Research PaperMotivations to initiate injectable hydromorphone and diacetylmorphine treatment: A qualitative study of patient experiences in Vancouver, Canada
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.
References (61)
- et al.
Improving entry to methadone maintenance among out-of-treatment injection drug users
Journal of Substance Abuse Treatment
(2003) - et al.
Problematizing the DSM-5 criteria for opioid use disorder: A qualitative analysis
International Journal of Drug Policy
(2020) Fentanyl in the US heroin supply: A rapidly changing risk environment
International Journal of Drug Policy
(2017)- et al.
Epidemiology of pain among outpatients in methadone maintenance treatment programs
Drug and Alcohol Dependence
(2013) - et al.
Characterizing pain and associated coping strategies in methadone and buprenorphine-maintained patients
Drug and Alcohol Dependence
(2015) - et al.
Factors associated with methadone treatment among injection drug users in Bangkok, Thailand
Journal of Substance Abuse Treatment
(2012) - et al.
Factors associated with methadone maintenance therapy use among a cohort of polysubstance using injection drug users in Vancouver
Drug and Alcohol Dependence
(2005) - et al.
Patient-centredness: A conceptual framework and review of the empirical literature
Social Science & Medicine
(2000) - et al.
The impact of low-threshold methadone maintenance treatment on mortality in a Canadian setting
Drug and Alcohol Dependence
(2015) - et al.
The effect of motivational status on treatment outcome in the North American Opiate Medication Initiative (NAOMI) study
Drug and Alcohol Dependence
(2010)
Trends in methadone maintenance treatment participation, retention, and compliance to dosing guidelines in British Columbia, Canada: 1996–2006
Journal of substance Abuse Treatment
Treatment with injectable hydromorphone: Comparing retention in double blind and open label treatment periods
Journal of Substance Abuse Treatment
Comparing Canadian and United States opioid agonist therapy policies
International Journal of Drug Policy
Patterns of drug treatment entry by Latino male injection drug users from different national/geographical backgrounds
Evaluation and Program Planning, 31
Suspected determinants of enrollment into detoxification and methadone maintenance treatment among injecting drug users
Drug and Alcohol Dependence
“Everything is not right anymore”: Buprenorphine experiences in an era of illicit fentanyl
International Journal of Drug Policy
Trajectories of retention in opioid agonist therapy in a Canadian setting
International Journal of Drug Policy
Trends in engagement in the cascade of care for opioid use disorder, Vancouver, Canada, 2006–2016
Drug and Alcohol Dependence
Opioid users’ willingness to receive prolonged-release buprenorphine depot injections for opioid use disorder
Journal of Substance Abuse Treatment
Chronic pain, craving, and illicit opioid use among patients receiving opioid agonist therapy
Drug and Alcohol Dependence
Pain among high-risk patients on methadone maintenance treatment
The Journal of Pain
Providers’ experiences treating chronic pain among opioid-dependent drug users
Journal of General Internal Medicine
Addiction and Heroin-assisted treatment: legal discourse and drug reform
Contemporary Drug Problems
Guideline for opioid therapy and chronic noncancer pain
CMAJ, 189
‘Crisis’ and ‘everyday'initiators: A qualitative study of coercion and agency in the context of methadone maintenance treatment initiation
Drug and Alcohol Review
Trends in opioid analgesic abuse and mortality in the United States
New England Journal of Medicine
The State of Opioid Agonist Therapy in Canada 20 Years after Federal Oversight
The Canadian Journal of Psychiatry
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