Exploration of the Attitudes and Aspirations of Clients in OST
Research type
Research Study
Full title
A pilot study on investigating outcomes of OST in shared care, and the attitudes and aspirations of patients in treatment
IRAS ID
106364
Contact name
Mark Gabbay
Contact email
Sponsor organisation
University of Liverpool
Research summary
A recent clinical audit undertaken in secondary care in Merseyside Addiction services identified around 20% of subjects who were persisting in regular heroin use while in treatment. These patients mostly reported low mood, poor quality of life, but were also resistant to changes to their treatment (notably, increasing methadone dose) designed to assist them to stop using heroin. Keyworkers commented that for many patients stopping heroin use was not a priority.
There are several hypotheses which may explain this behaviour. One hypothesis is that some long-term, socially excluded heroin users become demoralised, have little sense that change is possible, and have few limited aspirations – they become “stuck” in a cycle of low expectations. It is also possible that some people use treatment, not as a path to change, but as a way of sustaining a drug-using lifestyle. It has long been recognised that people enter treatment (and leave treatment) based on estimating the particular short-term advantages and disadvantages of doing so (Gerstein and Harwood, 1991), and the challenge of treatment may be seen as promoting engagement and positive change. In such interaction, keyworker attitudes and assumptions are critical, but it is possible that some keyworkers come to share patients’ low expectations.
We are now seeking to extend this clinical audit in three ways.
Firstly, we propose to describe the pattern of participation in OST in Merseyside over the last 7 years, analysing NDTMS data from the NWPHO. This will characterise retention in treatment, the extent of cycling in and out of episodes of treatment, and the number of “new” patients presenting with no history of prior treatment. The hypothesis underlying this analysis is that the great majority of patients who leave treatment re-enter within 12 months, regardless of the listed reason for leaving treatment; that longer episodes of treatment will be associated with less likelihood of readmission within 12 months; and that there are few “new” entrants to treatment.
Secondly, we propose to repeat the clinical audit. The previous clinical audit focused exclusively on patients persisting in regular heroin use, and the proposed audit will investigate outcomes more comprehensively, and will focus on primary care rather than secondary care. UK research into primary care based treatment has confirmed that outcomes are similar to those observed in secondary care, but there has been little detailed investigation of patient attitudes and treatment delivered in this expanding area of treatment. The audit will review clinical records, looking at treatment delivered and outcomes in shared care and intermediate care, looking at treatment outcomes, and elements of service delivery – appointments, medication prescribed, dosages, levels of supervision, urine test and self-reported results.
The third component of this project builds on the file audit, and involves research interviews. The research is a pilot study, investigating two approaches to trying to explore patient and keyworker attitudes and beliefs about treatment – and, in particular, whether keyworkers and patients had similar ideas about the objectives of treatment and means of achieving those objectives.
This research is timely. The Drug Strategy 2010 is based on the perception that many people in OST are not deriving optimal benefit from being in treatment, and introduces the “recovery agenda”, which, in conjunction with Payment by results (PbR) is designed to focus treatment on outcomes. This current policy approach (within the Recovery Agenda), of abstinence and returning to employment, is part of a wider political remit of reducing benefit claimants and individuals making a contribution to the wider society – through work or volunteering. This backdrop is crucial to consider when looking at how treatment and outcomes are managed and operationalised between patients and health and social care workers.
REC name
North West - Liverpool Central Research Ethics Committee
REC reference
13/NW/0376
Date of REC Opinion
14 Jun 2013
REC opinion
Further Information Favourable Opinion