“Holding on by the Seat of Their Pants” A Mixed Methods Exploration of Retention, Completion and Recovery in Opioid Substitution Treatment

Abstract

This is a mixed-methods, multi-disciplinary thesis, which seeks to answer the overarching research
question “what are the facilitators of and barriers to retention, completion and recovery in opioid
substitution treatment (OST)?”

I have gathered evidence from multiple sources within the Person-Based Approach to intervention
development to answer my research questions with a view to directly informing future
interventions. Firstly, I carried out a systematic review and thematic synthesis of qualitative
studies (n=37). Results were considered within the framework of the socioecological model.
Stigma appears to be a particularly key barrier to recovery and was present at every level of the
socioecological system. Secondly, I carried out an analysis of routinely collected data using
survival methods and multivariate logistic regression. I found that unplanned discharges were
common whereas planned discharge was a comparatively rare event. Episodes that ended in
unplanned discharge were also associated with higher rates of representation to treatment. The
logistic regression demonstrated several factors associated with decreased likelihood of planned
discharge – these were crack cocaine use, injecting drug use, unstable housing and being female.
Finally, I carried out 25 semi-structured interviews with staff (13) and service users (12) of the
three organisations responsible for delivering OST in Bristol. I used reflexive thematic analysis to
develop the following five themes: 1) The System is Broken; 2) Power Struggles; 3) Preparing for
Change; 4) Filling the Void; and 5) Redefining Recovery. Together the themes show that recovery
within OST is the result of complex interactions between the system and the individual. These
findings present a picture of a system that is perceived by both service users and providers to not
be delivering what is appropriate or adequate in helping people recover from opioid dependency
within OST.

My findings have helped to re-frame recovery in OST as being the result of complex interactions
between levels of the system in which OST service users are situated within. To my awareness, the
OST system had not previously been mapped in this way. Additionally, I have shown that the
current definition of ‘success’ in OST, as a binary concept of abstinence, is too narrow and fails to
reflect the continuous and nebulous nature of recovery from opioid dependence. The overall
implications of this research are that recovery in OST is a complex problem that requires complex
and multi-faceted solutions. System-wide change is required to improve recovery outcomes in
OST. Stigma and trauma are both key barriers to service users being able to achieve more recovery
outcomes and living fulfilling lives. Focussing on ‘successful’ treatment completions whilst
neglecting other important outcomes means that even those service users who are able to detox
from opioids and leave treatment do so in such a precarious way that it leaves them vulnerable to
relapse, or “holding on by the seat of their pants”.

Date of Award	25 Jan 2022
Original language	English
Awarding Institution	University of Bristol
Supervisor	Joanna Kesten (Supervisor), Olivia M Maynard (Supervisor), Matt Hickman (Supervisor) & Kyla H Thomas (Supervisor)