Citizens Perspectives of Suboxone Substitution Treatment: Improving Treatment Quality

Transcription

1 Citizens Perspectives of Suboxone Substitution Treatment: Improving Treatment Quality

2

3 Citizens perspectives of Suboxone substitution treatment: Improving treatment quality Methodology: Qualitative descriptive analysis of 7 interviewees who have switched either to Suboxone or off it for the treatment of their opioid use disorder

4 Beyond the acceptance that stigma played a part, there was no clear understanding in the research as to why people prefer Suboxone or methadone. Our current advice to clients around which medicine they would most benefit from is currently a well informed best guess.

5 Most of the data around Suboxone is from systematic reviews of RCTs comparing Methadone to Suboxone, and comparing Suboxone to no treatment. The broad criteria for these studies is retention in treatment, ongoing use of other opiates, I.V. use, and mortality. Methadone has a higher retention in treatment than Suboxone. Those on Suboxone use less intravenous illicit opioids. But

6 ...It is a draw. Although there are differences.

7 Methadone is easier to stay on and Suboxone is easier to come off, and there are pharmacological reasons for this: methadone is a long acting full agonist, and Suboxone is a longer acting partial agonist. Anecdotal reports are that methadone dampens you down and Suboxone is energizing.

8 Methadone has endocrine effects which reduce testosterone and drive. Suboxone reveals anxiety and distress often masked by full agonist opioids. Methadone substitution resulted in reduced conceptual flexibility. Suboxone did not. Methadone substitution hours post dose resulted in increased perseverative responses. Suboxone did not.

9 In Aotearoa New Zealand, treatment for opioid use disorder aims to reduce harm during the initial stages of treatment, but as people do better the notion of recovery melds with harm reduction. For the clinician, treatment and recovery should be considered from the outset. The nursing mantra of discharge planning at initial assessment rings true, yet this is a distant bell that tolls. Do things become static on opioid substitution treatment?

10 People who had switched between methadone and Suboxone and were diagnosed with Opioid Use Disorder according to the DSM 5 was the only inclusionary criteria. People with active suicidal ideation or active psychotic symptoms were excluded People under the age of 19 years of age were excluded Participants were selected randomly. Seven in total, two identified as Maori

11 Small sample size generated data saturation surprisingly quickly People who switched from Suboxone to methadone were reluctant to be interviewed meaning six of the seven participants had switched from methadone to Suboxone We still do not know the long term outcomes from Suboxone

12 Drivers for opioid substitution treatment change. Readiness for Suboxone substitution treatment. Absence of effect from Suboxone. An increased sense of citizenship on Suboxone.

13 Stigma: I didn't want that attached to me A loss of control: Tied to the pharmacy every day Methadone responses: That whole sedation thing and that lack of motivation Methadone : Just Another Drug

14 A chance to get your head around things. 100% commitment I Wasn t Ready Well I came out of my daze and quite liked not being in a daze.

15 I m not muddled or befuddled I suppose Suboxone, you keep some of the effects but the bubble is gone It just levels you out during the day so you get some opiate effect, it's not being clean as such but I think cognitively you stay pretty clear and pretty on to it. You don t get that I need this thing with Suboxone because 1) it s got a really long half-life and 2) because the lack of effect it doesn t feel like you re getting a fix

16 It just kind of crept up on me since the change It s making me cope and look at what I ve got to actually do. I ve got to sort out the underlying issues; it s not so much the drugs. It s the issues that are causing me to use the drugs Not just getting off the drugs but the reasons behind why you take the drugs I want to deal with the causes Before when I was on methadone, I went for a job and I got all these bits of paper and I thought well I can t be stuffed filling these out. This time I filled them all out and then got a job. So that s the difference.

17 Stigma as a switch Stigma is an important part of a decision matrix around the selection of Suboxone for citizens seeking opioid substitution treatment, but the change is motivated by more than stigma The effects of methadone: Re-inforcing opioid use disorder For many, including participants in this study, methadone, experienced as very helpful in reducing chaos and steady the ship for a period is then experienced as just another drug.

18

19 Harm Reduction, Recovery, Readiness, and Absence of Effect Readiness for Suboxone relates to how the participants located themselves on the recovery pathway. Suboxone is a partial agonist, and as it is only doing part of the job of a full opiate, it can be experienced as highly beneficial or highly disruptive. Citizens experiences of sedation on methadone, and clarity on Suboxone can be explained in part by expectation, but also by the pharmacological and neuropsychological research on both medicines and their effects on the endocrine system and on cognition. Absence of Effect: Citizenship, and Freedom Increased citizenship can be seen as both an outcome of perceived freedom of being released from the social constraints of being on methadone, and related to the pharmacological lightness of touch that Suboxone is reported as providing.

20 The psycho-social and pharmacological imperatives of treatment delivery In addition to thinking within social and psychological parameters about who best would respond to Suboxone, we need to consider the impact pharmacology plays on the selection of either Suboxone or methadone. Clinicians should offer a choice to the majority of citizens commencing opioid substitution treatment, but qualify that choice by clearly outlining the respective benefits of each medication from the outset of treatment.

21 If citizens seeking treatment for opioid use disorder wish to experience sedation, and their view of recovery does not include abstinence from opiates, then methadone may be the best treatment option. If citizens seeking treatment for opioid use disorder do not want to experience sedation, and their view of recovery includes an end point of abstinence from opiates, then Suboxone may be the best treatment option.

22 Bamber, 2008 DSM-5 Kalechstein & van Gorp Mattick et al Summit study White& Cloud, 2010 I have the full reference list if you want it: blair.bishop@ccdhb.org.nz