The lived experience of 'opioid use disorder' in Ireland in the 21st century

peer-reviewedThis thesis focuses on three critical phases in the life journey of a person with an opioid use disorder (OUD) ; Initial, random intermittent opioid use, termed ‘Recreational Sporadic Use’, transitioning to increased persistent opioid use, labelled ‘Intensified Sustained Use’, culminating in complete impulsivity and full opioid dependence, coined, ‘Loss of Control’. The crucial role of the neurobiology of dependence, explored in depth in this thesis, underpins these key phases in developing and sustaining an opioid dependence. Building on this framework the thesis unravels the effect of Adverse Childhood Experiences on the likelihood of experimenting with opioids and subsequently cultivating a dependence. It then recounts the effect of both dual diagnosis and concurrent benzodiazepine abuse on sustaining and intensifying one’s dependence until an individual eventually surrenders to the inevitable destructive effects of an opioid dependence and loses all voluntary control over their usage. The thesis then delves further into the lives of individuals with OUD by illuminating both positive and negative factors in their life journeys, which influence the remitting, relapsing nature of their illness. Invariably, given the neurobiological factors nourishing drug dependence the negative factors triumph, and relapse to drug use prevails. In unravelling the complexities of the neurobiology of dependence, this thesis, highlights that undoubtedly the best approach to help, support and where possible treat individuals with an OUD is under the umbrella term of harm reduction. A special focus is placed on the harm reductive properties of methadone as a therapeutic agent in combatting OUD, with a particular emphasis on the need to educate all members of society on its therapeutic benefits. Undoubtedly, the most harrowing outcome for all in this often-thwarted journey is fatal overdose (OD), unfortunately the outcome for which far too many individuals succumb. Therefore, the most pivotal of harm reduction strategies to ebb the flow of death in OUD, ‘Take Home Naloxone Programmes’ (THNPs) are examined in the latter half of this thesis, with particular scrutiny given to Ireland’s THNP. As this thesis highlights, in Ireland, we have made much progress in our approach to addressing the opioid crisis but, as always, there is much room for improvement and advances. Aims The predominant aim of this thesis echoes a key strategic purpose of Ireland’s latest drug strategy, ‘Reducing harm, supporting recovery: a health-led response to drug and alcohol use in Ireland 2017- 2025’, which is to reduce the morbidity and mortality associated with OUD. Two studies are undertaken to achieve this purpose. Study 1 aims to give clients of the Mid-West of Ireland’s Programme for Methadone Maintenance Treatment (MMT) a voice, to document their lived experience of opioid dependence before, during and after their ‘three-phase journey’ through OUD. It aims to co-develop with clients a tailored care plan to enhance their chance of successfully engaging with the MMTP. Study 2 aims to gain an overall appreciation of Ireland’s national THNP to optimise its functioning. A second objective of this study is to improve the likelihood of a patient attending hospital post administration of naloxone in the community, a step that is associated with overall better survival rates. Methods This thesis employs a mixed method research design. Study 1 is a qualitative study; Study 2 employs a quantitative method. Results Study 1 reveals an enriching insight into the personal experience of each individual client’s journey. Their journeys, though each unique, had common chronological sub-themes which are recounted in depth. Subsequent data analysis identifies common life experiences, which influence their journey both negatively and positively. Final data analysis identifies clients’ individual suggestions for improving their journey. The results of Study 2 reveal inadequacies in the current reporting mechanism currently in place on the use of naloxone in the community setting in Ireland. Descriptive analysis then looks at the characteristics pertaining to overdose patients themselves and subsequently the characteristics of the overdose scene are documented. Thereafter, using a logistical regression model, statistical results on the variables that influence a patient’s hospital attendance are presented. Conclusion The thesis concludes with recommendations for improvement in the management of OUD. It proposes how knowledge of ACEs should influence the MMTPs in Ireland and internationally, to adopt a more ‘trauma informed’ ethos. Subsequently, recommendations centre on dually diagnosed individuals, with a specific focus on addressing benzodiazepine misuse. Next, the theme of therapeutics is explored, listing specific proposals on how to both promote education and reduce stigma in relation to methadone, as a treatment option in OUD. Finally, the thesis focuses on recommendations with regard to THNPs. Initial suggestions focus on improving the Irish THNP and subsequently general recommendations applicable to THNPs internationally are addressed