“I’m Going to Stop Myself Before Someone Stops Me”: Complicating Narratives of Volitional Substance Use Treatment

Abstract

Background: Often people assume that entry into drug treatment is a voluntary action for persons who use drugs (PWUD). This narrative informs the organizational and regulatory structure of most treatment programs and consequently affects patients’ ability to exert agency over their own treatment. Yet, this view ignores the complex interplay between individual and structural factors in peoples’ decision-making processes, particularly among people who use drugs who are stigmatized and criminalized. Treatment programs that assume voluntary entry may lack appropriate services for the populations of treatment seekers that they serve.Methods: This paper uses semi-structured interviews with 42 participants in Opioid Substitution Treatment (OST) (including patients, clinic doctors and staff, and advocates) informed by one of the author’s own lived experience in OST, to examine patients’ treatment decisions, and in particular, if and how, the structural context of drugs’ illegality/criminalization affected their willingness to pursue treatment. A Critical Discourse Analysis was used to identify key themes.Results: Interview data demonstrates that most people who use drugs enter treatment under constrained conditions related to drugs’ illegality. Themes that emerged included: 1. A feeling of limited choices due to drugs’ illegality; 2. Peer and family pressure; 3. Fear of losing children; and 4. Internalized stigma (i.e. feeling they are dirty or bad for using).Conclusion: Narratives that frame PWUD’s treatment decisions as volitional provide political cover to policies that criminalize PWUD by obscuring their effect on PWUD’s treatment decisions. Treatment models, particularly those that serve highly criminalized populations, should be re-conceptualized outside of normative narratives of individual choice, and be broadened to understand how larger structures constrain choices. By looking at macro-level factors, including the interplay of criminalization and drug treatment, programs can begin to understand the complexity of PWUD motivations to enter drug treatment. Recognizing the role of the War on Drugs as a force of oppression for people who use drugs, and that their treatment decisions are made within that setting, may enable people in treatment, and providers, to develop more productive ways of interacting with one another. Additionally, this may lead to better retention in treatment programs.

“It’s like ‘liquid handcuffs”: The effects of take-home dosing policies on Methadone Maintenance Treatment (MMT) patients’ lives

“…In other words, whether patients pursue abstinence or not, MMT provides them with a shelter from harms stemming from the criminalization of drug use. Similarly, Frank & Walters have problematized the notion of consent in MMT by pointing out the ways that structural, legal, and cultural forces constrain the decisions of people who use illegal opioids [ 29 ]. In this light, restrictive take-home policies, and those who enforce them appear as yet another structural barrier preventing PWUD from obtaining safe access to opioids.…”

“…Because they are regulated differently, buprenorphine providers have far more latitude to determine the most appropriate take-home schedule for their patients and generally provide take home doses more often than MMT clinics [ 45 ]. In fact, research shows that some PWUD choose buprenorphine over MMT, despite a preference for methadone, because of the access it provides to take-home doses, and that—since buprenorphine is only a partial agonist and methadone is a full-agonist—such choices could lead to negative healthcare outcomes [ 29 ].…”

“…Moreover, as he has done in previous studies, Frank regularly disclosed his status as someone with lived experience of opioid use who was currently on MMT to study participants [ 9 , 15 ]. Although he has discussed many of the methodological issues associated with this choice in other articles (see for example [ 29 ], in short, the authors believe that by disclosing Frank’s shared history, he was able to develop a level of comfort and trust with study participants that facilitated more robust and honest conversations and a richness of data that would not have been possible otherwise. There is an extensive literature describing the mistrust that PWUD often feel towards public health and substance researchers that similarly recognizes the importance of research conducted by and involving community insiders [ 30 – 32 ].…”