Background
Methods
Sociodemographic characteristics | ||||
---|---|---|---|---|
Gender | Female | Male | ||
Characteristic | Frequency | Percentage (%) | Frequency | Percentage (%) |
Age | ||||
Under 30 | 2 | 15.4 | – | – |
30–39 | 3 | 23.1 | 8 | 88.9 |
40–49 | 8 | 61.5 | 1 | 11.1 |
Marital status | ||||
Partner | 8 | 61.5 | 6 | 66.7 |
No partner | 2 | 15.4 | – | – |
Not mentioned | 3 | 23.1 | 3 | 33.3 |
Level of education | ||||
< grade 10 | 1 | 7.7 | 1 | 11.1 |
Grade 10 | 6 | 46.2 | 4 | 44.4 |
> grade 10 ≤ grade 12 | 3 | 23.1 | 3 | 33.3 |
Post high school education | 2 | 15.4 | 1 | 11.1 |
Ethnicity | ||||
First Nations | 13 | 100 | 8 | 88.9 |
Other | – | – | 1 | 11.1 |
Employment | ||||
Employed | – | – | 1 | 11.1 |
Unemployed | 12 | 92.3 | 7 | 77.8 |
Not mentioned | 1 | 7.7 | 1 | 11.1 |
Healthcare providers | no | Experiences in the clinic |
---|---|---|
Methadone Case coordinators | 4 | 1–14 years |
Physicians | 4 | 1–4 years |
Pharmacists and pharmacist technicians | 6 | 6 months to 19 years |
Laboratory technologists | 1 | 11 years |
Managers | 2 | 1–3 years |
Results
A focus on biopsychosocial perspective
[When patients come to enroll for treatment] we interview the patients first and do a full bio, social, psycho[logical], and spiritual assessment. The report is then given to the doctor, who decides if the patient is a good candidate to be enrolled in the program. Once enrolled, we start moving them through the stages of recovery (Methadone Case Coordinator 1).
They're [The patients in our program] very complex… and we know that [late stage] drug use, there isn't an area that hasn't been touched in their lives. Their health has been [affected], their children have been taken away, they're in the correctional system, they don't have a home... so yeah. They're very complex because there is mental health issues, [and] there are health issues… (Methadone Case Coordinator 1).
What we've been noticing is that primary health care physicians don't want to take these patients as patients because they're so complicated. Prescribing methadone physicians don't want to be their primary healthcare provider either. But I think if really, if we want to look at holistic care, we need to provide care to these patients for their other conditions as they have chronic diseases and other social needs that need to be addressed (Manager, 1).
"I think I need to get my place back and get back into school and stay away from these people… stop going around their places" (Female patient, 39 years).
Component of PCC | Quote | How it facilitates PCC | How it does not support PCC (Barriers) |
---|---|---|---|
Biopsychosocial perspective | When patients come to enroll for treatment, [we] interview them first and do a full bio, social, psycho[logical], spiritual assessment. The report is then given to the doctor, who decides if the patient is a good candidate to be enrolled in the program. Once enrolled, we start moving them through the stages of recovery (Methadone Case Coordinator) | Comprehensive assessment of patients during intake allows for a deeper understanding of the patients physical, mental and social needs | Since the clinic provides specialist care, patients have to seek care for the identified needs elsewhere |
Patient as person | You give them their drink, and you might have a little bit of a conversation. They [the patients] might be, you know, like one gal said, 'Oh I walked over here today and, you know, I'm trying to get back into- I used to run and,' so you learn a little bit about their lives and, you know, as you interact with them, one guy that is a drywaller so I was asking him is it busy right now?' He said, 'Yeah I got lots of drywall jobs,' so you learn a bit personal about them (Pharmacist) | HCP interest in understanding a patients’ lived experience motivates HCPs to be advocates and allied in care | There are limits to what HCPs can do for these patients who are dictated by treatment guidelines that governed the clinic operationalization |
Sharing power and responsibility | I was taking Suboxone at the time, and then, I started getting depressed, really depressed inside. I would take Suboxone, and I'd pretty much sleep for three days or four days. So, I went back, and I talked to her [the methadone case coordinator] about it, I said, "This is not working." She was wondering because I quit taking Suboxone. I told her, "Well, do you think we can try methadone?" And she's like, "Okay." That was my first round with methadone (Female patient, 38 years old) | When patients are able to contribute to their treatment plan, they may be more successful in treatment adherence and recovery | A significant power imbalance between HCPs and patients exists, which had a significant bearing on patients' ability to discuss their treatment goals |
Therapeutic alliance | If we need any help in basically anything like we need somebody to talk to or job, resume hunting or something… 'Cause I needed a little bit of money last week for my daughter's graduation gift so they hired me to do some cooking. I went in there and cooked them a quick couple meals and boom, gave me some money. So if I need some stuff like that, they help out…they help out a lot. These two ladies are very well, they do a good job (Male patient, 38 years old) | Patients benefited from positive and mutually respectful encounters with HCPs as it makes patients feel valued | A lot of time is needed to develop therapeutic alliance between the patient and the HCPs. Noncompliance with the treatment plan is a significant threat to the therapeutic alliance |
Doctor as a person | I've never taken things personally [with patients on methadone treatment]. It's gotta be professional. And with my prior careers too and stuff, I've always been able to deal with situations well. It's never affected me mentally or emotionally. And that's the type of person I am. How I've seen it affect people—death has affected people. I've seen that. I've seen death numerous times, and never affected me. So, in a case where these people are, it's professional, right? One patient got emotional yesterday, and I feel for her, but it just doesn't affect me (Methadone Case Coordinator) | Because of complexities involved in the caring of patients with OUD, objectivity in care can be protective to both the patient and the provider | Some patients may feel the boundaries set by HCPs and the treatment contract acted as barriers to achieving full recovery, ultimately hindering the ability to form a therapeutic alliance |
The “Patient-as-Person”
When I first started off, it was just alcohol. For that, I started off with the drinking when I was a kid, and I was drinking until... I drank heavily for years, and years, and years until about 2013, 2014. That's actually the last time I drank, so I drank heavily with that. But all along the way, I was doing stuff like cocaine, crack, I smoked weed a lot during the time, I did a lot of that. I did pretty much anything a guy could get high on and I did a lot of that, minus the hairspray and stuff like that, there were certain things I wouldn't do. But anyway, I had [done]a lot do drugs in my life (Male patient, 38 years old).
…Because I'm scared. I'm tired of feeling pain all the time. I'm scared of the withdrawal for one, and I'm scared that the withdrawal is gonna be so bad for me. I'm scared I'm gonna... [Crying] Sorry… I'm scared that I'm gonna end up committing suicide. I look out my apartment window and I see the rivers, the trees, the bridge. I don't want [my husband] to know, but I've thought of hanging myself so everybody can see me… I'm scared of withdrawal, and pain, and you just want it all to go away (Female patient, 42 years old).
You give them their drink [of methadone], and you might have a little bit of a conversation… so you learn a little bit about their lives and, you know, as you interact with them. One guy that is a drywaller, so I was asking him “is it busy right now?” He said, “Yeah I got lots of drywall jobs,” so you learn a bit personal about them (Pharmacist 1).
Sharing power and responsibility
I was taking Suboxone at the time, and then, I started getting depressed, really depressed inside. I would take Suboxone, and I'd pretty much sleep for three days or four days. So, I went back, and I talked to [the methadone case coordinator] about it, I said, "This is not working." She was wondering because I quit taking Suboxone. I told her, "Well, do you think we can try methadone?" And she's like, "Okay." That was my first round with methadone (Female patient, 38 years old).
[The doctor] says I have to wait [for dose adjustment] because I have to keep taking my methadone, but I keep on missing [taking the medication] because I don't have the money, and every time I miss… if I miss so much, then I don't go up [in dose]. I have to wait 'til I have like seven drinks and then move up, but I keep on missing because I don't have the money to get it so it's taking a while (Male patient, 39 years old).
Developing a therapeutic alliance
I just do a lot of encouragement and just like we believe in you, we love you [laughs] you know. I've known them for ten years. Like one patient I said “man we could be sisters. I've seen you in your good times, I've seen you in your bad times, I've seen you grouchy, [laughs] dope sick”, I've seen just because I've worked in so many like see them on the street, see them in the clinic, see them you know. So really, at the end of the day, I think the biggest thing is a relationship (Methadone Case Coordinator 2).
If we need any help in basically anything like we need somebody to talk to or job, resume hunting or something... 'Cause I needed a little bit of money last week for my daughter's graduation gift, so they hired me to do some cooking. I went in there and cooked them a quick couple meals and boom, gave me some money. So, if I need some stuff like that, they help out…they help out a lot. These two ladies are very well, they do a good job (Male patient, 38 years old).
I had a guy that he, he just started a new job that was a Monday to Friday kind of like 8:30 to 6:00 job like he was doing trucking. So, he couldn't, he legitimately couldn't make it into the store, and it was a new job for him, he was trying to do really good, trying to better himself, and so I talked to the doctor and recommended that we switch to like a Saturday pickup so that he could then make it to work every day and you know he was a patient that was doing pretty well before so it was something that I recommended to the doctor and the doctor agreed because we need to, we need to work with patients (Pharmacist 2).
No, I'd say the regular patients are not that- they're not challenging at all. When we get some new patients, sometimes there can be challenges. It's almost like kind of getting them to getting to know where their boundaries are, right? And if they had a much bigger boundary before, they usually get reeled in pretty quick. So that's a challenge. Just for them to know what's acceptable and not acceptable at our place, right? How much running we're going to do for them, and how much we're not (Pharmacist 1).
Well, the system, the Suboxone program, yeah, it is a big help, actually. I was going through some stuff here the past month and the coordinator, their doctor, really helped me through it, and he was really helpful (Female patient, 32 years old).
Applying the “Doctor as a Person” concept
I've never taken things personally [with patients on methadone treatment]. It's gotta be professional. And with my prior careers too and stuff, I've always been able to deal with situations well. It's never affected me mentally or emotionally. And that's the type of person I am. How I've seen it affect people—death has affected people. I've seen that. I've seen death numerous times, and never affected me. So, in a case where these people are, it's professional, right? One patient got emotional yesterday, and I feel for her, but it just doesn't affect me (Methadone Case Coordinator 3).
There's some patientele that I enjoy working with. And there's some patientele I don't usually, because they [the patients] don't do anything for themselves, right? So, for the ones that are proactive and wanting to legitimately better themselves, I enjoy working with them (Methadone Case Coordinator 3).
[when talking about carries] the doctors are really just… I can't explain it. Maybe they had some really bad experiences that makes them… I don't know, I don't wanna judge them because I don't know. But I think there's a really big lack of education, big time…. (Female patient, 43 years old).
No, no. Actually, the staff out here has been pretty good. They [the staff] actually come to me with questions wanting to talk so they've been pretty good (Male patient, 31 years).
Success can be a number of things. Sometimes it can be as little as harm reduction, whereby instead of using substances fourteen times in two weeks, maybe they've used it four times. It can be making progress in their recovery whereby at the time of enrollment in the program, all they had was a backpack. And then, a month or two later, they found stable housing, and then they're working on going to get their children back. Like this is the most rewarding career in terms of seeing the changes that happen so quickly in patients' lives (Methadone Case Coordinator 4).