Injectable opioid agonist treatment: An evolutionary concept analysis

Abstract

Canada is currently in the midst of an overdose crisis. With new and innovative approaches desperately needed, injectable opioid agonist treatment (iOAT) should be considered as an integral treatment option to prevent even more fatalities. These programs provide injectable diacetylmorphine or hydromorphone to clients with severe opioid use disorders. Currently, they remain an under‐executed and under‐studied treatment modality. To better understand why this may be, we performed an evolutionary concept analysis as described by Rodgers. The attributes, antecedents, consequences, and surrogate terms of iOAT were unpacked and explored. Further, four themes were identified within the literature: (1) physical and mental health, (2) illicit drug use, (3) criminal behavior, and (4) ethical considerations. Recommendations surrounding the need for additional studies that focus on the perspectives of people who use opioids (PWUO), the necessity of nursing advocacy in iOAT, and the consideration of a changing illicit drug supply were explored. Further, theoretical analysis coupled with direct input from PWUO was discussed as a necessity to move forward with iOAT.

‘This is hardcore’: a qualitative study exploring service users’ experiences of Heroin-Assisted Treatment (HAT) in Middlesbrough, England

“…Frankie described his experience of treatment as follows; ‘you can’t do nothing because you’ve got to come here twice a day, it’s really hard, it’s really difficult’ . This supports previous criticisms of HAT as restrictive and constraining, or a form of social control that dictates service users’ daily movements and activities [ 42 ]. Consequently, participants relied on family and friends for assistance with transport, or filled time between doses with shopping, accessing wrap around support, visiting family or volunteering within the service.…”

“…Additionally, methadone was prescribed to alleviate withdrawal symptoms between short-acting diamorphine doses, with methadone collection monitored through contact with the pharmacy. Such highly regulated and intensive drug treatment models have been criticised for restricting service users’ daily movements, constricting freedom, and compromising service users’ autonomy [ 40 – 42 ]. Furthermore, moving away from illicit drug use can comprise multiple challenges, with reports of social isolation, separating from entrenched social networks, and stigmatisation described as ‘pains’ impacting recovery outcomes [ 43 , 44 ].…”

‘I feel like I found myself again’ – Rethinking ‘recovery’ in a qualitative exploration of Heroin Assisted Treatment (HAT) service users’ experiences

“…This may bound service users' opportunities and ambitions, and minimise the perceived value of non-abstinence related treatment outcomes. As suggested in previous literature, such stringent legislation may be indicative of institutionalised stigma and state control of a marginalised, criminalised and mistrusted population (37,38). More exible delivery methods may enable greater service user freedom, autonomy and social re-integration, while still mitigating engagement with illicit drug markets.…”

“…Middlesbrough HAT's twice-daily supervised, on-sight injecting schedule was in ways stabilising and facilitative of enhanced service engagement, but also restricted participants' daily activities. Hat adherence required participants to sacri ce a degree of agency, autonomy and freedom, potentially limited HAT's harm-reducing potential as participants were less able to fully and freely engage in the social world (37). Furthermore, the constraining effects of twice-daily clinic appointments may inadvertently 'push' patients towards abstinence-focused treatment goals (12) as loner-term goals such as employment, education and holidays are rendered almost impossible while in treatment.…”

“…Additionally, methadone is prescribed to alleviate withdrawal symptoms between short-acting diamorphine doses, with methadone collection monitored through contact with the pharmacy. Such highly monitored and in exible drug treatment models have been criticised for controlling service users' movements, constricting freedom and compromising patient autonomy (23,29,37,38). It is not currently well documented how these constraints impact services users' experiences, treatment desirability, acceptability, retention and effectiveness.…”