Table 1 summarizes the sociodemographic variables of the 17 participants enrolled in this study. The majority were males (70.6%) and aged between 21 and 30 years (41.2%) with an age range of 23 to 50 years, and the duration of treatment ranged from 11 to 36 months. Participants started using opioids during their teenage years to early adulthood and were preceded by other drugs, especially marijuana and cigarettes, that participants were exposed to early. Most participants were introduced to substances by people close to them, such as family members, friends, peers, or close relatives.

Table 1 Sociodemographic characteristics of study participantsThemes identified

Four themes were identified from data analysis: (a) the impact of opioid use before starting methadone treatment; (b) learning about methadone treatment; (c) experiences with care at the methadone treatment clinic; (d) barriers to optimal methadone treatment. A summary of the themes is shown in Table 2.

Table 2 Summary of themes identified in the studyTheme 1: impact of opioid use before starting methadone treatment

Participants reported that opioid use significantly impacted their physical, social, and economic aspects. As a result of opioid use, most participants reported neglecting self-care and activities of daily living, such as showering and doing laundry. Subsequently, their friends avoided them because of their unkempt appearance and foul body odor.

“They used to hate me because I looked dirty, and I used to stink; therefore. They knew that I was using something bad and that I was on drugs” (Male, 47).

“That thing has destroyed my life in many ways; it made me separate from my wife, sleep outside, and became hopeless. It destroyed my life because when I separated from my wife, I used to sleep outside and became very dirty” (Male, 50)

Due to opioid use, participants health suffered significantly from lack of appetite, poor eating habits, and unhealthy eating. Others spent their income on drugs at the expense of food, and as such, they suffered hunger or survived on unhealthy food such as cakes, biscuits, and juice leading to poor health over time.

“Eating was a problem that is why you see the drug users are very skinny. The appetite seems to vanish whenever you use the drug and comes back when the money is finished” (Male, 47).

Gastrointestinal symptoms such as diarrhea and nausea related to withdrawal from opioids were also responsible for the worsening health of most participants who could not always afford to use opioids every day. Until recently, since there was no treatment for opioid use disorder, clients presenting at health facilities were either misdiagnosed or treated for other illnesses such as malaria, whose symptoms were often confused with withdrawal symptoms.

“There was a time I had gone upcountry due to how stuff had affected me. To avoid it while I was there, I only stayed a day and fell ill. I was taken to hospital and diagnosed with malaria, but I told them what I was using, and they could not help me beyond that, so I went back to the den” (Male, 23).

When left untreated, opioid use disorder increases the user’s risk for blood-borne infections such as HIV/AIDS from sharing used needles and engaging in unprotected sex. Poorly disposed needles increase the risk of contracting a blood-borne infection due to environmental hazards.

“Heroin use made me find myself in situations I never expected. Although I never injected heroin, I used it with people who did it. It was not uncommon to find used syringes carelessly disposed of on the ground, increasing the risk of needle pricks. Other times, some users used dirty needles as a weapon to threaten or prick someone when in a fight. I am certain my HIV infection is not due to sex with men but unsafe needle disposal” (Female, 25).

Women were more vulnerable to sexual exploitation in exchange for opioids. Others kept multiple sexual partners to sustain their expensive heroin addiction, and they risked unwanted pregnancies and infection with HIV. Because of a lack of strong social support, such women started families on the street.

“Girls who are into heroin are exploited and violated by the men to finance their heroin use, an expensive drug. Desperate for a fix, a man would offer to share his supply with you in exchange for sexual favours” (Female, 25).

Opioid use also predisposed users to engage in unlawful behaviours such as stealing to fund their OUD leading to frequent arrests. Moreover, opioid use attracted significant stigma from society, and users were often treated with suspicion, regularly interrogated, and denied access to shops and malls. Others experienced hostility in public and have been deemed a menace to society. Subsequently, many respondents lived isolated to limit contact with the public, while others ran away from home to be homeless.

“Because of stealing, you are always at loggerheads with other people you steal from. That is why you find people with their own homes leaving and opting to do all their stuff from the streets. They eat in the streets, steal, and go back to the streets, and sleep there. You live like a homeless person, yet you have a place to live. I had also left home but later went back” (Male, 21).

Opioid use significantly impacted family and social relations. Participants expressed a common concern of constant quarrelling with parents, siblings, and significant others due to opioid use. Family conflict also arose when participants sold family property such as cell phones and household goods to fund their opioid use disorder. Besides family infights, some participants were estranged from their families through marriage dissolution or separation due to substance use.

“Like my parent (father) when he heard that I had come here and indulged myself in bad things like smoking heroin, he alienated me. Like they didn’t even tell me when my mum passed on, but when I started methadone treatment, I even got their numbers, and we started communicating that's when they even told me that my mum had passed on” (Female, 25).

Those that had been exposed at an early age to opioids were unable to continue with their education. Therefore, many did not possess formal academic credentials, which hindered their ability to find decent jobs. Those with a decent source of income wasted them on substances and were thus unable to invest, save, or hold on to jobs. Such clients were dismissed from work for engaging in illegal activities like stealing from a client and employer or due to performance issues while others sold personal items at a throwaway price to afford opioids.

“When I started taking heroin, I used to take my business items and sell them. Sometimes I would sell them at low prices compared to how much I had purchased them. The people who used to give me work realized that I would steal some parts when they bring their cars, and I started losing jobs.” (Male, 34).

OUD had significant social, economic, and health impacts that hindered participants’ ability to participate fully in society. As ostracized citizens, they lived on the margins of society with minimal hope.

Theme 2: learning about methadone treatment

Participants learned about the methadone treatment program, from friends and family members and community outreach events. Outreach programs were the commonest channels through which these participants were recruited to the methadone treatment program. These drop-in centers are run by civil society organizations that reach out to persons with substance use disorder, conduct the initial screening and other harm reduction strategies, and refer those willing to start methadone treatment. Incentives, such as free food and training, were provided to attract heroin users to the methadone program.

“There were some doctors who used to come in the streets and give us milk and bread and tell us that a drug has been brought that would help us quit taking heroin. They also said it would be nice if we reformed and came for classes where we would be taught” (Male, 41).

“You go there and listen to what you are being taught…After observing how you are improving, they now set up a date and tell you when you will start taking methadone” (Female, 25)

Some were introduced to the methadone treatment program by individuals who had stopped opioid use, who impressed them with the transformation that methadone brought to their lives. Such participants were amazed that their friends did not appear interested in using opioids anymore, heightening their curiosity about what change had happened in their lives and gave them motivation to seek treatment.

“When we went back to town with my friend, I bought heroin and started smoking. Unlike in the past, he didn’t ask me for it; he was my partner and a close friend. The fact that I escort him to come here shows he is a dear friend. I wondered why he would not smoke heroin” (Male, 41).

Others were encouraged to enroll in treatment by their relatives and family members who had prior experience with the methadone treatment program and its transformative impact.

“My husband used to get methadone at (the other clinic). He always used to tell me to join methadone treatment because it was good, and he always insisted, but I did not think it would help because people used to say that methadone was just another drug.” (Female, 23).

Although participants could see evidence of methadone use transformation among former opioid users, some were reluctant to join the methadone bandwagon. This was partly due to misinformation, bad advice, methadone stigma, and lack of knowledge about how methadone worked to treat heroin addiction.

“I saw a friend who was on methadone treatment improving. She talked to me about the importance of methadone. We were told that methadone use would lead to sterility and even death but on research, I found out that they were all lies. I, therefore, went to (a drop-in Centre) and talked to the doctors there who directed me on how to start.” (Female, 32).

Despite the discouragements and misinformation regarding methadone and its side effects, participants somehow pressed on to investigate it and eventually enrolled in it. They hence got a first-hand experience with the treatment.

Theme 3: experiences with care at methadone treatment clinic

Most participants reported that methadone treatment transformed their lives. This transformation was evidenced by their improved appearance, physical health, and restoration of broken or lost relationships. With their lives changing, they experienced less stigma and discrimination from society. Some participants experienced this transformation within a short time of starting methadone treatment.

“After 1 month of taking methadone, I had seen big changes. I used to sleep well. I have an appetite, sometimes I took a shower two to 3 days per week but now you see, the first day I took methadone, the next day I woke up in the morning at 5, I showered, went to the mosque and prayed, it's something I mean something I have never done” (Male, 43).

Because methadone helped clients deal with withdrawal symptoms and cravings from opioid use, participants found it easy to stop using opioids. The monies they otherwise used to fuel their opioid use were redirected to a better cause, such as improving self-care and saving. Being able to earn an honest living was gratifying too.

“We can see a lot of difference, and we have changed; we are clean, the money we used to smoke we don’t waste anymore. At least if you get even one hundred, you can buy some clothes and be smart like other people.” (Female, 25).

The family restoration was an invaluable benefit participant got after their lives were stabilized by methadone treatment. Families were willing to take them in once they witnessed the difference that methadone treatment made in their lives.

“I brought back my family because they had fled. I had been hated even by my mother and many people with me before I started taking heroin. They started ignoring and avoiding me. But now I tried and made other friends, I also avoided those we used to take drugs together, now am a different person” (Male, 41).

The social stigma participants faced when they used opioids dissipated when they enrolled for methadone treatment and friends who had previously avoided them reconnected with them.

“A lot has improved; people do not believe that I changed, and those who used to see me using heroin are ashamed of talking to me. Those who are no longer ashamed to talk to me do it with happiness. They usually ask me what changed, and I tell them it is methadone, something you are given, and you no longer feel like taking drugs” (Male, 50).

Methadone treatment stabilized their lives in a way that allowed them to restore their social connection, earn an honest living, and improve their health. Subsequently, they restored their lives and engaged in positive living as responsible citizens.

Theme 4: barriers to optimal methadone treatment

Participants came from far distances to access the methadone treatment program. Most of the participants are unemployed and rely on casual jobs for their upkeep, so spending time working to seek treatment for OUD denied them opportunities to earn. Also, paying for bus fare to come to the clinic for daily methadone dosing under observation caused a financial strain which made some to miss clinic appointments or to skip a methadone dose. Some clients resulted in risky behaviours such as boarding cargo trucks to take them to the clinic, risking injuries from jumping off a fast-moving truck and others trekking long distances to the clinic, an exhausting and time-consuming exercise. Participants struggled to find a babysitter to leave their dependents with; therefore, coming with a baby to the clinic added to the logistical difficulties.

“People are too many, and these services are very far, so you find people coming from very interior places to town. Some do not have the transport money, and you find that they hang on trucks to come here, risking their lives. Then you find that there are people who come from far and maybe on reaching the stage, it is almost time, so they resort to spending more on a motorcycle.” (Male, 21).

Participants felt that enrolling in the methadone treatment program did not address other social challenges faced by most, such as homelessness. Street families constantly contended with hunger, poor hygiene, and environmental exposure. Such a lifestyle sabotaged their recovery process.

“Methadone alone is not enough, and one is supposed to change their thoughts and behaviour as well as their ways of life, everything! …If a person stays in a place where they are stable, somewhere they do not have stress, they can reform very quickly. Somewhere with food, housing, they will reform very fast even if it is not giving them everythin.” (Male, 21).

Many factors led participants to miss their methadone dose. These include apprehension by police for various misdemeanors, lack of bus fare, and inflexible work schedules. Missing any methadone dose eroded any recovery gain they had made in the treatment.

“ If there is a way you can assist if someone misses, let’s say today if you go to the doctor tomorrow, if they can give you methadone rather than deny you, it would be helpful because when you leave there, you will hurt, and your mind will lead you to nowhere else than to heroin. So instead of telling me to go back to the streets, you better send me to a counsellor” (Female, 25).

Because the clinic served a large catchment area, many clients experienced a prolonged waiting time due to overcrowding. Moreover, since the clinic was not operating outside of regular working hours, clients with limited working hours missed out on their doses. The challenges the clients experience in accessing care are related to the socioeconomic status of most clinic attendees and the nature of the clinic operation. Addressing these barriers can create a client-friendly environment that can increase clients' retention to care.

“You can see, for example, when a person is late by just one minute or thirty seconds, they are just locked outside…. You are denied your dosage, and there is nowhere you can buy it; there is nothing you can do, yet you have decided to change. Like there is a guy who used to come here, I don’t know what he had done, but that is how he was expelled from the program, you see he had no option but to go back to drugs; if someone has decided to reform, they should not be denied this drug over petty issues that can be solved here” (Male 21).

Personal and systemic factors outside the clients’ control presented significant barriers to treatment adherence, ultimately impacting the clients’ recovery journey.