Negotiating structural vulnerability following regulatory changes to a provincial methadone program in vancouver, canada: A qualitative study

Abstract

While regulatory frameworks governing methadone maintenance therapy (MMT) require highly regimented treatment programs that shape treatment outcomes, little research has examined the effects of regulatory changes to these programs on those receiving treatment, and located their experiences within the wider context of socialstructural inequities. In British Columbia (BC), Canada, provincial regulations governing MMT have recently been modified, including: replacing the existing methadone formulation with Methadose® (pre-mixed and 10 times more concentrated); prohibiting pharmacy delivery of methadone; and, prohibiting pharmacies incentives for methadone dispensation. We undertook this study to examine the impacts of these changes on a structurally vulnerable population enrolled in MMT in Vancouver, BC. Qualitative interviews were conducted with 34 people enrolled in MMT and recruited from two ongoing observational prospective cohort studies comprised of drug-using individuals in the six-month period in 2014 following these regulatory changes. Interview transcripts were analyzed thematically, and by drawing on the concept of ‘structural vulnerability’. Findings underscore how these regulatory changes disrupted treatment engagement, producing considerable health and social harms. The introduction of Methadose® precipitated increased withdrawal symptoms. The discontinuation of pharmacy delivery services led to interruptions in MMT and codispensed HIV medications due to constraints stemming from their structural vulnerability (e.g., poverty, homelessness). Meanwhile, the loss of pharmacy incentives limited access to material supports utilized by participants to overcome barriers to MMT, while diminishing their capacity to assert some degree of agency in negotiating dispensation arrangements with pharmacies. Collectively, these changes functioned to compromise MMT engagement and increased structural vulnerability to harm, including re-initiation of injection drug use and participation in high-risk incomegenerating strategies. Greater attention to the impacts of social-structural inequities on MMT engagement is needed when modifying MMT programs, especially as other jurisdictions are adopting similar changes. Comprehensive environmental supports should be provided to minimize adverse outcomes during transitional periods.

Antiretroviral Therapy Interruption Among HIV Postive People Who Use Drugs in a Setting with a Community-Wide HIV Treatment-as-Prevention Initiative

“…Once the final thematic categories were established, data were recoded to ensure their trustworthiness. The concept of structural vulnerability was employed when interpreting these themes to focus attention on how social-structural factors and sociocultural processes produced treatment fatigue [31, 32]. …”

“…The concept of structural vulnerability focuses attention on how the interplay of structural inequities (e.g., disparities in incarceration rates under drug criminalization, housing instability) and socio-cultural processes (e.g., racism, sexism) render marginalized populations susceptible to harm [31, 32], and is particularly useful in understanding adverse ART outcomes among PWUD. For example, previous studies have demonstrated that factors associated with structural vulnerability, such as incarceration and homelessness [33, 34], contribute to ART discontinuation among PLHIV who use drugs in Vancouver, Canada, a setting with a community-wide TasP initiative.…”

“We’re giving you something so we get something in return”: Perspectives on research participation and compensation among people living with HIV who use drugs

“…drug criminalization, racism, poverty, sexism), as well as institutional structures (e.g. policies, regulations) (McNeil et al, 2015; Quesada, Hart, & Bourgois, 2011). Researchers and research ethics boards recognize that compensation incentivizes participation (Ripley et al, 2010) and may prompt PWUD and other structurally vulnerable populations to engage in low or high-risk research primarily out of financial need (Dickert & Grady, 1999).…”

Advancing patient‐centered care for structurally vulnerable drug‐using populations: a qualitative study of the perspectives of people who use drugs regarding the potential integration of harm reduction interventions into hospitals

“…Social-structural forces operating within hospitals often deny the subjective health experiences and agency of ‘structurally vulnerable’ patient populations. These populations occupy marginal positions within social hierarchies due to social-structural inequities (e.g., drug criminalization, racism) and institutional arrangements (e.g., policies and practices), which render them vulnerable to adverse outcomes (28,29). For example, institutionalized racism within hospital settings often constrains patient-centered communication and shared decision-making for racialized populations (e.g., Indigenous or African-American populations) (23,30,31).…”