Perceptions and experiences toward extended-release buprenorphine among persons leaving jail with opioid use disorders before and during COVID-19: an in-depth qualitative study

Participant characteristics

The study team approached 17 patients who initiated XRB in jail for OUD under the pilot study, and 16 participants agreed to complete the individual interviews. Study participants were primarily male (n =13, 81.3%), with a mean age of 45 years (range 30, 55). Race/ethnicity were not re-collected among the 16 participants; the parent trial enrolled 81% Black, Hispanic, or self-reported ‘other’ adults. Respondents reported a prior history of injection drug use (n =7, 41.1%), alcohol use (n =5, 29.4%), and nonopioid illicit substances (n =10, 58.8%). In their lifetime, most participants were previously experienced with SLB (n =13, 76.5%) and methadone (n =12, 70.6%). Few had ever received extended-release naltrexone (n =3, 17.6%). The mean length of time from jail release to the interview date was 9 weeks (range, 3–16 weeks).

Medication-related factors for initiation and retention on XRB

Most participants had no prior knowledge of XRB until approached by the study staff for enrollment in the trial during a jail incarceration and prior to a scheduled release date. Some participants compared XRB’s subjective effects to SLB with the benefit of experiencing its treatment effect for approximately 1 month:

“They give it to you for a month—they give it to you once a month and it stays in your system… it’s like the equivalent between 2 and 3 strips [of SLB] a day. And it like just like coasts you through the month.” [43]

Familiarity with daily SLB proved to be a motivating factor for participants to receive XRB. Nonetheless, some respondents expressed concerns about XRB, including precipitating fears of being exposed to needles during monthly injections and the reduced efficacy of a medication administered subcutaneously versus more reliable oral or sublingual dosing of MOUDs:

“Alright so one of the issues was because I am definitely afraid of needles. I was apprehensive… the doctors explained to me it’s kind of like a TB shot it goes under the skin but it goes in the stomach so I was apprehensive but I did it and it wasn’t bad at all.” [46]

“You don’t know what’s the outcome or nothing, so it’s like you get the shot and you be like damn what’s going to happen, is my body going to reject to it, that’s the cue if you’re allergic to anything, but I was saying to myself if I was allergic to suboxone… then I definitely won’t get a reaction off of this because it’s almost the same thing. You know maybe it’s different because it’s going in your skin but other than that I ain’t have a problem with it.” [49]

After receiving XRB, participant endorsement of injection-site pain consisted of soreness around the injection site, reports of bruising and discomfort adjusting to the palpable lump remaining in their subcutaneous abdominal tissue:

“And then actually getting the shot was painful. It’s like a real, real bad stinging pain. You know, and after, you know, it’s like a lump. You know, with time it goes down. I’m guessing as the medication releases, it goes down. But it’s pretty annoying. Like when you are putting on your clothes, it’s painful. Anything that touches, it’s like you know, it bothers.

And then you get a real bad bruising around the area. That’s the only part, it’s bad.” [19]

Some participants originally expressed trepidation about the medication’s efficacy in rapidly quelling cravings, pain, and withdrawal symptoms, but those concerns largely subsided after the resolution of those symptoms post-injection:

“But when he took away the needle and the next day I went to work, I felt good, I didn’t feel pain… I feel pretty good. I’m still using it.” [06]

“After the shot, the first time, I felt like it wasn’t going to work… I gave it a couple of days, I knew I was going to get high again, was going to be buying the suboxone, but time passed through…two weeks, three weeks… and no getting high.” [06]

Nearly all respondents reported no longer using illicit opioids while on XRB and some attributed their treatment success to having tested the blockade effect of XRB after using illicit opioids without experiencing any euphoria:

“This time I was controlled. Like I said, you know, it’s really a block. You cannot get high no matter how much you try. No matter how much you do, it’s not gonna work. Your body rejects it...You can’t do too much on that at all. That’s actually a great thing, if you ask me.”[19]

Participants commonly elicited a perceived sense of normalcy after initiation on XRB. Some attributed that feeling to the monthly treatment visits and pharmacological effects of the long-acting injectable that averted the onset of cravings and withdrawal symptoms that “reminded (me) of the addiction”:

“...just knowing that you do it that one time and then I don’t have to worry about it all month. I don’t have to worry about if I lose my medicine, if I’m going to vacation or something. It’s just in you already, it’s like a thing to not worry about. Versus taking a pill, you gotta worry. Wake up each morning and make sure you have it. I just think the shot was better.” [21]

“You’re your regular self, you can go on every day and do whatever you want and you don’t have to be reminded of the addiction… I don’t have an addiction as far as I’m concerned...I’m not reminded every day that I’m taking something for the addiction because.. it’s not there... I don’t have to think about it at all.” [22]

While XRB diminished opioid craving and heroin/fentanyl use as designed, stimulant use persisted for most.

“The way I do heroin and cocaine, I do heroin and cocaine together, since eleven years old. And I leave heroin, I want to keep the cocaine. I’ll be honest. I want to keep the cocaine. I like the rush, I like the high, for the cocaine. This one works for the heroin, nothing works for the cocaine. It’s the same rush with the injection or without the injection.” [6]

“Yeah, I still have an issue using cocaine. And I really wish there was a shot for that. And you know what, I don’t even really want to do it but I still fucking do it. I just don’t understand myself, but I do it and I wish I didn’t but I do.” [43]

Patient-level barriers and facilitators

Participants highlighted a multitude of factors that facilitated their decision to pursue treatment with XRB while in jail. Patient-level factors included preferences for monthly injections on XRB in the jail OTP program, reduced risk of opioid reuse while incarcerated, and a desire to avoid opioid withdrawal symptoms and overdose episodes while incarcerated and post-release.

Most participants had been released from jail on either SLB or methadone in the past and expressed satisfaction with how their recent reentry experience on XRB prevented them from experiencing any withdrawal symptoms and reducing the potential risk of reengaging in criminal activities to procure illicit opioids:

“A lot of people’s first thought it’s like, “Yeah I’m gonna get high.” When you come out on the shot it’s like “Nah.” I want some good food, you know, stay home, relax… It didn’t make me want to rip and run the streets. It’s like I’m good, I don’t feel sick. I don’t feel the need to have to go and have to get anything else.” [19]

Participants frequently highlighted their improved likelihood of securing employment following reentry while on XRB since monthly depot injections and clinic visits were less likely to interfere with work schedules:

“Yes and functionally I can work, I don’t wake up sick every day, don’t gotta make sure I got money to go to work to get drugs, seven in the morning so I could get up. I don’t gotta worry about that, so I’m able to do all these things.” [01]

Three of the 16 interviewed participants transitioned from XRB to SLB within the 8-week study period. One participant decided to discontinue XRB due to their personal preference for the subjective “boost” that they experienced daily with SLB in place of the similar perceived effect they previously experienced with heroin and reducing their risk of engaging in illicit activities:

“Especially in early recovery... complete abstinence is very difficult, for myself. I saw it as the lesser of two evils, in a sense... Meaning I would rather look forward to getting a little boost off of suboxone than sniffing heroin and having a habit and committing a crime to get it… It’s like taking alcohol away from an alcoholic. You’re going to be miserable for a little while.” [08]

A second participant chose to discontinue XRB in light of significant post-injection site pain. The third participant felt persistent withdrawal symptoms and attributed to being under-dosed by clinicians following induction on XRB:

“Maybe if I would’ve started at the correct amount I feel like I probably would’ve just stood on it. Like I said it’s more convenient. I wish they would find a way to work out that little stinging pain... As long as they find everybody’s level, I would advise it to anybody. I would personally do it again, myself, if it just...had a little fixing.” [19]

Systems-level barriers and facilitators

Participants highlighted a variety of factors that influenced their decision to initiate XRB, including their interactions with peers, CJS staff, and clinic staff. Prior to initiation of XRB, participants enrolled in the Key Extended Entry Program (KEEP), NYC’s jail opioid treatment program (OTP), described social pressures by other inmates to divert their daily doses of buprenorphine or methadone. Factors influencing diversion included financial need, social pressures within jail, and in one case, a desire to provide MOUD to those who were unable to enroll in the same OTP.

Financial concerns elicited by one participant forced them to reconcile between adhering to their prescribed dose of SLB or selling it for money to procure food. However, maintenance on XRB was perceived by another respondent to avert the risk of diversion regardless of any personal or social circumstances.

“The thing with the pill is that you can take the pill. Like you wanna buy, and I don’t got food… I’m bringing it and giving it to you. With the shot, it’s different.” [33]

“If you ask me, that is what they need to prescribe in jail. Because anything else is making it out of there and it’s gonna be sold… If you really need that medication, you are gonna take your shot.” [19]

Reduced interactions with corrections officers was elicited as a motivational factor for initiating XRB to daily MOUD as they were perceived to be stigmatizing or inattentive to patients’ health needs leading to more time-intensive processes to receive their daily doses of methadone or SLB:

“It's that the staff [corrections officers] is just lollygagging. It’s the culture, that’s the word I’m looking for. The culture of the staff is a non-caring culture, they could care less about you. When they respond to an emergency they walk to an emergency. They don’t rush, they walk...” [46]

“I didn’t have to go every single day, you know. I wouldn’t have to get up and wait for escorts [corrections officers] and be locked in a cage waiting for hours for my medication.” [01]

Privacy concerns were expressed by some participants with enrollment in SLB and methadone treatment services in jail. One respondent noted that attending a medical clinic daily revealed her status as a patient receiving MOUD, while a monthly visit for XRB was perceived by fellow inmates and corrections officers as a “regular appointment, like the dentist, doctor, checkup, GYN [Gynecology]…” [19]. Another participant recalled feeling “embarrassed” by the daily overhead announcements for them to arrive for their opioid medication visits:

“In the Six Building, not everybody gets high. So you’re standing around with a bunch of dudes and there might be two or three of you. And when they call KEEP [the jail OTP] you have to get up and go and everybody knows your business. Everybody knows that [I’m] a dope fiend.” [24]

Positive peer experiences with XRB encouraged some respondents to seek treatment with XRB. Participants acknowledged that hearing about the perceived clinical benefits of XRB from other prisoners maintained on the medication motivated their participation in the study:

“Well in jail, word gets around…So when I was in the dorm, somebody was like, ‘Yo, they got this new stuff, this new study that they put in your skin and you don’t got to worry, they only got to do it once.’ I was like, ‘Alright, how you get to buy it?’” [49]

“I was trying to ask to receive as much information as I could from the fellow inmates that were in there that were receiving the shot. How did they feel and it made me feel like I could try because of the fact that they were explaining it to me and for them it helped. The ones that really want to try to stay off of drugs, it helps.” [30]

One participant however recalled how XRB was still susceptible to the common critique of MOUD by misinformed friends and family as “substituting one drug for another”:

“This friend of mine that I’m real close to, she’s like, ‘Don’t take that shot. What do you need that?’... Because to her it’s alternating a substance for another substance. But they don’t understand that it works man, it works. You know, what if it’s keeping me clean? [46]

Although respondents typically learned about XRB from peers, they infrequently received information about XRB from their healthcare providers. One participant noted the difficulties of initiating treatment with a novel substance in jail, highlighting the limited information provided pertaining to its mechanism of action, risk of adverse events, and other pertinent details:

“Sometimes, the nurse doesn’t explain anything to you. They’ll be like, ‘Yo, we got something new, this is the name. You wanna try it?’ and that’s it. But he’s supposed to explain to you everything, step by step, how it works, the side effects, everything. The nurse in the island don’t explain to you nothing. They give you the shot… ‘Do you want it, yes or no?’” [33]

Challenges with long-term maintenance on XRB was elicited by some barriers and attributed to barriers to resuming XRB in community treatment due to limited availability and cost. One participant suggested initiating a peer support group specific to XRB recipients to collectively address concerns and share experiences pertaining to the medication:

“I said I like talking with other people who have the shot. Hearing ideas, like what you’re going to do after this… when this is done. Are you planning on staying on this forever? What are you trying to do? How can you go about that, like what’s going to happen after this shot is off and then there’s no more?” [24]

COVID-19 pandemic: experiences and perceptions on XRB

Amidst the COVID-19 pandemic, participants described numerous challenges pertaining to OUD treatment and COVID risk. Most participants remaining on XRB were transitioned to SLB due to an outpatient clinic shutdown at Bellevue Hospital, NYC-wide stay-at-home orders, and the emerging success of buprenorphine telehealth visits.

This unexpected transition gave further insight into experiences transitioning from XRB to SLB. One participant noted that during his last scheduled monthly XRB injection, he was prescribed SLB. However, due to social distancing measures post COVID-19, he avoided going to the pharmacy to pick up his prescription of SLB and recalled not experiencing any cravings or withdrawal symptoms 5 weeks after his last injection:

“So they got me script at the pharmacy, I have no way to pick that up yet. I’m getting ready to go and pick that up when we finish today…y’all told me it would last 4–5 weeks...I’m at 5 weeks. I ain’t had nothing else”. [41]

Other participants expressed satisfaction with monthly injections since they could maintain social isolation if they were infected by COVID-19.

“I believe that if I get sick I can stay home for fourteen days as long as I have my medication, my pill, my shot, I can stay in the house as long as I want”. [33]

One participant highlighted XRB’s beneficial impact following the implementation of stay-at-home measures during COVID-19, including mitigating exposure to actively using peers or engaging in illicit activities:

“You know. It’s not like the normal way of living. I see people just trying to get high, their regular habits. They not able to do that. Going crazy and stuff. Here I am, I don’t have to do that because I have something in my system, that I can wake up and not have to run to go do this and that.” [41]

The narrative of a parole-supervised participant during re-entry, re-incarceration, and COVID-19 illness while on XRB highlighted both positive XRB treatment effects and the barriers presented by housing instability and parole conditions. The female participant was assigned to a women’s shelter by parole upon release from jail in Nov 2019, then found new private housing through a family friend and left the shelter, which resulted in a new technical parole violation for unauthorized change of address and re-incarceration in NYC jail Feb–April of 2020. She then contracted COVID-19, was isolated in a COVID-19 housing unit, and was then abruptly released prior to the scheduled release date. She then resumed XRB at Bellevue Hospital.

留言 (0)

沒有登入
gif