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

Abstract

Background Heroin-Assisted Treatment (HAT) is well evidenced internationally to improve health and social outcomes for people dependent on opioids who have not been helped by traditional treatment options. Despite this evidence base, England has been slow to implement HAT. The first service outside of a trial setting opened in 2019, providing twice-daily supervised injections of medical-grade heroin (diamorphine) to a select sample of high-risk heroin users in Middlesbrough. This paper explores their experiences, including the negotiation of the strict regularly controls required of a novel intervention in the UK context. Methods We conducted in-depth interviews with service providers and users of the Middlesbrough HAT service between September and November 2021. Data from each group were thematically analysed and reported separately. This paper details the experiences of the twelve heroin dependent men and women accessing HAT. Results Participants’ accounts of HAT treatment evidenced a tension between the regulatory constraints and uncertainty of treatment provision, and the positive outcomes experienced through supportive service provision and an injectable treatment option. Limited confidence was held in treatment efficacy, longevity of funding, and personal capacity for treatment success. This was counteracted by a strong motivation to cease engagement with the illicit drug market. While attendance requirements placed restrictions on daily activities, participants also experienced benefits from strong, supportive bonds built with the service providers through their continued engagement. Conclusions The Middlesbrough HAT programme provided benefits to a high-risk population of opioid dependent people who were unable or disinclined to participate in conventional opioid substitution treatments. The findings in this paper highlight the potential for service modifications to further enhance engagement. The closure of this programme in 2022 prohibits this opportunity for the Middlesbrough community, but holds potential to inform advocacy and innovation for future HAT interventions in England.

Exploring Patients’ Perceptions on Injectable Opioid Agonist Treatment: Influences on Treatment Initiation and Implications for Practice

“…Regarding treatment-deterring perceptions, our results concur with findings from the UK [27], Australia [24], and Belgium [28] in which people living with OUD were reluctant to start iOAT due to the daily supervised application. Procedural factors such as daily visits are known to jeopardize the initiation and maintenance of both oOAT [37] and iOAT [12,38].…”

“…Individuals unresponsive to oOAT were motivated to start iOAT as a result of perceived benefits such as the reduction of street heroin use and criminal activities, achieving stability and normality, improving their health status, and having a dependable source of safe opioids [21][22][23][24][25]. While this is comparable to studies on oOAT, recent qualitative enquiries additionally found perceptions of the ineffectiveness of oOAT and the option to inject as encouraging for iOAT initiation [26,27]. Although less extensively studied, there are some data that represent perceptions that deter enrolment in iOAT.…”

“…Although less extensively studied, there are some data that represent perceptions that deter enrolment in iOAT. These include procedural aspects such as the daily supervised application as well as individuals' fears of exacerbating their OUD and not seeing their goals of recovery reflected in iOAT [24,27,28]. These findings, however, might not be easily transferable to iOAT in Germany due to variations in social and healthcare contexts, including the limited [28] or uncertain [27] time-frame of the programmes studied in the past.…”

“…These include procedural aspects such as the daily supervised application as well as individuals' fears of exacerbating their OUD and not seeing their goals of recovery reflected in iOAT [24,27,28]. These findings, however, might not be easily transferable to iOAT in Germany due to variations in social and healthcare contexts, including the limited [28] or uncertain [27] time-frame of the programmes studied in the past. Furthermore, as most studies have focused on either positive or negative aspects, it remains questionable how encouraging and deterring perceptions interact and might hinder iOAT engagement in practice.…”

“…Furthermore, as most studies have focused on either positive or negative aspects, it remains questionable how encouraging and deterring perceptions interact and might hinder iOAT engagement in practice. When studies did explore both positive and negative perceptions on iOAT, they did so either in a highly theoretical setting where iOAT was not a realistic option for participants [24] or focused solely on people currently engaged in iOAT [27].…”