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Drug and Alcohol Review (November 2013), 32, 566–573 DOI: 10.1111/dar.12062
Treatment expectations and satisfaction of treatment-refractory opioid-dependent patients in RIOTT, the Randomised Injectable Opiate Treatment Trial, the UK’s first supervised injectable maintenance clinics TEODORA GROSHKOVA1,2, NICOLA METREBIAN1, CHRISTOPHER HALLAM1,3, VIKKI CHARLES1, ANTHEA MARTIN1, LUCIANA FORZISI1, NICHOLAS LINTZERIS1,4,5 & JOHN STRANG1,4 1
National Addiction Centre, King’s College London, London, UK, 2European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal, 3International Drug Policy Consortium, London, UK, 4Academic Health Sciences Centre, King’s Health Partners, London, UK, and 5Langton Centre, Sydney University, Sydney, Australia
Abstract Introduction and Aims. The study investigates patients’ pre-treatment expectations of, and post-treatment satisfaction with, supervised injectable opiate treatment delivered within UK’s first such clinics within the Randomised Injectable Opiate Treatment Trial (RIOTT) (ISRCTN0133807). Design and Methods. Data were collected from 127 chronic heroin addicts recruited to RIOTT and randomised to receive supervised injectable (heroin or methadone) treatment or optimised oral maintenance treatment at supervised injectable maintenance clinics in London, Darlington and Brighton. Results. Of 127 RIOTT patients, 113 (89%) provided responses to structured enquiry about treatment expectations, and 94 (74%) subsequent responses about treatment satisfaction (at six months). Patients were hoping that injectable heroin treatment would: reduce substance misuse (81%); help achieve normality, routine and structure (16%); and increase education and work prospects (15%).At six months, an area of treatment satisfaction most commonly reported by all three trial groups was reduced substance misuse (supervised injectable heroin 59%, supervised injectable methadone 56%, optimised oral methadone 54%). Most found supervision acceptable, but some desired modifications were also identified. Discussion and Conclusions. Patients previously considered non-responsive to treatment appear to have similar treatment expectations and aspirations as other drug users in treatment. Supervised injectable opioid treatment patients consistently reported treatment satisfaction but also that more could be done to optimise aspects of current arrangement. This raised the challenging issue of the extent to which opinions of patients need to be taken into consideration in shaping future treatment provision. Future research may need to examine the extent of expectations ‘fit’ and the relationship between treatment sought and received. [Groshkova T, Metrebian N, Hallam C, Charles V, Martin A, Forzisi L, Lintzeris N, Strang J. Treatment expectations and satisfaction of treatmentrefractory opioid dependent patients in Randomised Injectable Opiate Treatment Trial, the UK’s first supervised injectable maintenance clinics. Drug Alcohol Rev 2013;32:566–573] Key words: supervised injectable opiate treatment, expectation, treatment satisfaction. Introduction The importance of engaging service users in the process of health-care delivery has been increasingly recognised and is reflected in UK’s Health and Social Care Act [1]. Within this national agenda, there is a general shift towards a more service–user- (consumerist) ethos in which patients’ expectation and satisfaction
have gained widespread recognition as a key quality indicator. The National Treatment Agency [2] states that UK substance misuse service providers need to ensure adequate patient involvement, indicating that the experience of users is a recognised marker of adherence to clinical standard. Yet traditionally, patients’ experience has received relatively little research attention in the context of evaluating the effectiveness of
Teodora Groshkova PhD, Researcher, Nicola Metrebian PhD, Senior Research Fellow, Christopher Hallam BSc, Research assistant,Vikki Charles MA, Researcher, Anthea Martin BSc, Researcher, Luciana Forzisi DClinPsych, Researcher, Nicholas Lintzeris PhD, Clinical Associate Professor, John Strang MD, Professor and Head of Department. Correspondence to Dr Teodora Groshkova, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Praça Europa 1, Cais do Sodré, 1249-289 Lisbon, Portugal. Tel: (351) 211 21 02 45; E-mail:
[email protected] Received 6 November 2012; accepted for publication 24 May 2013. © 2013 Australasian Professional Society on Alcohol and other Drugs
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substance misuse services. More attention needs to be paid to patients’ subjective views of their experience and satisfaction [3]. A few studies have examined patient satisfaction with substance misuse treatment and provided insights into patients’ perceptions [4–6]. In medically supervised injectable opioid treatment (IOT), patient satisfaction studies must include areas that are specific to this unusual type of treatment. Few studies have asked patients not benefitting from oral substitution treatment what they want from treatment, whether they would prefer IOT and their experience of and satisfaction with IOT. Prescribing of both injectable methadone and injectable heroin under unsupervised conditions to heroindependent individuals has been a distinctive feature of the UK drug treatment system, albeit on a very small scale [7,8]. Reports of 104 patients receiving injectables in the “British system” [9] document that half of the patients receiving injectable methadone treatment were satisfied with it, but many wanted to change to injectable diamorphine. Another UK study giving drug users a choice of either injectable heroin or injectable methadone, found that one third chose to receive injectable methadone [10]. Qualitative research, albeit limited, has illuminated treatment satisfaction with IOT. Romo et al. [11], based on 21 patients receiving supervised injectable heroin (SIH) treatment in Spain, documented patients’ recognition that SIH not only offered ‘legal medicine’, but it also fundamentally changed the situation in which heroin was acquired and administered, as well as improving a range of areas of patients’ lives, such as physical and mental health, family relationships and work. Blanken et al. [12], using qualitative accounts of 24 patients receiving SIH in the Netherlands, provided further evidence for the consistency in patients’ appreciation of the quality of prescribed heroin and the positive experiences in relation to secured heroin availability in the injectable maintenance clinic. In the UK context, it is particularly interesting to know what opinions patients hold; not just about the injectable medication, but, more importantly, how they perceive supervision. A substantial change in providing this treatment in the UK is that it is provided under medical supervision with no take-away injectable medication doses. The examination of opiate-dependent patients’ perceptions and experiences of this new supervised IOT is particularly relevant at a time when the UK Government is considering wider provision of this treatment through an expanded network of supervised injecting clinics [13]. This paper consequently examines expectations and satisfaction of treatment-refractory heroin-dependent
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patients attending UK’s first supervised injectable clinics [14].
Methods Between September 2005 and September 2008, 127 patients were recruited to the Randomised Injectable Opiate Treatment Trial (RIOTT) conducted at three newly established supervised injectable clinics (South London, Darlington and Brighton) and randomly allocated to one of three treatment conditions—SIH, supervised injectable methadone (SIM) and optimised oral methadone (OOM) (as reported elsewhere [14,15]) (see Supporting Information Tables S1 and S2, for key features of the new supervised injectable clinics and the characteristics of treatment options). In line with the trial’s eligibility criteria [15], patients were chronic heroin addicts who, despite receiving conventional oral maintenance treatment (at least six months), continued to inject illicit heroin regularly (at least 50% days in preceding three months). RIOTT patients’ characteristics have been reported elsewhere [16]. The study had ethical approval and all patients provided informed consent prior to interview. Questionnaires comprising of both fixed response and open-ended questions were administered in faceto-face interviews with patients before randomisation— to elicit their expectations of treatment, and at six months—to elicit their satisfaction with the treatment they were assigned to. Questions related to treatment expectations (baseline) include: (i) treatment preference (three responses categories were provided either first, second or third choice); and (ii) expectations of treatments ability to reduce illicit drug (street heroin, crack and other drug use) and alcohol use [response categories: either yes (would reduce drug/alcohol use) or no (would not reduce drug/alcohol use) were provided]. Satisfaction with trial treatment (six months) included: (i) asking patients again about treatment preferences; and (ii) impact of treatment on illicit drug and alcohol use. At baseline and follow-up, open-ended questions explored life areas in which help was most needed by the patient during this treatment episode (baseline) and the improvements made during treatment (follow up). Finally, questions explored satisfaction with aspects of IOT received, including injecting room, injecting sites, injecting attempts allowed, clinic opening hours, twice daily clinic attendance and no take-away doses. Five response categories were provided: very dissatisfied, dissatisfied, mixed, satisfied and very satisfied. In addition, treatment plans were also explored. Questionnaires took on average 29 min (range 18–40) to complete. © 2013 Australasian Professional Society on Alcohol and other Drugs
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Quantitative data were entered onto a computerised database and analysed using the Statistical Package for the Social Sciences (IBM Corporation, Armonk, NY, USA). Patients were excluded from analysis if they failed to comply with the interview. Patients’ answers to open-ended questions were recorded verbatim. These responses were entered into a word document for analysis. The analysis was inductive and responses were coded by emergent themes. Responses with common themes were grouped together. A theme was formed if three or more participants reported a particular topic. Themes mentioned only once or twice are not reported. Results Completion of interviews Of 127 RIOTT patients, 113 patients responded to the treatment expectations questionnaire (baseline) and 94 patients to the satisfaction questions (6-month follow up). Baseline data were missing for 14 (11%) patients (13 males and 1 female; OOM: 5; SIM: 7; SIH: 2) and at follow up for 33 (26%) (27 males and 6 females; OOM: 18; SIM: 6; SIH: 9). Of the 33 participants who did not comply with post-treatment interviews, over a half (66.7%) were lost to follow up or not in treatment
at the 6-month point (OOM: 14; SIM: 5; SIH: 3). Twelve patients did not start treatment (OOM: 7; SIM: 4; SIH: 1), five were lost to follow up (OOM 4; SIH 1) and five had discontinued treatment (OOM: 3; SIM: 1; SIH: 1). Of the 94 who were interviewed at six-month follow up, the majority (90%) were part of the 113 originally interviewed. Treatment preferences The majority of patients (87%) expressed a preference for SIH treatment [S3a], with small numbers (11%) reporting a preference for SIM and only two patients wanting OOM. At 6 months, there was a modest increase in the proportion of patients wanting to receive OOM.’ It is particularly important for this to be included as it is later referred to as a key observation (in the opening paragraph of Discussion). Treatment expectations Before being randomly allocated to their treatment group, patients were asked whether they expected their use of ‘street’ heroin, crack, another drug or alcohol to reduce if they were randomly allocated to, and received, OOM, SIM or SIH (Table 1). The majority of patients
Table 1. Expectations for impact of treatment on drug use, by trial treatment group
SIH treatment Reduction in street heroin use Missing data Reduction in crack use NA or missing data Reduction in alcohol use NA or missing data Reduction in other drug use NA or missing data SIM treatment Reduction in street heroin use Missing data Reduction in crack use NA or missing data Reduction in alcohol use NA or missing data Reduction in other drug use NA or missing data OOM treatment Reduction in street heroin use Missing data Reduction in crack use NA or missing data Reduction in alcohol use NA or missing data Reduction in other drug use NA or missing data
SIH, n = 41
SIM, n = 35
OOM, n = 37
Total, n = 113
30 (88.2) 7 10 (30.3) 8 10 (30.3) 8 2 (6.1) 8
15 (53.6) 7 15 (55.6) 8 8 (29.6) 8 3 (11.1) 8
18 (60.0) 7 7 (24.1) 8 7 (24.1) 8 2 (6.9) 8
63 (68.5) 21 32 (28.3) 24 25 (28.1) 24 7 (7.9) 24
16 (47.1) 7 4 (12.1) 8 5 (15.2) 8 5 (15.2) 8
17 (60.7) 7 6 (21.4) 7 7 (25.0) 7 3 (11.1) 8
17 (58.6) 8 2 (6.9) 8 6 (20.7) 8 2 (6.9) 8
50 (54.9) 22 12 (13.3) 23 18 (20.0) 23 10 (8.8) 24
11 (32.4) 7 5 (15.2) 8 2 (6.1) 8 0% 8
5 (17.9) 7 2 (7.1) 7 4 (14.3) 7 1 (3.7) 8
8 (27.6) 8 2 (6.9) 8 5 (17.2) 8 1 (3.4) 8
24 (26.4) 22 9 (10.0) 23 11 (12.2) 23 2 (2.2) 24
OOM, optimised oral methadone; SIH, supervised injectable heroin; SIM, supervised injectable methadone. © 2013 Australasian Professional Society on Alcohol and other Drugs
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Table 2. Areas of life patients most wanted help with SIH n (%)
SIM n (%)
OOM n (%)
Total n (%)
35 (85.4) 9 (22.0) 4 (9.8) 4 (9.8) 5 (12.2) 4 (9.8) 5 (12.2) 3 (7.3) 2 (4.9) 1 (2.4)
29 (82.9) 1 (2.9) 7 (20.0) 4 (11.4) 4 (11.4) 5 (14.3) 3 (8.6) 4 (11.4) 4 (11.4) 1 (2.9)
27 (73.0) 8 (21.6) 6 (16.2) 6 (16.2) 4 (10.8) 4 (10.8) 5 (13.5) 1 (2.7) 1 (2.7) 1 (2.7)
91 (80.5) 18 (15.9) 17 (15.0) 14 (12.4) 13 (11.5) 13 (11.5) 13 (11.5) 8 (7.1) 7 (6.2) 3 (2.7)
Areaa Reduce substance misuse Achieve stability, normality, routine and structure Improve education and work opportunities Improve housing situation Improve physical health Improve psychological wellbeing Improve finances Improve relationships with family and friends Increase non-drug scene socialisation Reduce criminal activity
Note: aPatients were invited and stated multiple areas. OOM, optimised oral methadone; SIH, supervised injectable heroin; SIM, supervised injectable methadone.
(69%) thought SIH treatment would help them to reduce their ‘street’ heroin use compared with SIM or OOM (55% vs. 26%, respectively). A higher proportion of patients expected SIH (28%) to reduce crack use than SIM or OOM (28% vs. 13% and 10%, respectively) and alcohol use (28% vs. 20% and 12%, respectively). A higher proportion of patients later allocated to SIH expected SIH would reduce their street heroin use than those later allocated to SIM or OOM (88% vs. 54% and 60%). Similarly, a higher proportion of patients later allocated to SIM expected SIM to reduce street heroin use than those later allocated to SIH or OOM (61% vs. 47% and 59%, respectively). In an open-ended question, patients were asked, ‘what areas of your life would you most like help with?’ One hundred and thirteen patients responded (SIH = 41; SIM = 35; OOM = 37) and their answers were grouped into 10 overlapping themes (Table 2). The most frequent area of life patients’ reported wanting most help with was in reducing their drug use (81%). Other areas of life included achievement of stability, normality, routine and structure in one’s life (16%); improve education and work opportunities (15%); improve housing situation (12%), physical health (12%), psychological wellbeing (12%) and finances (12%). While there were few differences between treatment groups, those in the SIM group were far less likely to report wanting help to achieve stability, normality, routine and structure than those in the SIH and OOM groups (3% vs. 22% and 22%). Post-treatment satisfaction At six months in treatment, the majority of patients reported that their treatment had helped reduce their
use of ‘street’ heroin. Nearly all of those receiving IOT (SIH: 97%; SIM: 85%) reported that their treatment had led to substantial reductions in ‘street’ heroin use, and nearly two-thirds (62%) of those receiving OOM also reported that their treatment had contributed to reduced use of ‘street’ heroin. Similarly, a larger proportion of those receiving IOT (SIH: 52%; SIM: 39%) reported that their treatment had helped reduce their use of crack than those receiving OOM (24%). A comparison of the responses pretreatment and the responses at 6 months revealed that larger proportions of each treatment group reported, after 6 months of treatment, that they were satisfied with how their treatment had helped reduce ‘street’ heroin use than those reporting that they expected it to reduce their ‘street’ heroin use (SIH: 97% vs. 88%; SIM: 85% vs. 61%; OOM: 62% vs. 28%) (Table 3). In an open-ended question, patients were asked to identify those areas in their lives in which treatment has helped them the most. Ninety-four patients responded and their answers were grouped together into 10 overlapping themes (Table 4). The most frequent area of life patients reported that treatment had helped them with was reducing their drug use (SIH: 59%; SIM: 56%; OOM: 54%). Another area of their lives where patients felt treatment had helped them the most with include physical health improvement (SIH: 47%; SIM: 17%; OOM: 21%): I’ve put on at least a stone . . . and look, you know, the difference that it can make if you are stable . . . (male; 37 years; SIM) Another area is on improvement in finances (SIH: 48%; SIM: 17%; OOM: 21%): © 2013 Australasian Professional Society on Alcohol and other Drugs
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Table 3. Responders’ satisfaction with perceived substance use reduction, by trial treatment group
Reduction in street heroin use Missing data Reduction in crack use NA or missing data Reduction in alcohol use NA or missing data Reduction in other drug use NA or missing data
SIH, n = 34 n (%)
SIM, n = 36 n (%)
OOM, n = 24 n (%)
30 (96.8) 3 16 (51.6) 3 4 (12.5) 2 5 (16.7) 4
28 (84.8) 3 13 (39.4) 3 4 (12.1) 3 5 (15.6) 4
13 (61.9) 3 5 (23.8) 3 3 (14.3) 3 4 (22.2) 6
OOM, optimised oral methadone; SIH, supervised injectable heroin; SIM, supervised injectable methadone. Table 4. Areas of life in which treatment has helped
Area Reduction of substance use Finances Improvement in physical health Family and relationships Stability, normality, routine, and structure Education and opportunities for work Psychological health and wellbeing Housing Criminal activity Non-drug scene socialisation Other Everything None
SIH, n = 34 n (%)
SIM, n = 36 n (%)
OOM, n = 24 n (%)
20 (58.8) 16 (47.1) 16 (47.1) 12 (35.3) 8 (23.5) 7 (20.6) 5 (14.7) 4 (11.8) 3 (8.8) 2 (5.9) 7 (20.6) 5 (14.7) 0%
19 (55.6) 6 (16.7) 6 (16.7) 6 (16.7) 2 (5.6) 4 (11.1) 8 (22.2) 6 (16.7) 3 (8.3) 4 (11.1) 9 (25.0) 6 (16.7) 1 (2.8)
13 (54.2) 5 (20.8) 5 (20.8) 3 (12.5) 0% 4 (16.7) 7; (29.2) 2 (8.3) 1 (4.2) 1 (4.2) 6 (25.0) 4 (16.7) 0%
Got some money in the bank for when the baby is born [male; 34 years; SIH]. Many reported improvements in family and relationships (SIH: 35%; SIM: 17%; OOM: 13%): I have my children back in my life’ [female; 35 years; SIM], [it] helped me to make my family see I was serious about sorting my life out [male; 30 years; OOM]. Some had embraced the opportunity to pursue studies or voluntary occupation that could help them gradually acquire paid work (SIH: 21%; SIM: 11%; OOM: 17%): There is space and time now as I’m not out and about scoring, so I could get work [female; 32 years; SIM], I want to finish my education and get work [female; 36 years; SIH]. © 2013 Australasian Professional Society on Alcohol and other Drugs
Furthermore, attaining stability, normality, routine and structure in one’s life was a predominant theme among patients in the SIH group (SIH: 24%; SIM: 6%; OOM: 0%): the RIOTT structure is holding me [female; 36 years; SIH], [I am] getting up earlier [male; 31 years; SIM]. Back to normality was a thread that could be traced in various life domains, including psychological wellbeing (SIH: 15%; SIM: 22%; OOM: 29%): I’m living a more healthy lifestyle altogether [male; 45 years; SIH], [I am] happy with myself [male; 44 years; OOM],
Satisfaction with injecting clinic Finally, some appreciated the reduced involvement in the drug scene (SIH: 6%; SIM: 11%; OOM: 4%):
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Table 5. Proportions satisfied with aspects of the injecting clinic Treatment group SIH (n = 34) SIM (n = 36) SIH (n = 34) SIM (n = 36) SIH (n = 34) SIM (n = 36) SIH (n = 34) SIM (n = 36) SIH (n = 34) SIH (n = 34) SIM (n = 36)
Domain Supervised injecting room Injecting sites Allowed injecting attempts Clinic opening hours Twice daily clinic attendance No access injectable take-aways
Very satisfied
Satisfied
8 (27.6) 8 (27.6) 10 (37.0) 7 (24.1) 4 (14.3) 3 (14.3) 3 (10.7) 5 (17.9) 5 (17.9)
19 (65.5) 17 (58.6) 15 (55.6) 13 (44.8) 18 (64.2) 10 (47.6) 18 (64.3) 14 (50.0) 16 (57.1)
2 (7.1) 2 (7.1)
Not sure
Dissatisfied
1 (3.4) 1 (3.4) 4 (13.8) 0% 0% 1 (3.7) 3 (10.3) 5 (17.2) 1 (3.6) 4 (14.3) 3 (14.3) 3 (14.3) 2 (7.1) 4 (14.3) 4 (14.3) 5 (17.9) 4 (14.3) 3 (10.7) Once daily clinic attendance 6 (21.4) 9 (32.1) 7 (25.0) 8 (28.6) 12 (42.9) 4 (14.3)
Very dissatisfied
No answer
0% 0% 1 (3.7) 1 (3.4) 1 (3.6) 2 (9.5) 1 (3.6) 0% 0%
5 7 7 7 6 15a 6 8 6
4 (14.3) 2 (7.1)
6 8
Note: aNot applicable to most SIM patients, the majority of whom injected intramuscularly and had limited experience of needing multiple attempts to administer the drug. SIH, supervised injectable heroin; SIM, supervised injectable methadone.
I mix with more non-users than I used to [male; 37 years; SIH]; Also, the disengagement from criminal activity that treatment had enabled (SIH: 9%; SIM: 8%; OOM: 4%): I ain’t got to thieve [anymore] [male; 37 yr; SIH]. Most patients reported being very satisfied/satisfied (SIH: 28%/66%; SIM: 28%/59%) with injecting in the clinic under medical supervision (Table 5). Those who were satisfied, when prompted, described that the best things were that the injecting room was clean and tidy; there is a safe, caring environment where they could get help and support; and there was ‘someone there if things go wrong!’. On the other hand, those who were dissatisfied reported the worst aspects were the lack of privacy, having to inject in front of nurses, in a nosy and distracting environment, the negative attitude of some staff, and limitations with facilities provided (lack of adequate lighting and height of mirrors). Large proportions of patients in both IOT groups reported that they were very satisfied/satisfied (SIH: 37%/56%; SIM: 24%/45%) with the injecting sites they were allowed to use and the number of injecting attempts they could make (very satisfied/satisfied: SIH: 14%/64%; SIM: 14%/48%). However, some reported that they were not allowed to use their preferred injecting sites (e.g. femoral vein, see [17]) or have sufficient injecting attempts before being asked to use oral methadone. Nearly three quarters in the SIH (11%/64%) and SIM (18% and 50%) groups were very satisfied/ satisfied with the clinic opening hours. However, some
dissatisfied patients when prompted stated that they would have preferred longer opening hours because working was perceived as incompatible with treatment time-schedules, or because of sleeping problems and worries over night-time withdrawal symptoms. Three quarters of SIH patients (not applicable to SIM patients, who attended clinic once a day for supervised injecting) reported that they were very satisfied/ satisfied (18%/57%) with twice-daily clinic attendance for supervised injecting. Individuals in this group recognised frequent clinic attendance as a feature of the highly intensive treatment regime and appreciated the time structure it introduced into their lives. A small number were concerned that the demand for frequent attendance might pose a challenge to potential work. Of those receiving SIH, nearly 40% were dissatisfied with the lack of access to injectable takeaways compared with 21% of those receiving SIM. Although such access would have been preferred, the rationale for this rule and the safety of supervised self-administration of IOT were understood and accepted. Discussion We have examined treatment expectation and satisfaction in opioid-dependent patients treated in UK’s first supervised injecting clinics. The majority of patients (87%) expressed a preference for SIH treatment. At 6 months, there was a modest increase in the proportion of patients wanting to receive OOM. IOT was introduced with the express intent of helping patients reduce or quit their use of ‘street’ heroin. A larger proportion of patients expected SIH to help reduce their street heroin use than SIM or OOM. © 2013 Australasian Professional Society on Alcohol and other Drugs
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Expectations differed between those allocated to different treatments. A higher proportion of patients who were then allocated to SIH expected that SIH would reduce their street heroin use than those later allocated to SIM or OOM. Similarly, a higher proportion of patients later allocated to SIM expected SIM to reduce street heroin use than those who were then allocated to SIH or OOM. Although randomisation ensures that no systematic differences exist between treatment groups, differences between treatment arms in important predictive factors can still arise by chance. Such differences can be balanced by selecting certain baseline covariates (called stratifying variables) and incorporating them into the randomisation scheme in a way that forces a certain degree of balance between the treatment arms.The trial did not stratify by expectation of treatment effect on drug use. Patient expectations of treatment effect on street heroin or other drug use may influence treatment outcome or satisfaction with treatment. However, we found that larger proportions of each treatment group reported that they were satisfied with how their treatment (at six months) had reduced their drug use, compared with those reporting that they expected it to reduce their ‘street’ heroin use. Patients nominated similar life domains that they wanted treatment to help them with. The most common was to reduce their substance misuse. They shared the aim and expectation to achieve improvement in their daily life structure, housing and financial situation, as well as to create opportunities for education and work, and to achieve and maintain better physical health and psychological wellbeing. Sell and Zador [9] have previously noted that, for patients in the ‘old British system’, one of the most important reasons for seeking IOT was access to a drug supply of known dose and purity. The motivations and aspirations of the current sample would suggest that IOT is expected to address wider treatment needs involving, but not limited to, reduction of street heroin and other drugs. The clear pretreatment aspirations led extensively to the sought-after outcome, and also resonated with participants’ satisfaction with perceived treatment gains. Analysis revealed very high treatment satisfaction across all three treatment groups and particularly in both injectable groups (greatest in SIH), with reductions achieved in street heroin use. Compared with reported expectations of treatment to help with drug use, actual satisfaction when interviewed at 6 months with treatment was higher for all three treatment modalities. Participants also recognised a range of other benefits, which served to give them a structure to their daily lives and helped them to improve family relationships and identify and engage in meaningful activities. The verba© 2013 Australasian Professional Society on Alcohol and other Drugs
tim accounts give a sense of achievement for individuals. Participation in meaningful activities, including training and courses, was appreciated as a valuable area of treatment gain and a positive factor in recovery, as evident from two independently-produced accounts from two of the RIOTT patients [18,19]. This would suggest that when discussing IOT, individual patients’ aspirations and needs should be identified and addressed. Overall, patients reported moderately high levels of satisfaction with most key aspects of this intensive treatment. This suggests that the current method of IOT delivery is generally very well received by patients. Future models of IOT should retain the core features while seeking to improve clinic opening times to offer greater flexibility for attendance, and address apprehension with injecting in front of others. IOT addresses patients’ immediate needs of resolving substance misuse. However, it also provides the context in which transformation and identity change could be initiated, by taking into account patients’ need for structure and routine. Eventually, achieving a period of stability allows individuals to turn to areas such as personal development via education and contribution to family, others and the community. This study has some limitations that should be considered when interpreting the results. The satisfaction measures were not tested for reliability or validity. Nevertheless, the individual items had face validity, clear response choices and covered the range of domains characterising IOT [20]. They might be used by similar studies and programmes. In conclusion, there are several important take-home messages. Firstly, despite their long-standing failure to benefit from previous treatments, many patients nevertheless articulated strong aspirations and expectations—to reduce and quit their use of street heroin and to make other broader gains. Secondly, after 6 months of treatment, considerable progress had been achieved by many, with greater proportions having made gains than had originally been set as personal objectives (SIH in particular). Finally, we need to note the dynamic nature of aspirations and that, having made good progress during their six months of IOT, we find that many of our trial participants have moved on in their aspirations and seek further broader recovery, thus necessitating a dynamic responsive treatment system that moves with the patient and their progress. Acknowledgements We thank all participants of the trial as well as the research and treatment funders (Research Grant from Action on Addiction; they received funding from the Big Lottery, the Hedley Foundation and Tees, Esk and
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Wear Valleys NHS Foundation Trust NIHR Flexibility and Sustainability Funding). Conflict of interest statement J. S. and N. L. have contributed to UK National Treatment Agency for Substance Misuse and Department of Health guidelines on the role of injectable prescribing in the management of opiate addiction (2003; chaired by J. S.), and J. S. has chaired the broader-scope pan-UK working group preparing the 2007 Orange Guidelines for the UK Departments of Health, providing guidance on management and treatment of drug dependence and misuse. J. S. has provided consultancy advice to Britannia/Genus, Auralis and Martindale Pharmaceuticals and other pharmaceutical companies; J. S. and J. S.’s institution have received support and funding from the Department of Health (England) and National Treatment Agency (England); and J. S. has close associations with the charity Action on Addiction. N. L. has received honoraria, travel and conference support, and consultancy fees from Reckitt Benckiser and Schering-Plough. J. S., N. L. and N. M. have previously undertaken research study of British heroin policy and have given varied commentaries and contributed to professional and public debate.T. G., C. H., V. C., A. M. and L. F. declare that they have no conflicts of interest. References [1] Department of Health. Health and Social Care Act. London: Department of Health, 2008: Available at: http:// www.dh.gov.uk/en/Publicationsandstatistics/Legislation/ Actsandbills/HealthandSocialCareBill/index.htm (accessed March 2011). [2] National Treatment Agency (NTA) for Substance Misuse: NTA Guidance for Local Partnerships on User and Carer Involvement. London: NTA, November 2006: Available at: http://www.nta.nhs.uk/Who-service-involved.aspx. (accessed March 2011). [3] Department of Health. Essence of Care: benchmarks for Promoting Health. London: Department of Health, 2006: Available at: http://www.dh.gov.uk. (accessed March 2011). [4] Hunt G, Rosenbaum M. ‘Hustling’ within the clinic: consumer perspectives on methadone maintenance treatment. In: Inciardi JA, Harrison LD, eds. Heroin in the age of crack-cocaine, drugs, health, and social policy series. Thousand Oaks, CA: Sage Publications, 1998:188–214. [5] Neale J. Drug users’ views of drug service providers. Health Soc Care Community 1998;6:308–17. [6] Bacchus L, Marsden J, Griffiths P, et al. What do clients say in-patient treatment: a qualitative account with implications for service delivery. Drugs Educ Prev Policy 1999;6:81–97. [7] Mayet S, Manning V, Sheridan J, et al. The virtual disappearance of injectable opioids for heroin addiction under the ‘British System’. Drugs Educ Prev Policy 2010;17:496– 506.
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Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Table S1. Characteristics of the new injecting clinics. Table S2. Characteristics of SIH, SIM and OOM treatment and injecting clinic. Table S3. (a) Treatment preference. (b) Treatment preference by group.
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