Opioid maintenance treatment retention and perceptions of care among long-term opioid dependent men and women

Background: Opioid dependence is a chronic relapsing disease with a number of related harms. Despite the proven effectiveness of opioid maintenance many men and women are not engaged or retained in this treatment. Accounting for patient perceptions of their interactions with health care providers may offer important evidence as to meeting gender specific heath and treatment needs of this population. Objective: This thesis investigates access to health care and addiction treatment services among long-term opioid dependent men and women. Factors associated with retention to opioid maintenance treatment are explored among participants and stratified by gender. Perceptions of encounters with health care providers as potentially offensive, degrading, or abusive are considered. Finally, the feasibility of sharing study findings with long-term opioid users are explored. Methods: The Gender Matters in the Health of Long-term Opioid Users study is a descriptive cross-sectional study of long-term opioid users in the Downtown Eastside of Vancouver. Descriptive variables were explored and logistic regression models were built to determine associations between independent variables and the opioid maintenance treatment retention and perceived abuse in health care outcomes. Two formats of sharing study findings with participants were piloted and participant perceptions of study findings and the meeting formats were gathered. Results: Rates of opioid maintenance treatment retention were similar among men and women while factors associated with retention differed by gender. Half of participants reported perceived abuse in health care, which was associated with childhood maltreatment and psychological health problems. The majority of participants felt it was important for participants to be involved in knowledge translation, while few had previously had the opportunity to do so. Conclusions: Gender, along with other structural factors have strong implications for the appropriateness and success of the treatment and models of care provided to opioid-dependent men and women. Patient histories and perspectives must be accounted for to determine suitable treatments and to ensure health care encounters are not perceived as offensive, degrading, or abusive. The involvement of participants in knowledge translation can serve as a means of empowering participants and accounting for patient voice in recommendations for service provision and policy.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofGraduat

Processes and patterns of cocaine use among patients receiving injectable opioids for the treatment of opioid use disorder : a multi-method study

Background: Injectable opioid agonist treatment with hydromorphone (a licensed opioid analgesic) or diacetylmorphine (pharmaceutical grade heroin) is effective at reducing illicit opioid use and improving health and social functioning among patients with opioid use disorder. Concurrent cocaine use is prevalent among patients receiving injectable opioid agonist treatment, however modest declines have been observed in the proportion of patients using cocaine and in the number of days of cocaine use while engaged in treatment. To date, studies have not explored what processes might explain these reductions, or how patterns of cocaine use might vary over time at the intra- and inter-individual levels. Methods: This study was conducted with patients receiving daily injectable hydromorphone or diacetylmorphine for the treatment of opioid use disorder at a clinic in Vancouver, Canada. The qualitative analysis was guided by a grounded theory approach involving one-on-one patient interviews (n=31). Findings directed covariate selection for the quantitative analysis. The profile of participants using cocaine was characterized (n=166), and multilevel models were used to explain variation in cocaine use over 24-months, using data from a baseline visit and six follow-up visits. Results: Qualitative analysis revealed that access to injectable opioid agonist treatment promoted the self-management of cocaine use. Participants distanced themselves from the street environment, made efforts to “control” their cocaine use, and sought supports to bolster these efforts. Quantitative analyses identified significant intra- and inter-individual variation in cocaine use over 24-months. On average, cocaine use decreased over time, however the rate of change varied from one participant to the next. Women reported more cocaine use than men, and participants with more lifetime years of cocaine use at baseline reported more cocaine use over 24-months. Conclusions: This research highlights heterogeneity in patterns and processes of cocaine use. Intra- and inter-individual variation in cocaine use was identified, and was explained by participant characteristics, including demographics and substance use histories. Given daily contact with care, injectable opioid agonist treatment serves as an optimal setting to integrate treatments for cocaine use disorder. Care providers can communicate with patients about their patterns of cocaine use and associated characteristics to guide treatment plans.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofGraduat

Feasibility of Applying the Life History Calendar in a Population of Chronic Opioid Users to Identify Patterns of Drug Use and Addiction Treatment

Uncovering patterns of drug use and treatment access is essential to improving treatment for opioid dependence. The life history calendar (LHC) could be a valuable instrument for capturing time-sensitive data on lifetime patterns of drug use and addiction treatment. This study describes the methodology applied when collecting data using the LHC in a sample of individuals with long-term opioid dependence and aims to identify specific factors that impact the feasibility of administering the LHC interview. In this study, the LHC allowed important events such as births, intimate relationships, housing, or incarcerations to become reference points for recalling details surrounding drug use and treatment access. The paper concludes that the administration of the LHC was a resource-intensive process and required special attention to interviewer training and experience with the study population. These factors should be considered and integrated into study plans by researchers using the LHC in addiction research

Use of sustained release dextroamphetamine for the treatment of stimulant use disorder in the setting of injectable opioid agonist treatment in Canada: a case report

Background: For people with opioid use disorder who are not responding to oral opioid agonist treatment, evidence supports the effectiveness of injectable opioid agonist treatment with injectable hydromorphone (an opioid analgesic) and diacetylmorphine (pharmaceutical grade heroin). While this treatment is effective at reducing illicit opioid use, concurrent cocaine use is prevalent. Dextroamphetamine (a central nervous system stimulant) has been found to be a safe and effective treatment for cocaine dependence among people receiving injectable opioid agonist treatment in Europe. We present the first report of dextroamphetamine prescribing offered for the treatment of stimulant use disorder among a patient receiving iOAT outside of a clinical trial. This case report can be used to inform clinical practice in the treatment of cocaine use disorder, an area where interventions are currently lacking. Case presentation: Dextroamphetamine was prescribed to a 51-year-old male who was diagnosed with concurrent opioid and stimulant use disorder in an injectable opioid agonist treatment clinic in Vancouver, Canada. He reported smoking crack cocaine daily for more than two decades and was experiencing health consequences associated with this use. He presented to his routine physician visit with the goal of reducing his cocaine use and was prescribed dextroamphetamine for the treatment of stimulant use disorder. After 4-weeks the patient was tolerating the medication with no observed adverse events and was achieving his therapeutic goal of reducing his cocaine use. Conclusions: Dextroamphetamine can be prescribed to support patients with stimulant use disorder to reduce or stop their use of cocaine. The case demonstrated that when dextroamphetamine was prescribed, a significant reduction in cocaine use was experienced among a patient that had been regularly using cocaine on a daily basis for many years. Daily contact with care for the opioid medication promoted adherence to the stimulant medication and allowed for monitoring of dose and tolerance. Settings where patients are in regular contact with care such as oral and injectable opioid agonist treatment clinics serve as a suitable location to integrate dextroamphetamine prescribing for patients that use illicit stimulants to reduce use and associated harms.Medicine, Faculty ofOther UBCNon UBCPopulation and Public Health (SPPH), School ofReviewedFacult

The relationship between sense of community belonging and self-rated mental health among Canadians with mental or substance use disorders

<p><i>Background</i>: One-third of Canadians meet the criteria for a mental or substance use disorder at some point in their lifetime. While prevention and treatment efforts have been focused on the individual, studies suggest the importance of incorporating social and community factors.</p> <p><i>Aims</i>: This study investigates the relationship between community belonging and self-rated mental health among Canadians with mental or substance use disorders.</p> <p><i>Methods</i>: The Canadian Community Health Survey-Mental Health (2012) is a nationally representative survey of Canadians aged 15 years and older (<i>n</i> = 25,113). The present analytic sample is comprised of respondents reporting a mental or substance use disorder in the previous 12 months (<i>n</i> = 2628). The relationship between community belonging and self-rated mental health is depicted with a multivariable multinomial logistic regression model.</p> <p><i>Results</i>: Self-rated mental health was reported as follows: poor or fair (38.1%); good (33.7%); and very good or excellent (28.2%). In the multivariable multinomial model, a positive relationship was observed. Those reporting very strong compared to very weak community belonging had an increased odds of better mental health.</p> <p><i>Conclusions</i>: Findings indicate the importance of social and community-based interventions to effectively engage and retain individuals in services for the prevention and treatment of mental and substance use disorders.</p

Identifying behaviours for survival and wellness among people who use methamphetamine with opioids in British Columbia: a qualitative study

Abstract Background British Columbia (BC) has been in a state of public health emergency since 2016, due to the unprecedented numbers of fatal and non-fatal drug toxicity (i.e. overdose) events. Methamphetamine detection in illicit drug toxicity deaths increased from 14% in 2012 to 43% in 2020 suggesting a concerning trend of concurrent methamphetamine and opioid use in BC, consistent with rising patterns identified across North America. People who use methamphetamine concurrently with opioids face an elevated risk of harm. This study aimed to identify behaviours for survival and wellness practiced by people who concurrently use methamphetamine and opioids. Methods One-on-one semi-structured interviews were conducted by peer research assistants in person and by telephone. Thematic analysis was carried out to identify patterns in behaviours participants described as important to their safety in the context of concurrent use of methamphetamine and opioids. Results Participants (n = 22) were distributed across the province with at least four participants from each of the five geographic health regions: 64% self-identified as men, and 50% self-identified as Indigenous. Daily methamphetamine use was reported by 72.7% of participants, and 67.3% reported using alone either often or always. Participants made several considerations and adaptations in order to balance the perceived benefits and risks of their use of methamphetamine with opioids. Two overarching themes were identified to describe how participants adapted their use for survival and wellness. The first was personal safety behaviours which included self-regulation and self-care behaviours. The second was interpersonal safety behaviours which included using alongside peers, and engaging with peer-led services (e.g. community outreach organizations) and public health-led services (e.g. overdose prevention sites) to reduce the risk of harm. Participants identified many gaps in available services to meet their diverse needs. Conclusions This manuscript identified diversity in participants’ methamphetamine and opioid use (i.e. frequency, route of administration), and a range of behaviours that were performed to improve wellness and survival while using methamphetamine and opioids. Harm reduction and treatment responses must be robust and adaptable to respond to the diversity of patterns of substance use among people who use methamphetamine and opioids concurrently, so as to not perpetuate harm and leave people behind.Medicine, Faculty ofNon UBCPopulation and Public Health (SPPH), School ofReviewedFacult

Stimulant use disorder diagnosis and opioid agonist treatment dispensation following release from prison : a cohort study

Background: Concurrent opioid and stimulant use is on the rise in North America. This increasing trend of use has been observed in the general population, and among people released from prison in British Columbia (BC), who face an elevated risk of overdose post-release. Opioid agonist treatment is an effective treatment for opioid use disorder and reduces risk of overdose mortality. In the context of rising concurrent stimulant use among people with opioid use disorder, this study aims to investigate the impact of stimulant use disorder on opioid agonist treatment dispensation following release from prison in BC. Methods: Linked health and corrections records were retrieved for releases between January 1st 2015 and December 29th 2018 (N = 13,380). Hospital and primary-care administrative health records were used to identify opioid and stimulant use disorder and mental illness. Age, sex, and health region were derived from BC’s Client Roster. Incarceration data were retrieved from provincial prison records. Opioid agonist treatment data was retrieved from BC’s provincial drug dispensation database. A generalized estimating equation produced estimates for the relationship of stimulant use disorder and opioid agonist treatment dispensation within two days post-release. Results: Cases of release among people with an opioid use disorder were identified (N = 13,380). Approximately 25% (N = 3,328) of releases ended in opioid agonist treatment dispensation within two days post-release. A statistically significant interaction of stimulant use disorder and mental illness was identified. Stratified odds ratios (ORs) found that in the presence of mental illness, stimulant use disorder was associated with lower odds of obtaining OAT [(OR) = 0.73, 95% confidence interval (CI) = 0.64–0.84)] while in the absence of mental illness, this relationship did not hold [OR = 0.89, 95% CI = 0.70–1.13]. Conclusions: People with mental illness and stimulant use disorder diagnoses have a lower odds of being dispensed agonist treatment post-release compared to people with mental illness alone. There is a critical need to scale up and adapt opioid agonist treatment and ancillary harm reduction, and treatment services to reach people released from prison who have concurrent stimulant use disorder and mental illness diagnoses.Medicine, Faculty ofOther UBCNon UBCPopulation and Public Health (SPPH), School ofPsychiatry, Department ofReviewedFacultyResearcherPostdoctoralOthe

The Role of Gender in Factors Associated With Addiction Treatment Satisfaction Among Long-Term Opioid Users.

To identify factors associated with Opioid Agonist Treatment (OAT) satisfaction and to determine whether these relationships are gender specific.This study was based on data collected in a cross-sectional study among long-term opioid-dependent individuals (n = 160; 46.3% women). Participants completed the Client Satisfaction Questionnaire in reference to OAT episodes. Sociodemographic, illicit substance use, health, and addiction treatment history data were collected. Multivariable linear regression was used to determine the relationship between these variables and treatment satisfaction. To explore the potential role of gender in these identified relationships stratified multivariable models were tested. Additional open-ended questions regarding positive and negative perceptions of treatment were collected, and a thematic analysis was conducted.In the multivariable linear regression model, participants who were older, of Aboriginal ancestry, and currently receiving OAT had higher OAT satisfaction scores, whereas participants who had methadone dose preferences of 30 mg or less had lower OAT satisfaction. In stratified analyses among women, the relationship between preferred methadone dose and current OAT remained significantly associated with satisfaction. Open-ended positive and negative perceptions complemented and provided further valuable data to interpret these identified relationships.To our knowledge, this is the first study to explore the potential role of gender in factors associated with OAT satisfaction. These findings provide valuable information to health care providers working in OAT settings regarding how to address women and men's OAT needs and improve treatment satisfaction

The Role of Gender in Factors Associated With Addiction Treatment Satisfaction Among Long-Term Opioid Users.

ObjectivesTo identify factors associated with Opioid Agonist Treatment (OAT) satisfaction and to determine whether these relationships are gender specific.MethodsThis study was based on data collected in a cross-sectional study among long-term opioid-dependent individuals (n = 160; 46.3% women). Participants completed the Client Satisfaction Questionnaire in reference to OAT episodes. Sociodemographic, illicit substance use, health, and addiction treatment history data were collected. Multivariable linear regression was used to determine the relationship between these variables and treatment satisfaction. To explore the potential role of gender in these identified relationships stratified multivariable models were tested. Additional open-ended questions regarding positive and negative perceptions of treatment were collected, and a thematic analysis was conducted.ResultsIn the multivariable linear regression model, participants who were older, of Aboriginal ancestry, and currently receiving OAT had higher OAT satisfaction scores, whereas participants who had methadone dose preferences of 30 mg or less had lower OAT satisfaction. In stratified analyses among women, the relationship between preferred methadone dose and current OAT remained significantly associated with satisfaction. Open-ended positive and negative perceptions complemented and provided further valuable data to interpret these identified relationships.ConclusionsTo our knowledge, this is the first study to explore the potential role of gender in factors associated with OAT satisfaction. These findings provide valuable information to health care providers working in OAT settings regarding how to address women and men's OAT needs and improve treatment satisfaction

Identifying behaviours for survival and wellness among people who use methamphetamine with opioids in British Columbia: a qualitative study

Background: British Columbia (BC) has been in a state of public health emergency since 2016, due to the unprecedented numbers of fatal and non-fatal drug toxicity (i.e. overdose) events. Methamphetamine detection in illicit drug toxicity deaths increased from 14% in 2012 to 43% in 2020 suggesting a concerning trend of concurrent methamphetamine and opioid use in BC, consistent with rising patterns identified across North America. People who use methamphetamine concurrently with opioids face an elevated risk of harm. This study aimed to identify behaviours for survival and wellness practiced by people who concurrently use methamphetamine and opioids. Methods: one-on-one semi-structured interviews were conducted by peer research assistants in person and by telephone. Thematic analysis was carried out to identify patterns in behaviours participants described as important to their safety in the context of concurrent use of methamphetamine and opioids. Results: Participants (n = 22) were distributed across the province with at least four participants from each of the five geographic health regions: 64% self-identified as men, and 50% self-identified as Indigenous. Daily methamphetamine use was reported by 72.7% of participants, and 67.3% reported using alone either often or always. Participants made several considerations and adaptations in order to balance the perceived benefits and risks of their use of methamphetamine with opioids. Two overarching themes were identified to describe how participants adapted their use for survival and wellness. The first was personal safety behaviours which included self-regulation and self-care behaviours. The second was interpersonal safety behaviours which included using alongside peers, and engaging with peer-led services (e.g. community outreach organizations) and public health-led services (e.g. overdose prevention sites) to reduce the risk of harm. Participants identified many gaps in available services to meet their diverse needs. Conclusions: this manuscript identified diversity in participants’ methamphetamine and opioid use (i.e. frequency, route of administration), and a range of behaviours that were performed to improve wellness and survival while using methamphetamine and opioids. Harm reduction and treatment responses must be robust and adaptable to respond to the diversity of patterns of substance use among people who use methamphetamine and opioids concurrently, so as to not perpetuate harm and leave people behind