-based treatments is currently underway in some settings in Canada. Past research has underscored the importance of treatment initiation in shaping onward treatment trajectories, however structural factors that influence participants' motivations to access injectable HDM or DAM have not been fully characterized. This study examines peoples’ motivations for accessing HDM/DAM treatment and situates these within the social and structural context that shapes treatment delivery by employing the concept of structural vulnerability.

Methods

Fifty-two individuals enrolled in injectable HDM/DAM programs were recruited from four community-based clinical programs in Vancouver, Canada to participate in qualitative semi-structured interviews. Approximately 50 h of ethnographic fieldwork was also completed in one clinical setting, and one-on-one with participants public spaces. Interview transcripts and ethnographic fieldnotes were analyzed through a structural vulnerability lens with a focus on treatment initiation.

Results

Participants’ previous experiences and perceptions of other drug treatments (e.g. methadone) foregrounded their initiation of injectable HDM/DAM. Social and structural factors (e.g. fentanyl-adulterated drug supply, poverty, drug criminalization) influenced participants’ motivations to address immediate physical risks and their initial perception of this treatment's ability to align with their opioid use experiences. Similar social and structural factors that drive immediate physical risks, were also evidenced in participants’ motivations to make changes in their daily lives and to address broader opioid use goals.

Conclusion

Participants descriptions of their motivations to initiate HDM/DAM highlight how structural vulnerabilities shaped participants’ experiences initiating injectable HDM/DAM.

Introduction

North America is in the midst of a devastating overdose crisis (Dart et al., 2015), fueled largely by the proliferation of fentanyl and fentanyl-adulterated opioids (Ciccarone, 2017). In the United States, 67367 people died from overdose in 2018, and synthetic opioids were involved in 67% of deaths (Centers for Disease Control and Prevention, 2019). In Canada, more than 15393 apparent opioid-related deaths occurred between January 2016 and December 2019, with 77% in 2019 involving fentanyl (Government of Canada, 2020a). The scale-up of opioid treatments has been identified as an urgent public health priority amidst this crisis (Government of Canada, 2020b). While this has primarily involved the expansion of oral medications for people diagnosed with opioid use disorder (MOUD) (e.g., methadone/Methadose, buprenorphine/naloxone), there has also been increased attention to the role of injectable hydromorphone (HDM) and diacetylmorphine (DAM) as treatment options in Canada and in the United States (Canadian Research Initiative in Substance Misuse [CRISM], 2019a; Kilmer et al., 2018; Maghsoudi, Bowles, & Werb, 2020).

Injectable HDM/DAM is now recommended in Canada as part of a stepped and integrated continuum of care which progresses in treatment intensity from oral to injectable medications (CRISM, 2019a). Despite growing availability of oral MOUD, implementation gaps still exist across the cascade of treatment with regards to retention and treatment stabilization (Socías et al., 2020, 2018). Understanding how injectable HDM/DAM impacts treatment uptake and retention when offered as part of a continuum of care has not been fully explored. Further, implementation and scale-up of this treatment is currently underway in some Canadian settings in the context of the fentanyl-driven overdose crisis. Understanding ways to improve implementation of injectable HDM/DAM within the cascade of care remains an important focus in understanding the role of treatment interventions in reducing overdose deaths (Nolan et al., 2015; Sordo et al., 2017).

Previous research has underscored how experiences initiating MOUD plays an important role in treatment engagement. While notably DAM and HDM have high retention rates (Oviedo-Joekes et al., 2016, 2019), treatment initiation remains a critical point in treatment engagement that is not well-understood in relation to these treatment options. Research on first-line oral MOUD has highlighted how treatment initiation is associated with specific demographic characteristics and social-structural exposures, including older age (Fairbairn et al., 2012; Lloyd et al., 2005), having been incarcerated, homeless, or unstably housed (Reynoso-Vallejo, Chassler, Witas, & Lundgren, 2008; Schütz, Rapiti, Vlahov & Anthony, 1994), living with HIV (Kerr, Marsh, Li, Montaner & Wood, 2005; Zule & Desmond, 2000), and a having a history of adverse childhood experiences (Moran, Keenan & Elmusharaf, 2018). Factors associated with treatment initiation also include drug use patterns, including frequency of drug injection, (Reynoso-Vallejo, Chassler, Witas, & Lundgren, 2008; Zule & Desmond, 2000) and overdose experiences (Kerr et al., 2005) as well as prior drug treatment experiences (Schütz et al., 1994; Zule & Desmond, 2000).

Further research on oral MOUD initiation has found that willingness to join treatment programs is influenced by a desire to reduce drug use and improve health (Tompkins, Neale, & Strang, 2019), an interest in joining treatment to alleviate the financial burden associated with drug use (Booth, Corsi & Mikulich, 2003) and a desire to change social networks, improve employment status, avoid involvement in criminalized activities (Stöver, 2011) and police interactions (Ghaddar, Khandaqji & Abbass, 2018). Willingness to enroll in treatment has also been found to be related to the perceived treatment effectiveness (Booth et al., 2003; Tompkins, Neale, & Strang, 2019; Zule & Desmond, 2000). Clinical trial data on injectable DAM note that the most frequently cited reasons for participating in this type of treatment included, “free heroin”, “reduced impact of heroin” and “limit illegal activity” (Nosyk et al., 2010). These motivations signified the opportunity for participants to introduce stability and “get their lives back” (Oviedo-Joekes et al., 2014).

Other studies have drawn attention to how initiation experiences structure treatment engagement. For example, pre-existing views regarding treatment prior to enrollment have been shown to predict early treatment termination (Kayman, Goldstein, Deren & Rosenblum, 2006). Further, coercive practices that leverage patients’ vulnerability during crisis initiation experiences can lead to negative treatment perceptions and early treatment discontinuation (Damon et al., 2017). Therefore, understanding the factors that impact treatment initiation is important in developing a robust understanding of treatment implementation. Herein, we examine peoples’ motivations to access HDM/DAM treatment and situate these motivations within the social and structural context that shape treatment delivery by employing a structural vulnerability lens.

Section snippets

Structural vulnerability and drug treatment

Structural vulnerability is an outcome of social positioning – that is, the ways in which positioning within social hierarchies and diverse networks of power influence peoples’ vulnerability to physical and emotional suffering (Quesada, Hart & Bourgois, 2011). It is related to the concept of structural violence, which has highlighted socially structured patterns of distress and disease across population groups (Farmer, 1996), but extends the concept through increased attentiveness to how social

Context: injectable HDM and DAM in British Columbia

Health Canada announced changes to expand access to DAM and HDM (Maghsoudi, Bowles, & Werb, 2020), and national clinical practice guidelines for this treatment were released in September 2019 (CRISM, 2019a). However, access to injectable DAM is limited to Crosstown Clinic in Vancouver, Canada, the site of a previous clinical trial (Study to Assess Longer-term Opioid Medication Effectiveness-SALOME)(Oviedo-Joekes et al., 2016). Continued access to treatment in this setting stems from the

Methods

This qualitative research study is being implemented alongside an observational prospective study of injectable HDM and DAM. Together, these studies aim to examine the implementation and effectiveness of this treatment, and how it is influenced by social-structural forces. Participant interviews were conducted from May 2018 to September 2019 to explore the implementation of injectable HDM or DAM in Vancouver. This is a longitudinal study, in which participants are interviewed once per year.

Themes: motivations for treatment initiation

These themes are organized with attention to how structural vulnerability shapes participants’ motivations to access injectable HDM/DAM. It was uncommon for participants to report a single motivation for initiating treatment. Most participants had multiple reasons for initiating injectable HDM/DAM and this is reflected in the results. Participants’ demographic characteristics are outlined in Table 1. The majority (69%) of participants identified as men and 31% as women. Nearly 60% of people

Discussion

Participants’ descriptions of their motivations to initiate HDM/DAM highlight how structural vulnerabilities shape experiences initiating injectable HDM/DAM. Participants’ perceptions and experiences of ineffective treatments (e.g. methadone) structured their initial perceptions of this treatment. Structural vulnerabilities (e.g. fentanyl-adulterated drug supply, economic precarity) influenced participants’ motivations to address immediate physical risks and influenced perceptions of this

Funding source

US National Institutes of Health [Grant # R01DA044181; R01DA043408]

Declarations of Interests

No conflicts declared.

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