Many of us may have seen people who use heroin on the street, whether it be on our daily commute to work, or when we are just going about our day-to-day life in the town centre. Some of us may give money or even buy lunch for this person who uses heroin. However, have we ever stopped to think about the person behind the heroin use and their life experiences? Not everyone who uses heroin fits in with the above description. In my time as active treatment worker and researcher, I have met people who use heroin from a diverse range of backgrounds with a variety of life experiences.
Imagine you are feeling sick with the worst flu ever, but you still have to get up, go through dark alleys and ring dealers to find heroin. Because in your mind that is the only thing that will make you feel normal. Add then the pressure of trying not to get caught by the police because heroin is an illegal drug. This is the harsh reality for many people who are dependent on heroin. Research has shown that methadone and buprenorphine (prescribed substitutes for heroin) can help heroin users in many ways. But why is there still an increase in heroin related deaths and why are some people still not benefitting from treatment?
Before studying for my PhD, I worked as a substance use worker at a busy drug agency in South Wales. The work involved the use of evidenced-based interventions such as motivational interviewing, cognitive behavioural therapy, and social behaviour therapy. I used these interventions with a person-centred approach to empower people experiencing difficulties with their substance use, to utilise their inner strengths and make positive differences to their lives. I witnessed people who accessed support, experiencing other immense difficulties such as homelessness, domestic violence and mental health issues (just to name a few), use the strength of resilience and willpower to successfully overcome these obstacles. To this day, I believe that I have learned so much about determination from my therapeutic work experience with people who use drugs.
However, there are many people who are not able to overcome all of their problems. While supporting those affected by substance use, I noticed that a significant number of people who had difficulties with heroin, cycled in and out of treatment services, without gaining optimal benefits from treatments. Many were given opioid substitute treatment (OST) to support them to overcome the unpleasant withdrawal symptoms which occur when someone stops using heroin. OST also has a psychosocial element (known as the ‘talking’ element), which helps with stabilisation on the substitute medication and the initiation of positive lifestyle changes, to help overcome dependency on heroin.
For some people, OST helps support them to both stop using heroin and overcome their problems. Sadly, for others the journey is not so simple. While OST may help them to control their use for a while, some people struggle to sort out their lives and so return to heroin use again. However, the repeated entry into treatment services shows that this group of people want to achieve benefits from treatment. This raises the important question of how treatment services can improve the health and wellbeing of people who struggle to achieve positive outcomes from OST?
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This question formed the basis of my KESS funded PhD in partnership with the University of South Wales (USW) and Gwent Drug and Alcohol Service. Specifically, my research aimed to improve understanding of the barriers to success faced by this cohort and how these barriers could be overcome to improve the health and wellbeing of OST patients. To achieve these aims, a qualitative study was conducted that involved: 1) in-depth interviews with 38 OST patients who had been engaged with OST for five years or more on a continuous or intermittent basis, 2) in-depth interviews with 20 staff members who had direct experience of working with the above-mentioned population, and 3) a ‘microethnography’ of a busy drug treatment service operating across South Wales. The research involved co-production in which service users of the drug agency were actively involved in development of interview schedule, definition of recruitment criteria, order of interviewing participants, snacks for participants etc.
A significant finding was that ‘time’ with the OST patient is needed to fully understand the needs of those that access such treatment. This in-depth understanding of need, is in turn, important to match the needs of OST patients to appropriate interventions.
Another key finding was in relation to Buvidal. Buvidal is a relatively new form of OST that is used to stop withdrawal symptoms, relieve cravings and stop the use of heroin. Buvidal is a prolonged release solution of buprenorphine in a pre-filled syringe. The findings from my project suggested that Buvidal had many benefits. For example, the constant stream of medication prevented fluctuations between withdrawal and stability, which is common in other types of OST. Buvidal was also deemed to be associated with a ‘rapid return to normality’ by OST patients. Buvidal was also related with greater levels of flexibility to go on holidays without the constraints of having to transport huge quantities of Class A medication. However the blocking effects of Buvidal and subsequent cessation of heroin use were linked to ‘flooding of uncomfortable emotions’. This highlighted the importance of provision of appropriate psychosocial support.
Another important finding of my project was that stigma against people who used drugs, affected the health and wellbeing of OST patients. The stigma had an adverse impact on gaining employment, integration with society and even access to healthcare for basic physical and mental health needs.
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Dennis (2021) argues that drug related deaths are not an inevitable consequence of ageing but can be attributed to the inflexibility of treatment services. This implies that enhancing the efficacy of treatment services could in turn reduce the incidence of drug related deaths. My study extends this argument by suggesting that society too has an important role in improving the health and wellbeing of OST patients. Indeed, a participant in my study stated that treatment services have a responsibility to provide opportunities for reintegration within mainstream society, to challenge the stereotype of people who use drugs and promote the wellbeing of OST patients.
The most important ‘take away’ message that has emerged from my research is the need for society, and not just treatment, to look at the ‘person behind the drug use’ in order to help improve the health and wellbeing of OST patients.
I would like to thank all the people who access support at the Hub, who kindly contributed their time to the co-production of the project. A big thank you to all participants who gave up their time, especially during the Covid-19 pandemic. I need to also say thank you to my supervisors (Professor Katy Holloway and Dr. Marian Buhociou) for their invaluable support and going the extra mile. Finally, I would like to pay tribute to an individual I used to support, and participant of my research, who sadly passed away due to substance use during the duration of the project.
Sharmila Kumar graduated with her PhD in ‘Improving the health and wellbeing of long term opioid substitute treatment patients who are not benefitting from treatment‘ from the University of South Wales in January 2023. Sharmila is currently working as a Project Manager for the South East Wales Mental Health Partnership in improving access to mental health services for university students. Due to the invaluable lessons learned from her time as a substance use worker ,and the meaningfulness of working in the substance use field, Sharmila has since applied to be a volunteer with Gwent Drug and Alcohol Service.