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In Norway, Opioid Maintenance Treatment (OMT) is provided to people with opioid dependence. Understanding the experiences of patients and health personnel dealing with OMT can provide valuable information to improve quality of OMT services as well as to increase acceptability and accessibility to use OMT services.
We summarized 24 qualitative studies portraying patients’ and health personnels’ experiences with OMT services. For the analysis, we used Andersen’s model Behavioral Model and Access to Medical Care as a theoretical framework. Then, we used GRADE CERQual to assess the confidence of the results.
Our analysis resulted in six key findings:
- Stigma from people outside LAR was a barrier to seeking out and remaining in treatment (High confidence).
- Both patients and health personnel perceived that the OMT system contributed to further stigma (High confidence).
- Inadequate knowledge and competence among the health personnel reduced the quality of OMT, and negatively affected the patients' experiences with the OMT services and treatment outcomes (Moderate confidence).
- Communication and patient-health personnel relationships were either facilitators or barriers for treatment compliance in OMT (High confidence).
- Patients had many expectations related to non-medical treatment outcomes of OMT such as getting a job, finding housing and regaining their previous social relationships (Moderate confidence).
- The patients continuously balanced positive expectations of OMT, and negative outcomes, especially those outcomes that were related to stigma (Low confidence).
The Norwegian Institute of Public Health was commissioned by the Norwegian Directorate of Health to carry out a qualitative systematic review of patients’ and healthcare providers’ experiences with Opioid Maintenance Treatment (OMT). The Directorate of Health are going to produce national guidelines for the treatment of opioid dependence. OMT patients’ treatment experiences have a significant importance that can generate knowledge to improve acceptability, access to and usage of OMT services. In addition, healthcare personnel’s experiences with OMT can be useful to improve the competence of health care personnel and for policy development. The purpose of this review is to advance the knowledge base regarding the experiences of patients and health care personnel with OMT.
We conducted a systematic literature search in electronic databases in September 2019 and conducted an updated search for Norwegian studies in October 2019. Two reviewers independently screened all titles and abstracts and then full texts, to assess their relevance to the inclusion criteria. Three reviewers extracted the following data from the studies that met the inclusion criteria: Aim/research question, participants, context, methods, main results, and "data richness". Based on this information, three reviewers independently conducted a purposive sampling and came to a consensus for the final studies to include in this report. We assessed the methodological quality of the included studies using the CASP Checklist. We used NVivo software for coding in two rounds, and for the analysis, we used Andersen's model as a framework for understanding, describing contextual and individual factors, health behaviors and outcomes. Lastly, we assessed confidence in the results with GRADE CERQual.
We read the full text of 54 studies. We then carried out purposive sampling of 24 studies that were included in the report. There were 17 studies in which the participants were patients (N = 364), nine in which the participants were health care providers (N=327) and two that included the experiences of both patients and healthcare providers (N=86). The studies were conducted in the United States of America (7), Norway (6), the United Kingdom (5), Canada (2), Sweden (2), Belgium (1) and New Zealand (1).
Our analysis resulted into six key findings:
- Stigma from people outside LAR was a barrier to seeking out and remaining in treatment. Stigma emerged as a barrier, which can be understood as attitudes to LAR in the social context surrounding the individual. Stigma affected the individual’s own health beliefs. By hiding one’s drug addiction and not seeking treatment, one could avoid stigma, but by seeking OMT, one must accept stigma (High confidence).
- OMT was also a source of stigma as reported by both patients and healthcare providers. In addition to stigma from outside, both healthcare providers and patients reported stigma as an unfortunate characteristic of the treatment process (High confidence).
- Patients and healthcare professionals reported that inadequate knowledge and expertise among healthcare providers were barriers, which affected access to OMT, the quality of treatment, patients' experiences, and treatment outcomes. They also reported that inadequate knowledge and expertise regarding the client population and treatment affected their ability to have a good follow up for the patients. Inadequate knowledge may also have contributed to negative attitudes towards OMT patients and OMT treatment among healthcare providers (Moderate confidence).
- Patients and healthcare personnel perceived that communication and patient-provider relationships were crucial for the quality of the OMT and were perceived as either facilitators or barriers for treatment compliance and outcomes. Health care providers and patients identified that good communication and relationships could enable compliance, while poor communication and non-existent therapeutic relationships could negatively affect both groups’ experiences of OMT, and hinder compliance (High confidence).
- Patients had expectations of many non-health related outcomes of OMT, such as employment, housing, and getting back their previous social relationships. Our results indicate that the achievement of such outcomes was clearly tied to the patients’ satisfaction with the treatment. Patients identified a need for a more holistic and multidisciplinary approach to treatment beyond medical treatment (Moderate confidence).
- Patients continuously balanced positive outcomes of OMT, with negative experiences and stigma. A "normal life" was a frequently used phrase that can be understood as the patients compromise between the stigma that comes with OMT, their expectations of OMT, and the positive outcomes they hope to achieve (Low confidence).
Based on the GRADE-CERQual assessment, we had high confidence to three of the findings. Stigma from people outside OMT was a barrier to seeking out and remaining in treatment. OMT services itself was a source of stigma and communication and staff-patient relations were either facilitators or barriers to treatment compliance and outcomes. We had moderate confidence to two of the findings: Inadequate knowledge and competence among health professionals was a barrier as reported by both patients and healthcare providers, which affected the availability and quality of OMT, patients' satisfaction with OMT, and treatment outcomes. Patients had expectations of many non-health related individual outcomes of OMT. Our high confidence in these findings suggests that they are good representations of how participants experienced OMT.
By using the Andersen's model as a framework, we identified several dynamic factors that facilitate or hinder patients’ access to and usage of OMT. Patients' treatment compliance and outcomes of OMT were influenced by their social contexts and by various treatment processes such as communication with providers and providers’ competence, but also by patients' own expectations and attitudes towards OMT.
We have used a systematic method of searching, identifying, and analysing relevant studies. A well-conducted qualitative systematic review can provide thorough understandings of complex phenomena as one explores people's perceptions and experiences in relation to the context in which they are situated. Since we identified a large number of studies with very rich data, we chose to use a purposive sampling approach to select studies with sufficient broad geographical spread (with relevance to the Norwegian context), that had rich data and that were relevant to our research questions.
By limiting the number of studies to a manageable amount, it was possible for us to thoroughly analyse and summarize the material. By using Andersen’s theoretical model, we have highlighted how OMT-specific experiences and practices dynamically relate to contextual factors that may be inside or outside of OMT system.
Further research should focus on increasing healthcare professionals' expertise related to addiction and to OMT, as well as how stigmatising attitudes and behaviour among healthcare professionals inside and outside OMT can be prevented and addressed. There is also a need for more studies that explore patients’ experiences and needs related to treatment of addiction beyond their medical needs. In addition, there is a need for interventions that focus on non-health related outcomes (such as work, education, leisure interests, etc.) and how these can be integrated with OMT. Finally, there is a need for increased knowledge regarding how OMT can be organised to facilitate individualised treatment decisions and to reduce stigma.
Treatment-seeking behaviour, treatment compliance and outcomes of OMT are affected by stigma in society and within OMT, treatment processes such as communication and healthcare professionals' competence and patients' own expectations and attitudes towards OMT. Stigma is continuously weighed alongside expectations and needs as patients decide to seek OMT or to remain in OMT. These results show the need for increased competence, including competence in relational work, among OMT health care personnel, to improve the quality of OMT and to avoid stigma and negative attitudes among the health care personnel. OMT should also have a holistic approach to meet patients' non-health-related needs, as these seem to be crucial for treatment compliance and outcomes