Client satisfaction and perceptions of treatments in the North American Opiate Medication Initiative Kirsten Marchand, MSc Candidate at UBC SPPH Canadian Public Health Association Conference

NAOMI Study Description Compared the effectiveness of medically prescribed injected diacetylmorphine (or hydromorphone) to oral methadone in the treatment of chronic opioid dependence Randomized 251 participants to oral methadone (N=111), injectable diacetylmorphine (N=115) or injectable hydromorphone (N=25) 12 months of treatment + 3 months to taper and transition

NAOMI Inclusion Criteria DSM-IV opioid dependence ≥ 25 years of age > 5 years of opioid-dependence and current daily injection of illicit opioids ≥ 2 previous treatments for opioid dependence, including at least one attempt at methadone (≥ 60 mg/ 30days) No enrollment in methadone within the prior 6 months

Why Measure Participant's Experiences? Improves our understanding of how and why treatments work or not Potential to increase treatment engagement and retention Part of delivering patient-centered care

The NAOMI Participant’s Experience OBJECTIVES: 1.To determine changes in participant’s satisfaction with treatments delivered in NAOMI 2.To understand participant’s experiences with their allocated treatment

Methods 1.Client Satisfaction Questionnaire At T3: N = 232 (92%) At T12: N = 237 (94%) 8- item questionnaire on a likert-type scale + Optional open ended comments: N= 149 (60.3%) 2.Semi-structured Qualitative Interviews N=29: 11 oral and 18 injectable participants Thematic analysis

NAOMI Treatment Satisfaction Findings from the Client Satisfaction Questionnaire:

Oral Injectable Oral group: n=96 (86%); p-value = 0.007; Injectable group: n = 126 (90%); p-value < 0.001

Open-ended Comments Few participants and few sentences Common topics: General comments about the staff and program Concerns about randomization Disappointments about the study ending

Perceptions of NAOMI Treatment Findings from the Semi-Structured Qualitative Interviews:

Reduced illicit drug use, illegal activities and improved physical and mental health The injectable group expressed disappointments with study ending The oral group described being disappointed with the random treatment allocation Experiences with NAOMI Treatments

Experiences with Injectable Treatment And what the NAOMI project did for me was [to] let me realize what my life was before I started doing drugs and had to spend all my money on drugs and all my free time on getting money for drugs…And right now, to this day, I don’t do, any injection drugs at all…I feel a lot better about myself too, like I have self worth again. [Male participant, Age 40, Diacetylmorphine, Responder, Retained]

Experiences with Oral Treatment I came back about a month later and decided to go on the methadone. [...] Yeah the whole world just fell out from beneath me when they said the word methadone. [Male participant, Age 40, Methadone, Responder, Retained]

Perceptions of Injectable Treatment Challenges of attending clinic 2-3 times per day Stability, routine, support Flexibility in dosing schedule was needed Additional programs to support participants with how to fill this ‘free time’

[…] I found going [to the NAOMI clinic] three times a day was almost a full time job…With travel time there and back it, it took you know […] between five and six hours a day, right? And it’s basically impossible to uh, try and go back to work. [Male participant, Age 50, Diacetlymorphine, Responder, Retained] Perceptions of Injectable Treatment

Preferred the study’s model of care Able to reach more satisfactory and stable doses at a quicker pace Additional services, staff, support all under ‘one roof’ Perceptions of Oral Treatment

Dr. NAOMI put me up to, high enough dose…I think I was on 80 before when I was at this other clinic. But I mean it wasn’t, it wasn’t enough. By the time I came to…get my dose for the next day I was starting to go through withdrawals. And I was on methadone for like two months on that dose and I was using all the time. And the doctor wouldn’t put me up any more. [Male participant, Age 40, Methadone, Responder, Retained] Perceptions of Oral Treatment

12 months was not enough time for some to fully benefit from injectable treatment NAOMI injectable treatment allowed participants to stabilize and to consider transitioning to other treatments that they had previously not benefitted from Transition from Injectable Treatment

Well, you know one of the effects of NAOMI and I’m not sure how or why, I am more accepting of methadone now than I was before. More able to, uh you know, to accept, the reality of it. You know, uh [pause] I’m not using as much opiates ad I did before, uh, at NAOMI, you know? And I, I don’t, run to find opiates as quickly as I used to. [Male participant, Age 51, Diacetlymorphine, Responder, Retained]

Conclusions Satisfaction and perceptions of opioid substitution treatment are challenging to measure. Treatment satisfaction tools on their own may not be sufficient to understand participant’s experiences. Mixed-methods designs may be necessary to interpret and understand satisfaction scores.

Implications 1.For Patients May reduce barriers to care, improve treatment engagement and retention 2.For Service Providers Inform changes in policies or practices for sub-groups

Implications 3.For Research Further mixed-methods is needed Example modification to the Client Satisfaction Questionnaire.

Thanks and Acknowledgements  The NAOMI study participants who shared their time and stories.  My supervisor, Dr. Eugenia Oviedo-Joekes and the remaining NAOMI study investigators and research team.