Intended for healthcare professionals

Opinion

Rigid opiate agonist treatment programmes risk denying people their agency

BMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p400 (Published 20 February 2023) Cite this as: BMJ 2023;380:p400

Linked Analysis

Is daily supervised buprenorphine-naloxone dosing necessary?

  1. Judy Chang, executive director, International Network of People who Use Drugs, London

Greater flexibility is needed to create more person centred care in drug treatment services, but the prohibitionist ideas that underpin clinical practice need to be tackled too, says Judy Chang

Opportunities to deliver opioid agonist treatment (OAT) for drug dependency more flexibly emerged during the covid-19 pandemic, as lockdowns and social distancing restrictions led to the suspension of strict treatment policies in many settings across the world. The daily supervision of methadone and buprenorphine dosing in a pharmacy or clinic, for example, became impossible to comply with, and supervision frameworks had to be temporarily relaxed.1 That said, policy makers and programme managers missed an opportunity for greater disruption to the problematic rationale that underpins drug treatment and policies. The removal of requirements that force people to be supervised every day as they take opiate agonist treatment is a step in the right direction, yet we still have much further to go in creating person centred care for people who use drugs.

Punitive drug policies continue to shape and permeate clinical settings. Across the world, the current status quo of drug treatment is one in which policy makers and clinicians decide what is best for people who use drugs. More weight is given to prescribers’ concerns—fears of diversion and misuse, crime, a lack of commitment to abstinence—than clients’ autonomy, independence, and empowerment. People who use drugs are afforded little agency in their treatment options and protocols, and are subjected to social control imperatives that attempt to ensure people who use drugs conform to a drug-free life. These practices, which range from daily supervision to mandatory drug testing, would not be tolerated in other healthcare settings and are a kind of drug treatment exceptionalism. Sociologists have laid out the ways in which they enact harm.2 Policies for the restriction and supervision of OAT are underpinned by the logic of abstinence; consequently, they are both driven by and reinforce criminalisation and stigma.

Drug treatment exceptionalism also facilitates the polarisation of OAT, in which some medications are perceived as “good” while others, such as methadone, have a more negative connotation. Unsupervised buprenorphine-naloxone formulations,3 for example, have been more broadly accepted, but a similarly flexible approach has not been pushed for with methadone. Despite being the most commonly prescribed OAT, methadone has often been demonised and subject to stricter control and regulation because of fears of diversion and fatal overdoses. Methadone has long been the gold standard of treatment for drug dependency,45 and the evidence doesn’t justify such knee-jerk, disproportionate responses. Promoting take-home dosing for some forms of OAT but not others is an extension of the unhelpful demarcation between different forms of drug treatment.

Making person centred care a reality

We need to shift power from the clinic to clients, and by doing so change policies and practice within the drug treatment landscape. In recent years, we have seen a broad acknowledgement that person centred care—comprised of health services tailored towards the needs and preferences of the client—is required to improve health outcomes.6 If we are to move towards more person centred care in drug treatment, then expanded choice and flexibility in the delivery of programmes need to be coupled with a political commitment to remove structural barriers, including criminalisation, and challenge prejudice and discrimination.

To make flexible and person centred drug treatment approaches a reality, clients’ values and preferences must be integrated into the design of policies, research, and programming. Firstly, we need to develop drug policies and regulations that focus less on social control, and instead enable people to manage work, family, and personal commitments. Beyond offering clients the option of taking their medication at home, clinics should stop mandatory supervised urine testing and remove abstinence as a criterion of continued treatment. Many clients also currently face multiple difficulties even making it onto OAT treatment programmes, such as the need for a GP’s referral, long waiting periods, and mandatory appointments with additional specialists, when the process should be much easier.

Secondly, policy makers and clinicians need to better understand what people want from drug treatment, while appreciating that there is a limit to what can be learnt from conventional medical research. More qualitative research, not merely epidemiological research, must be supported and funded—particularly community led research that explores acceptability, feasibility, and clients’ preferences on drug treatment and service delivery modalities. Finally, programmes and services must incorporate mechanisms for clients to feed back about their experiences by creating community committees, promoting community led monitoring, and engaging networks led by people who use drugs in decision making.

The International Network of People who Use Drugs has long advocated for changes to the status quo in how OAT programmes are designed and delivered. We’ve celebrated some of the changes that covid-19 ushered in, but lament the fact that it took a pandemic to compel such progress.7 Arguments for more flexible and appropriate drug treatment should be propelled by a growing recognition of what people who use drugs want, deserve, and have a right to.

Some of the flexibilities introduced because of covid-19, such as take-home doses, have been rolled back in many countries, reversing the small gains made and making it more important than ever to disrupt prohibitionist practices in drug treatment that deny people their agency. People who use drugs should not have to negotiate rigid, inflexible, and arbitrary regulations that would not be acceptable for any other population to have to contend with. Person centred care means making as many options available as possible, not limited by stigma and prejudice, and providing services that accord with people’s everyday lives while respecting an individual’s dignity. No one should be forced to “choose” between treatment that disempowers and paternalises them, or no treatment at all.

Footnotes

  • Competing interests: none declared.

  • Provenance and peer review: commissioned; not externally peer reviewed.

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