7. 1 INTRODUCTION
This study investigated the microsetting of methadone treatment in general practice in Dublin illuminating the social meaning and practices associated with this harm reduction treatment. It also cast light on the macro setting of policy context and methadone protocol design. Results from this study can be transferred to other contexts and settings as transferability has been enhanced by richly described data. The data provides the research community with enough information to judge the themes and constructs of the study and it provides enough information to judge the appropriateness of applying the findings to other settings (Byrne 2001). The study design was not without its limitations. Self report may have affected participants responses where the researchers’
position, as nurse, may have given rise to both participant and researcher bias. However the usefulness of addressing the service users’ experience which has largely been neglected so far in the RoI has been proved to be worthwhile as many practical suggestions for change have been proffered as a result of listening to the accounts of their experiences. New information has been obtained by using this approach and by utilizing these methods some contradictory information to previous studies has been demonstrated. Future recommendations for research, in the light of the knowledge which has been gleaned from the study, are discussed.
Much of the grey literature up to this point in time has informed local knowledge and practice. The study findings contradict some of the small studies identified in the review of the literature (UISCE 2003, O’Reilly et al 2005, O’Reilly & O’Connor 2006). These studies asserted that service users were subject to methadone sanctions, discriminating
services and were being cared for under a ‘’one size fits all’’ umbrella method of service provision in general practice. The existing literature had overlooked ways of clearly viewing the phenomenon of MMT in general practice. The views which service users articulated provide insight into novel experiences which have up to now been left unheeded. The process of ‘’being heard’’ greatly improves our understanding of general practice provision and how it can be improved to benefit service users.
The findings of this study are novel as unlike quantitative research which can summarize key findings with numerical data, this research has achieved a deep understanding about how service users experience their treatment and this has been expressed in their own original way and language. ‘Actual care versus ideal practice’ (ICGP 2003) was investigated and found wanting.
7.2. CONCLUSIONS AND RECOMMENDATIONS
This study aimed to explore how the MTP was being implemented in general practice by describing the users’ lived experience of treatment, and their experiences of being involved in decision making and management of that treatment. What has been gained from this work is an insight into that experience and what the treatment trajectory creates. This work suggests that from the perspective of the service user there are both benefits and shortcomings in relation to receiving methadone treatment in General Practice in Dublin. The findings from these service users’ views can be translated into recommendations and there are many that can be proffered as a result of this exploration of their experiences.There are a number of implications for policy and service delivery that follow from the service users’ accounts of their experience of general practice however a tension remains as to how to involve service users effectively.
As acknowledged in the literature the presenting needs of service users accessing treatment services have been shown to be frequently bewildering in their complexity, often involving multiple substance use, physical and psychological health problems and relationship and family difficulties (Best et al 2008). Need has been defined, in the health care needs assessment literature, as 'ability to benefit' (Fountain et al 2000).
The major advantage and benefit of general practice identified in this study is that it provides a place where service users can avail of methadone treatment within an environment that they value. There is growing recognition of the role that place and setting can play in shaping the health of individuals and populations (Kerr et al 2007). The significance and social meaning of place in relation to the setting of general practice has been heretofore absent in the literature.
The overall personal, family and social functioning of the individual is being improved by methadone treatment however there were other issues of concern in relation to how child welfare should be addressed within drug treatment. Service users described differing issues in their lived experience of treatment which can be specific to gender or related to their past identity as drug misuser. Difficulties faced by drugmisusing women who are attempting to fulfill societal roles as mothers and provide the sort of childcare they and society wish for children has been highlighted in the literature (EMCDDA 2009). Female service users in this study attested to a supportive environment within general practice for their children and for themselves at varying intervals throughout pregnancy and child rearing. The development of a gendersensitive perspective on how to support women who misuse drugs is long overdue (Grant 2009). Risk environments have been described and highlighted by Rhodes (2009). In this instance the risk setting affected not only the service user but also babies, children and families.
Exploration is required into how the resilience of families and children in
particular can shape their own futures and how general practice can assist service users in this process.
The findings identify service users’ satisfaction with the transformative environment of general practice which can assist in the development of a new identity as opposed to the past identity of ‘’junkie’’. Identity is challenged within the environment of heroin addiction and the trauma involved in that lifestyle. Moving out of that lifestyle was described as difficult as identity had been fixed within that known environment. If identity plays as central a role in this process as the data suggests, and if this is interlinked with past traumatic experiences it is important to ensure that service providers in general practice are able to address issues of identity formation and change. Individual contexts can enable drug misuse and local contexts can shape local phenomena. Issues such as control, loss of freedom, stigma and labelling exist in Dublin but receiving treatment in general practice may ‘’dilute’’ or ‘’normalise ‘’
these feelings to some extent. Appropriate training is therefore required in identity formation and change which can help build awareness and knowledge among service providers and equip them to assist service users in this process. Further investigation into environments that enable change is required (Duff 2007).
The participants did identify that the treatment context of general practice provided a place which was fundamentally different from the environment of the treatment clinics, a place where potentially their drug treatment could be individualized. There was verbal evidence that the aims of the ICGP programme in relation to encouraging reduction strategies and supporting maintenance were being implemented by the majority of service providers. Service users spoke of valuing the confidential nature of the setting although there were instances where confidentiality was broken. Overheard disclosures can breech trust in the waiting room and among receptionists and all items of information
which relate to an attribute of an individual should be treated as potentially capable of identifying patients and hence should be appropriately protected to safeguard confidentiality (DoH 1994).
Awareness of this could prevent stigma and unnecessary exposure for the service user.
The doctor/patient relationship was paramount and in general contributed positively to the trajectory of treatment which had a positive effect on patient participation. The research also identified tension and negative experiences of treatment with the doctor who consults poorly.
This is a significant shortcoming which was identified within the treatment environment. A different consulting style was described and the term ‘’phy doctor’’ was identified and contrasted markedly with the consulting style of the majority of the other GPs. The general practice sites which were surveyed were well established sites for methadone treatment. If this is a finding within these sites the potential for further poor consulting within other new or established methadone prescribing practices may be of great significance for future quality and standards in practice.
The majority of service users reported being mainly satisfied with their treatment however service users have historically few expectations of care. What a consumer reasonably expects to receive from a service has been shown to be influenced by the concept of ‘expectation’ and
‘relative experience’ (Madden et al 2008). Caution has to be expressed therefore as to what service users reasonably expect to receive from general practice as historically there is an absence of engagement with service users. Nationally negotiated service level agreements which include service users in the development process may assist this process.
This research showed that there is verbal evidence that the aims of the ICGP programme are being achieved in minimizing harm associated with opiate misuse such as crime and the associated health risks such as the risk of HIV and screening for HCV. Given the complexity of the service users self described needs it would be feasible to suggest that the GP needs assistance with care planning and delivery as is the norm with other chronic diseases in primary care.
The findings point to service users’ satisfaction that general practice provides an environment which is providing a valuable service need for drug misusers. The general practice experience was sought after as a place where medical services were provided alongside drug treatment.
This service may require significantly more resources and ancillary staff such as trained nurses and counsellors. There were variable responses to whether the location of psychological care offered mattered to the service user.
This data calls for a comprehensive review of the MTP with particular attention paid to ensuring that mechanisms exist to allow service users to feedback their experiences and opinions. This requires considered engagement with both drug treatment service providers and users of drug treatment services. The findings inform service providers to consider how GPs and the wider multidisciplinary teams engage with the service user who is prescribed methadone. Supports for service users which include improved access to counseling and assistance in responding to methadone related issues that may serve as barriers to optimal treatment should be explored. This would involve targeted education about treatment plans, treatment side effects, withdrawal and potential for overdose. Service users will need support and training in the active planning and delivery of their own treatment. The focus could be to address client perceptions of treatment and broader psychosocial
needs. This at present is not possible to assess within the current audit system carried out by the ICGP and there is considerable variation in what services are provided. These broad recommendations for practice are further translated as the following:
• The ICGP who have responsibility for training and accreditation could consider a multidisciplinary focus which equips practitioners to identify psychological needs in association with prescribing methadone. The goals of the consultation need to be revisited and a comprehensive approach to service users’ needs could be addressed.
• Practices should consider conducting patient surveys on aspects of confidentiality as a means of looking for ways to improve management of patient identifiable information.
• Training initiatives are required for general practice service providers to better understand the gender issues of treatment and how these issues reflect on those receiving treatment.
• Shared care planning initiatives and interagency working will be required to improve the liaison links between service users, general practice service providers and maternity and infant services which may assist understanding in this respect.
The significance of methadone for the service user and the effect of substitution treatment on their lived experience were described. The objective of treatment according to the NDS (2001) is two fold. First, to enable those dependent on drugs to reduce dependency, improve health and social well being and ultimately to lead a drugfree lifestyle
and second, to minimize the harm to those who continue to engage in drug taking (Cox et al 2007).Treating care planning in general practice as ‘’treatment’’ is a realistic way to expect a treatment journey to be effective. The Report of the Methadone Treatment Services Review Group 1993 prior to the introduction of the 1998 protocol urged care in regarding methadone as an easy solution for a complex problem and warned that it should be regarded as an adjunct to treatment. The data suggest that methadone as a substitution treatment has emerged in a mostly positive light however as a substance negative emotions exist.
As a drug methadone was both despised and lauded as a life saver. As an evidenced based harm reduction treatment, service users attested to its benefits in terms of reduction of heroin use, crime and virus protection. The meaning attributed to methadone maintenance was the provision of stability and normality for both the service user and the family but methadone was also described as economically valuable to the local drug dealing environment and provides an opportunity for reciprocal care for drug misusers. The importance of street trading was therefore enmeshed within the context of treatment. Service users expressed that an alternative to methadone should be made available.
These findings highlight the important question of prescribing practices and have implications for the current policy of control on methadone diversion which has been established as a cause of opiate related death in the RoI. The data also highlight the importance of understanding how environmental influences shape peoples lives and understanding of methadone. This challenges general practice service providers to provide appropriate information, resource educational forums and raise their own awareness of how optimal dosing can be achieved by developing their communication skills in practice.
The findings also identified the meanings attributed to the substance of methadone. Three distinctive features of methadone identities were uncovered which are original findings in relation to the consumption of methadone. These were coconstructed categorizations which were defined as ‘’lifers’’, ‘’maintainers’’ and ‘’reducers’’. These new insights should aid practitioners to understand how service user’s view their treatment trajectory and inform them as to how this could be managed from their perspective.
There was sparse evidence that service users were educated about the effects of methadone and the dangers of polydrug misuse. Coming into contact with primary care provided virus identification of HCV but little education about the effects of methadone. The realities of the complex phenomenon of methadone treatment is that methadone, although criticized as a substance which produces negative emotions (such as the ‘’liquid handcuffs’’) is a substitution treatment which remains valuable in many ways. This creates a paradox.
The research identified the risk associated with treatment which is inconsistent in its approach. There is a need to communicate information about treatment which is culturally appropriate to service users. The need to revisit the prescribing practices of GPs and the rationale for or against low dose methadone is called for. The findings indicate formal targeted education in this respect. This could include information about methadone, advice about the risks of overdose and emergency treatment. The data calls for consideration of these issues.
• A more proactive role on the part of the practice nurse within a shared care system should be considered with a specific emphasis on educating service users on the importance of understanding the effects of treatment. Educational material to enable the service user