This thesis focuses on three critical phases in the life journey of a person with an
opioid use disorder (OUD) ; Initial, random intermittent opioid use, termed
‘Recreational Sporadic Use’, transitioning to increased persistent opioid use,
labelled ‘Intensified Sustained Use’, culminating in complete impulsivity and full
opioid dependence, coined, ‘Loss of Control’. The crucial role of the neurobiology
of dependence, explored in depth in this thesis, underpins these key phases in
developing and sustaining an opioid dependence. Building on this framework the
thesis unravels the effect of Adverse Childhood Experiences on the likelihood of
experimenting with opioids and subsequently cultivating a dependence. It then
recounts the effect of both dual diagnosis and concurrent benzodiazepine abuse on
sustaining and intensifying one’s dependence until an individual eventually
surrenders to the inevitable destructive effects of an opioid dependence and loses
all voluntary control over their usage. The thesis then delves further into the lives
of individuals with OUD by illuminating both positive and negative factors in
their life journeys, which influence the remitting, relapsing nature of their illness.
Invariably, given the neurobiological factors nourishing drug dependence the
negative factors triumph, and relapse to drug use prevails. In unravelling the
complexities of the neurobiology of dependence, this thesis, highlights that
undoubtedly the best approach to help, support and where possible treat
individuals with an OUD is under the umbrella term of harm reduction. A special
focus is placed on the harm reductive properties of methadone as a therapeutic
agent in combatting OUD, with a particular emphasis on the need to educate all
members of society on its therapeutic benefits. Undoubtedly, the most harrowing
outcome for all in this often-thwarted journey is fatal overdose (OD),
unfortunately the outcome for which far too many individuals succumb.
Therefore, the most pivotal of harm reduction strategies to ebb the flow of death
in OUD, ‘Take Home Naloxone Programmes’ (THNPs) are examined in the latter
half of this thesis, with particular scrutiny given to Ireland’s THNP. As this thesis
highlights, in Ireland, we have made much progress in our approach to addressing
the opioid crisis but, as always, there is much room for improvement and
advances.
Aims
The predominant aim of this thesis echoes a key strategic purpose of Ireland’s
latest drug strategy, ‘Reducing harm, supporting recovery: a health-led response
to drug and alcohol use in Ireland 2017- 2025’, which is to reduce the morbidity
and mortality associated with OUD. Two studies are undertaken to achieve this
purpose. Study 1 aims to give clients of the Mid-West of Ireland’s Programme for
Methadone Maintenance Treatment (MMT) a voice, to document their lived
experience of opioid dependence before, during and after their ‘three-phase
journey’ through OUD. It aims to co-develop with clients a tailored care plan to
enhance their chance of successfully engaging with the MMTP. Study 2 aims to gain an overall appreciation of Ireland’s national THNP to optimise its
functioning. A second objective of this study is to improve the likelihood of a
patient attending hospital post administration of naloxone in the community, a
step that is associated with overall better survival rates.
Methods
This thesis employs a mixed method research design. Study 1 is a qualitative study;
Study 2 employs a quantitative method.
Results
Study 1 reveals an enriching insight into the personal experience of each
individual client’s journey. Their journeys, though each unique, had common
chronological sub-themes which are recounted in depth. Subsequent data analysis
identifies common life experiences, which influence their journey both negatively
and positively. Final data analysis identifies clients’ individual suggestions for
improving their journey. The results of Study 2 reveal inadequacies in the current
reporting mechanism currently in place on the use of naloxone in the community
setting in Ireland. Descriptive analysis then looks at the characteristics pertaining
to overdose patients themselves and subsequently the characteristics of the
overdose scene are documented. Thereafter, using a logistical regression model,
statistical results on the variables that influence a patient’s hospital attendance are
presented.
Conclusion
The thesis concludes with recommendations for improvement in the management
of OUD. It proposes how knowledge of ACEs should influence the MMTPs in
Ireland and internationally, to adopt a more ‘trauma informed’ ethos.
Subsequently, recommendations centre on dually diagnosed individuals, with a
specific focus on addressing benzodiazepine misuse. Next, the theme of
therapeutics is explored, listing specific proposals on how to both promote
education and reduce stigma in relation to methadone, as a treatment option in
OUD. Finally, the thesis focuses on recommendations with regard to THNPs.
Initial suggestions focus on improving the Irish THNP and subsequently general
recommendations applicable to THNPs internationally are addressed.