Male patients’ preferences for opioid use treatment programs | BMC Psychiatry

The socio-demographic and therapeutic characteristics of the participants are shown in Table 1. The participants were aged 37 years old, on average, and had been living with OUD for more than 12 years. The majority of the respondents were married, educated, and undergoing treatment in private MMT centers. Patients would use at least one type of opioid. They reported opium, heroin, Asian crack (a heroin-based substance), and opium juice as their main drugs of choice.

Table 2 describes three themes and 13 subthemes regarding the patients’ preferences for opioid use treatment programs. These themes, subthemes, and issues are described in greater detail later in this study.

Treatment concerns

Anonymity

According to the participants, whether they were treated confidentially depended on their social environment (e.g., the presence of individuals who supported them and their relationships with them). Although they had fewer concerns about whether close family members were aware of their treatment process, they had different views where non-family members were involved. That is, while they preferred that their treatment be kept secret from non-family members, this was not the case where their close family members were concerned:

I don’t want to talk to strangers; I don’t want anyone to know what I’m doing. In my opinion, when someone understands my problem, they never trust me. For example, whenever I get angry about something else, other people think that I have a problem and that I use drugs … So, it is better that no one knows what problem I had once. (Participant 54)

I would like my family to know that I am in recovery because they will be happy and help me. But I don’t want others to know that I was once an addict. (Participant 41)

However, this perception differed when it came to opioid users’ friends, depending on whether these friends were also opioid users. Because opioid users wanted to prove themselves and win their non-user friends’ confidence and acceptance, they preferred to allow their non-user friends to know about their treatment. As for their opioid user friends, some patients preferred not to let them know about their treatment. OUD patients may be convinced by their peers to relapse, and this may lead to interference in the treatment process, so some respondents were hesitant to inform their peers. In this regard, one of the participants expressed the following:

I’m here, and my friends don’t know about it. The more that they don’t know, the better it is for me. If I contact them, it’s the same old story. The last time I went to the camp and then withdrew, they understood, and they kept coming to me and persuading me that they had good drugs and that they’re new ones, and … come on, I’ve always been tempted … Although I tried to stay away from my close friends, I’d always dreamed of drugs, so I relapsed. (Participant 27)

However, some other participants claimed that letting their opioid user friends know about their treatment motivated them to complete their therapy. In hearing that their peers had been able to quit, they felt hopeful that they could achieve the same goal.

Social stigma

OUD patients may be identified and stigmatized when seeking treatment. They feel embarrassed, as though they have lost their dignity and destroyed their reputation because of the harmful social and cultural stigmas associated with individuals who suffer from OUD. Therefore, these patients preferred a treatment program that did not have any social stigma associated with it.

The participants expressed that as a result of seeking treatment in the treatment centers, they were recognized as opioid users and experienced the social and cultural stigmas associated with OUD. One of the participants described this situation as follows:

The addict is known as the Village Pump. Now, many individuals often don’t consider an addict to be a patient. Write the word “addict” and then write whatever you want; that is, they call an addict everything. Parasites, robbers, and philanderers—they intend to ascribe these negative views to an addict. (Participant 6)

You see, addiction has its own consequences. It is enough for one to be known as an addict. They attach any stigma to him. Unfortunately, it is common for a person who uses a drug to have no credibility. People easily stigmatize him … They treat him like trash. (Participant 42)

Fear of treatment distress

Patients may be afraid to start a treatment program because they perceive it to be dangerous, painful, or harmful. A treatment process might be preferred if it helps patients overcome treatment apprehension. Patients seemed to prefer a treatment program that could reduce their fear of treatment-related side effects and distress. Unpleasant emotions or feelings caused by opioid treatments were the worry of many opioid users. Thus, many patients with OUD preferred treatment programs that address the fear of treatment programs. For example, one participant said the following:

Fear of the side effects of a treatment, yeah, everybody’s afraid of hangovers, physical pain, nervousness, mental illness, clumsiness, and insomnia. It seems impossible for us to be free from these …. They are scary, and they can cause a person not to participate in a treatment program … Okay, these fears need to be minimized. (Participant 50)

Furthermore, OUD patients who join treatment programs generally suffer from severe withdrawal symptoms that scare them, including physical and mental effects (e.g., aggression, insomnia, anorexia, headache, total body pain, impotency, anxiety, hysteria, and fainting) and undesirable effects on their quality of life (less intimate communication, less leisure time, fewer recreational activities, and less happiness). Therefore, many participants preferred treatment centers that could manage the fear of withdrawal effects. The interviewees shared that opioid treatment is often accompanied by physical and mental disorders. This negatively affects their quality of life. However, some treatment centers do not take the side effects of treatments into account, so many patients complained about such treatment centers. Two interviewees in a rehabilitation camp reported the following:

You see, withdrawal syndrome during treatment is really bothersome because the person who uses drugs no longer has a normal body. As the saying goes, the body’s systems completely disintegrate … like a glass that breaks, and then you want to stick the parts together again. I’ve been using drugs for 11 years, so I’ve never felt like I’m going to quit. But just a couple of days after I quit, my hair turned white… I lost one of my teeth, which did not happen to me when I used drugs. Not taking opioids really leaves the body sick. Personally, I’m not in agreement with that. (Participant 32)

In a camp like this, when a poor guy has severe stomach pain, he always moans that his stomach aches, he’s in a really bad mood, and so on. They tell him he’s taking drugs. You then endure the pain. He would squirm in pain before nightfall, before he dies, but if he had been rushed to the hospital, something would have been done to save him. (Participant 57)

Family concerns

Family consent regarding the treatment method and family emotional support during and after the treatment were among the main concerns of the respondents when it came to an acceptable treatment process. The participants shared that when family members were aware of and agreed to the treatment decision, they helped support the treatment process (emotionally and even financially). Particularly in the case of married opioid users, the loving care and understanding of their spouses were crucial factors in seeking treatment and keeping their spouses away from opioid use. The presence of OUD patients’ parents, spouses, and children in the treatment centers helped patients feel valued, respected, loved, and protected; their frustration induced by addiction diminished as a result.

Regarding residential treatment, visits from family were also seen as desirable: “Definitely, meeting with my family is necessary. They’re really important in supporting me. I’m here to make my family proud and satisfied” (Participant 32).

Treatment attributes

Treatment costs

The cost of treatment is one of the critical attributes affecting the appeal of a treatment option. The majority of respondents expressed that they did not seek treatment simply because they could not afford it or because the treatment was expensive: “I haven’t always had the money; I haven’t gone to the treatment program because of money-related problems; that is, I don’t have the funds to participate in the treatment program” (Participant 62).

Overall, many OUD patients indicated that they could not pay for treatment and/or faced exorbitant costs and poverty induced by treatment, mostly because they were unemployed or underemployed. A participant being treated at the public MMT center said the following:

After all, someone who’s addicted doesn’t have much money, and they’re not rich. Rich opioid consumers can be rare—1 out of 100. It’s generally difficult for a user to pay because many users don’t have a decent job or are unable to work. Most addicts, even if they have a healthy body, need to stay at home. (Participant 14(

Location of the treatment center

The location of the treatment center was also important to the participants. Some participants preferred treatment centers located in their neighborhoods because of their easy access (i.e., within the vicinity of their homes or work):

It’s close to my workplace and my home. It was easy for me to visit the doctor. If the treatment center were far away, then I would be worried about how to visit the doctor, especially in cold, rainy, and snowy weather. Now, I can come here from that side of the street on foot, visit the doctor, and return home quickly. (Participant 47)

Other participants preferred treatment centers located outside their neighborhoods because they could keep their visits discreet, and they were far from their peers and drug hangout locations: “Well, it is better here that it is far from where I live because no one sees or understands … I know a camp in our own city, but I don’t go there” (Participant 3).

In terms of city or suburban treatment center locations, there are several pros and cons. A respondent being treated at a private camp said the following:

There are a number of benefits to having a treatment center in the suburbs and a number of other benefits to having it within the city. If the center were in the city, families can come and visit more easily because it’s closer, or when one of the patients gets sick, it’s easier to access healthcare, and doctors can help the patient quickly; so, it’s good. On the other hand, if the center were far away and outside the city, it’s better because some addicts have conflicts with one another, make noise, engage in self-harm, and so on. Also, if the center were in the city, it wouldn’t have a good influence. Children can see patients, and they may be affected. Clients may become aggressive and lose their temper during the treatment process. They might want to run away and bang on doors and walls, fight, and shout continuously; if the center were in the city, these conditions may result in the annoyance of neighbors. (Participant 30)

Treatment period

The time allocated to the treatment program was another characteristic that affected treatment preferences. Notwithstanding differences in treatment duration, the respondents unanimously complained about prolonged treatment and believed that such treatments cause exhaustion, adverse effects, and high costs. In the case of methadone treatment, the participants were of the view that an extended treatment duration would not only increase the adverse effects of methadone on the body but also create a new drug use disorder. Prolonged treatment is also seen as unhelpful in residential treatment. During residential treatment, patients do not have access to drugs and are unable to use them, so they may pretend to comply with the treatment but relapse as soon as they can access the drug.

Regarding the flexibility of treatment duration, given that the experience of drug use is unique to each individual and drug use treatment is unique and based on the physical and mental capacity of each individual, the duration of treatment was perceived as follows:

You know, the treatment period cannot be fixed to a certain amount of time. It depends, in my opinion, on the person and the physician in the center. The physician supervising an addict knows the best amount of time needed to treat them. I mean, two or three months is enough for me right now, but it’s not the same for others. There are some people, for example, who can be successfully treated for opioid use in two to three months, whereas some individuals, like me, need more time. You’ve got to work on the mind, the body, and the way of thinking. All this has to be done, and you also have to work with the family. Well, these are all time consuming. That’s why I don’t think there’s a set time for treatment duration. (Participant 40)

Frequency of attendance

The frequency of methadone administration and consultation meetings, especially for maintenance treatment patients, was identified by the participants as another important attribute: “The sooner I get rid of it, the better. After all, methadone is a drug that replaces drugs; the sooner I quit it, the better. I think it’s better for my work and my personal life” (Participant 12).

The employed OUD patients tended to limit their attendance to avoid interruptions in their work lives. Other patients preferred frequent attendance because they felt that they were more involved in the treatment process when they visited the center and sought consultations often: “My opinion is that I’d better quit drug use as gradually as I entered it. I’d better quit it the same way—as gradually as I reached the peak of drug use. To do this, I should get more and more involved with treatment” (Participant 54).

Informed treatment

Another extracted subtheme was the preference of OUD patients for certain information related to various types of opioid treatments and for information during the treatment process. Many participants preferred informed treatment via medical specialists, mass media, books, articles, and even peers who were drug free and expressed that being uninformed about opioid treatment was a main obstacle to treatment-seeking behavior. An interviewee noted the following:

I think it’s a lot easier when I hear about treatment. When you know how to deal with your fears—for example, when you learn something about opioid treatment—then you know what to do or what not to do. If treatment strategies have been introduced, it’s really important [to know about them] because many individuals just don’t know, and a lack of understanding leads to fear. But once they’re aware, it’s a lot better, which in turn helps lessen the fear, and they seek advice. (Participant 49)

Treatment personnel

The interviewees mentioned a series of characteristics of treatment centers. Particularly, they discussed treatment personnel in terms of personnel–patient communication and personnel specialty. Regarding personnel communication, one of the interviewees commented the following:

One thing to say is that addicts are sensitive individuals, and they’re searching for excuses. Because they’re [sensitive] individuals and delicate, they’re very happy with small things, and they also easily become very upset with something small. All these make them look for excuses too early and do not follow the treatment. I saw in the clinic that there was a young boy, and he was the only son; his family took great care of him. The clinic counselor told him that because he’s an only child, he’s babyish, niminy-piminy, and… it made him really sad; that’s why he left the clinic. (Participant 57)

The interviewees also reported that the treatment centers should collaborate with other physicians, who are specialized when some side effects occur, including dentistry, psychiatry, neurology, gastroenterology, cardiology, and orthopedics.

Treatment type

Maintenance or abstinence

Opioid maintenance treatment involves medications, such as methadone, buprenorphine, and opioid tincture. Opioid abstinence treatments do not utilize any medications or opioid replacement therapies for OUDs. Aside from a few participants who wished to seek maintenance treatment for their convenience and painlessness, the respondents continued their everyday lives while undergoing opioid treatment; most did not prefer maintenance treatment: “I’d love to be treated in such a way that no other medications are used” (Participant 51) and “It’s much better to withdraw without drugs” (Participant 49).

Others highlighted the adverse effects of medications, particularly methadone, including liver damage, a prolonged treatment process, drug substitution, dual substance use disorder, and the impossibility of withdrawing and stopping methadone. One participant who had been treated with methadone stated the following:

I was undergoing methadone therapy, but it didn’t help at all. I was just getting methadone and taking drugs simultaneously. Methadone didn’t have any effect on me. I tried to use methadone again, but withdrawal was not easy; it was worse than with other drugs. Methadone treatment, in my view, makes no sense at all because methadone use can never be completely stopped. I didn’t want to take methadone; I couldn’t eat any more. I used methadone and put my drug next to it, so I took two drugs. I suffered from using two drugs. (Participant 33)

Residential or not

In residential treatment, patients with OUD receive treatment services in residential facilities, such as camps and inpatient centers. However, there are patients who receive treatment services (e.g., medications and consultations) from nonresidential facilities, including outpatient centers (office-based treatments) and DICs. Generally, the participants did not have a good experience with residential treatment. They reported that the only benefit of residential treatment was being kept away from their old environment, opioids, and their addicted peers:

Addicts suffer from serious problems. When we’re exposed to the extramural environment, the environment where we took drugs, the person who purchased the drugs, or the location where we used the drugs, all of it makes us think again—let’s relapse. Ah, we’re far from all that in the camp. (Participant 55)

However, most of the participants mentioned deficiencies in residential treatment, including pain, an unsuitable environment, a lack of freedom, limitations in family visits, indignation, and the search for new addicted mates. In this respect, several participants with experience with residential treatment noted the following:

The cost of the camp is much lower than here [private methadone treatment center], but the camp is a place with individuals who are likely to be offenders. Another issue is the immoral conduct that’s taking place in camps, which is not permitted and is unethical. I don’t want to go back to camp. I need to move to a place without such issues. In many camps, when addicts are forced to be treated, they become frustrated. As soon as they leave the camp, they try to make up for their anger, which in turn results in a relapse. (Participant 58)

In a camp, addicts make new friends, talk about the pleasures of taking new drugs, and are tempted to take some drugs after discharge. (Participant 40)

The camp is not a good place; you don’t have freedom, like a prisoner without visitation rights. It’s no different from being a bird with no wings. (Participant 5)

Community treatment or not

In community treatment, groups of opioid users provide mutual support to one another in self-help groups and are involved in counselling/talk therapy programs. Most participants preferred collective treatment for a couple of reasons. Empathy has been described as a key feature of community treatment. In counseling meetings, OUD patients can understand the feelings of other patients. Moreover, staff members might have experienced drug use disorders themselves or could put themselves in OUD patients’ shoes.

Regarding empathy—the ability to put oneself in the place of another and understand someone else’s feelings—a participant said the following:

Well, in meetings, you can meet your peers. Other people express the pain and sorrow they’ve experienced in life. I might be ashamed to talk about those pains, but I’ve experienced the exact same pain before, so I listen to the solutions, empathetic feelings, and compassion that other members bring. The members might be talking to another guy, but it’s as though they were talking to me. I am relaxed by the time I leave the meeting because I heard others. I received understanding and learned about my peers’ experiences, and I sought the right solutions. Consulting meetings are really successful. (Participant 55)

Some participants reported that specific solutions to avoid withdrawal syndrome and cope with pain are provided through community treatment. Because psychological and social factors are the main drivers of relapse, opioid users need to be free from temptation during community treatment. As members acknowledge the importance of successful and long-term treatment, OUD patients are encouraged to both pursue treatment and remain opioid free for a long time. Finally, several participants favored community-based treatment as a supplementary therapy to other maintenance and residential treatments.