Accessing drug treatment programs in Atlantic Canada: the experiences of people who use substances

Abstract

People who use substances (PWUS) (e.g. inject substances) are at risk of many harms. Various services help reduce risks including drug treatment programs such as withdrawal management and opioid agonist treatment. Much of the research on PWUS’ experiences of treatment programs is set in large urban centers creating a knowledge gap of experiences in other places. Our study helps address this gap by exploring PWUS’ experiences of treatment programs in Atlantic Canada which is a region with many small urban centers and rural areas. One-on-one qualitative interviews were conducted with 55 PWUS focusing on their experiences of treatment program facilitators (or what helped with access and retention), and/or barriers to treatment access and retention (or what was not helpful). Data were analyzed for key themes/subthemes and organized using a slightly modified Rhodes’ risk environment framework. PWUS’ experiences of facilitators and barriers cross all four environments of treatment programs: policy and practice, physical, social, and resource environments. For some PWUS, barriers impacted their access to or retention in treatment, and hence are of serious concern given the current toxic illicit drug supply in Canada. Several barriers are shaped by drug criminalization and thus this research points to the need for decriminalization to help reduce barriers.

Keywords:

• People who use substances
• drug treatment access and retention
• qualitative research

Introduction

In Canada, it is estimated that approximately 171,900 people injected drugs in 2016, an increase from the estimated 130,000 people who injected drugs in 2011 (Jacka et al., 2020, p. 47). Injection drugs include any drug that can be injected into a vein, a muscle, or under the skin, such as opioids and crack cocaine (Hope et al., 2016). There are varied health risks associated with injecting including risks of HIV and HCV (Mathers et al., 2008; Nelson et al., 2011; Strathdee et al., 2010). There are also risks associated with smoking substances (e.g. risks of smoking heroin) (National Institute on Drug Abuse, 2018), and smoking crack cocaine has been associated with risks of burns and lesions which may facilitate disease transmission (Buxton & Panessa, 2009; Strike & Watson, 2017).

In 2016, the Canadian Public Health Association reported that there was an ‘expanding opioid crisis in Canada’ (Canadian Public Health Association, 2016, p. 3), and in the same year a public health emergency was declared in the province of British Columbia because of the increase in overdose harms including death in that province (British Columbia Ministry of Mental Health & Addictions, n.d., p. 3). In recent years, there have also been increasing risks of death from substance use due to a toxic illicit drug supply (Report to the Chief Coroner of British Columbia, 2022; Watson, 2022). Between January 2016 and September 2021 approximately 26,690 individuals in Canada died from ‘apparent opioid toxicity’ (Special Advisory Committee on the Epidemic of Opioid Overdoses, 2022), and attention has been drawn to not only synthetic opioids such as fentanyl in the illicit toxic drug supply but also non-opioid substances such as benzodiazepines (Belzak & Halverson, 2018; Report to the Chief Coroner of British Columbia, 2022; Smyth, 2022).

A variety of services, such as drug treatment programs, help to reduce the harms of substance use (Jackson et al., 2014; Vickerman et al., 2014; Vipler et al., 2018). In Canada, there are government-funded treatment programs which include withdrawal management programs (or what are sometimes referred to as detoxification or ‘detox’ programs) (Rush et al., 2021, p. 6 and p. 10) and opioid agonist treatment (OAT) which can involve different types of medications such as methadone or Suboxone (British Columbia Centre on Substance Use, n.d.). Withdrawal management is at times the ‘first point of contact’ for individuals seeking treatment (Vipler et al., 2018, p. 2), and serves to safely manage any complications when withdrawing from different substances, ‘provide a period of rest and stabilization’ and, when appropriate, connect patients to other services such as mental health services (Rush et al., 2021, p. 5). Withdrawal management includes hospital or community-based programs as well as residential and outpatient programs (Rush et al., 2021). Some withdrawal management programs offer psychosocial supports in conjunction with medical withdrawal supports (Rush et al., 2021). OAT (also known as Opioid Substitution Therapy (OST) to some), is used mainly as ‘mid-term or long-term maintenance or relapse prevention’ although ‘OST drugs such as buprenorphine and methadone are also used in short-term detoxification interventions’ (Kourounis et al., 2016, pp. 2–3). OAT is sometimes initially provided through a specialized clinic and then through a primary care provider who ensures ongoing maintenance, or is sometimes started and maintained by a primary care provider (who might work in a solo or other type of practice) (Livingston et al., 2018).

Sorensen et al. (2002) argue that when treatment programs support decreased substance use, reduced risk behaviors, and educate patients about HIV, they are ‘one of the most powerful AIDS prevention techniques in our public health arsenal’ (p. 4). Vickerman et al. (2014) further maintain that the ‘beneficial effects of opiate substitution treatment’ for people who inject drugs include a reduction in mortality and crime, and increased quality of life (p. 2060). It has also been suggested that withdrawal management programs may provide housing for people who use substances experiencing homelessness and who do not have access to other housing options such as shelters (Vipler et al., 2018, p. 4), but further research is needed to understand more fully the link between withdrawal programs and housing respite.

Although withdrawal management programs and OAT have been found to reduce various harms of substance use, barriers to access and retention have been highlighted in the literature. Reported barriers include the distance to treatment programs and limited public transportation options (Pullen & Oser, 2014), the public stigma associated with treatment (Paquette et al., 2018), and fears of the potential for child apprehension (Elms et al., 2018; Vipler et al., 2018). Police surveillance in the vicinity of ‘methadone clinics’ has also been found to discourage treatment (Hayashi et al., 2017). Barriers linked specifically to the policies and practices of drug treatment programs include wait times (Elms et al., 2018; Kourounis et al., 2016; Peterson et al., 2010; Schultz et al., 2016), inflexible or strict intake criteria (Kourounis et al., 2016; Schultz et al., 2016), and abstinence requirements together with frequent urine testing (Fischer et al., 2002; Kourounis et al., 2016).

The literature on barriers to treatment highlights the many and varied types of barriers to access and retention but much of the research is from the perspective of professionals in the field (See, for example, Ashford et al., 2018; Bunting et al., 2018; Patrick et al., 2019; Pullen & Oser, 2014; Schultz et al., 2016). There are studies from the perspective of people who use substances (Frank et al., 2021; Kiriazova et al., 2020) or ‘individuals served by the treatment field’ (Ashford et al., 2018, p. 68), but relatively few within the Canadian context. (For some exceptions see Fischer et al., 2002; McCutcheon & Morrison, 2014; Lyons et al., 2015). A number of the studies that have been conducted from the perspective of people who use substances have centered on individuals living in large metropolitan centers (Fischer et al., 2002; Lachapelle et al., 2021; Lyons et al., 2015), and our research thus sought to help fill a gap in the literature by exploring barriers to treatment among people who use substances who live in smaller urban centers or rural places. Specifically, we explored experiences of accessing treatment in Atlantic Canada which is a region of the country composed of many rural communities, as well as numerous small and medium-sized urban centers. In July 2021, the largest municipality in Atlantic Canada had a population of 460,274 (Statistics Canada, 2022).

Our study focused not only on what people who use substances experienced as program barriers to access and retention but also facilitators or what was helpful about these programs in terms of access and retention. Given that much of the existing literature centers on barriers to access and retention, an exploration of facilitators was of interest. There is some research on facilitators such as the availability of OAT in primary care (Tofighi et al., 2019) and short wait times (Wisdom et al., 2011), but research on facilitators is relatively limited and tends to centre on facilitators for specific populations (Barnett et al., 2021; Kiriazova et al., 2020; Wisdom et al., 2011). For example, one study found that social support (including support from providers) facilitated OAT treatment uptake in a study of HIV-positive people who use drugs in Indonesia, Ukraine, and Vietnam (Kiriazova et al., 2020, p. 10).

Our study was specifically interested in experiences with publicly-funded or government-funded treatment programs in the Atlantic region as we wanted to understand the experiences of those who could potentially access treatment without facing the costs of a private program. There are private treatment programs within Atlantic Canada but they were not included in the scope of this research.

For our research, treatment programs were conceptualized as ‘microenvironments’ as per the risk environment framework developed by Rhodes (2002, 2009). This framework draws attention to the important role of microenvironment interventions (e.g. supervised consumption sites) in enabling or supporting risk reduction, and was a useful heuristic in conceptualizing treatment programs as risk reduction interventions (Rhodes, 2002, 2009). Rhodes (2002), notes that ‘a risk environment approach seeks to maximize risk reduction at the community level’ (p. 91), and ‘a priority for an enabling environment approach’ is the removal of any situational and structural factors that are obstacles to maximizing the harm reduction effect of interventions (e.g. regulatory practices impacting syringe distribution) (p. 91). As such, the framework draws attention to the importance of identifying barriers to access and retention that impact the enabling or risk reduction environments of treatment programs. The framework also highlights the need to recognize the ‘dynamic interplay’ between micro- and macro- levels of the environment, and how macro-level forces influence micro-level environments. The framework therefore suggests that any strategies for changing treatment programs (micro-environment level) and specifically barriers within treatment programs, must consider the role of the macro environment (e.g. drug criminalization policies) in shaping barriers.

Study setting

Atlantic Canada, our study setting, is composed of four provinces (New Brunswick, Newfoundland and Labrador, Nova Scotia, and Prince Edward Island) with a collective population of approximately 2.4 million (2019 data) (Statistics Canada, 2020a). In 2016 it was estimated that there were approximately 12,000 people who injected drugs across Atlantic Canada (Jacka et al., 2020,  p. 47), and the HIV diagnosis rate in the region in 2019 was 3.0 per 100,000 (with a national rate of 5.6 per 100,000) (Public Health Agency of Canada, 2020). Although the rate of Hepatitis C in Canada has declined since 2008 it is more prevalent among people who inject drugs than any other group (Challacombe, 2019).

Between January 2016 and September 2021 the Public Health Agency of Canada reported that there were just over 660 ‘apparent opioid toxicity deaths’ in the Atlantic region (Special Advisory Committee on the Epidemic of Opioid Overdoses, 2022, pp.20-21). In 2019, the Atlantic provinces had crude rates of apparent opioid toxicity deaths as follows: 4.5 per 100,000 in New Brunswick; 3.4 per 100,000 in Newfoundland and Labrador; 5.9 per 100,000 in Nova Scotia; and 3.2 per 100,000 in Prince Edward Island (Special Advisory Committee on the Epidemic of Opioid Overdoses, 2022, p. 21). All crude death rates in the Atlantic provinces were lower than Canada’s national rate of 9.8 per 100,000 (Special Advisory Committee on the Epidemic of Opioid Overdoses, 2022, p. 21). In recent years, many deaths in the Atlantic region have involved polysubstance use (Government of New Brunswick, Office of the Chief Medical Officer of Health, 2020, p. 11; Government of Prince Edward Island, 2022; Province of Nova Scotia, 2017, p.1; Special Advisory Committee on the Epidemic of Opioid Overdoses, 2022).

In 2011, the proportion of the Canadian population living in rural areas was 19%, with higher proportions for the four Atlantic provinces: New Brunswick (48%), Newfoundland and Labrador (41%), Nova Scotia (43%) and Prince Edward Island (53%) (Statistics Canada, 2015). The 2018 median after-tax income for each of the four provinces was less than the national median after-tax income of $61,400 (Statistics Canada, 2020b) pointing to a region where much of the population is socio-economically disadvantaged. The lower median after-tax income in the Atlantic region is not surprising given that people living in rural areas tend to have lower incomes compared to their urban counterparts (Singh, 2002). In the 1990s the Atlantic provinces were impacted by welfare reforms including cuts to health care as the Canadian welfare state ‘like welfare states elsewhere’ underwent ‘significant reform and restructuring’ (MacDonald, 1998, p. 389). For many years there have been difficulties in recruiting physicians to work in communities across Atlantic Canada (Davis, 2020; Reamy, 1994), and currently there is a physician shortage in many places with a number of communities underserviced (Davis, 2020; Schneidereit, 2021).

There are government-funded detoxification programs (Rush et al., 2021) as well as OAT programs (e.g. methadone) (Eibl et al., 2017) across Atlantic Canada but there are limited data on the number of Atlantic Canadians who have accessed these programs. The 2019 Canadian Alcohol and Drugs Survey has estimated that among Canadians who reported using substances defined as ‘alcohol, cannabis, psychoactive pharmaceutical, over-the-counter medications, and/or illegal drugs’, 2% had ‘ever’ accessed professional help (i.e. professional treatment or counseling plan) for their substance use, and among those who had ever received professional help 20% had accessed help in the previous year (Government of Canada, 2021a). More specific to Atlantic Canada, a 2018 document indicates that in New Brunswick the ‘approximate distinct number of individuals receiving either methadone or buprenorphine/naloxone for Opioid Replacement Therapy (ORT)’ was 3500 although the exact time period is not indicated (Government of Canada, 2021b). It has been reported that in 2020, 3306 ‘unique individuals were dispensed’ OAT in Newfoundland and Labrador ("Have you heard...", 2021), and that there were 2005 ‘active clients’ receiving ‘opioid use disorder treatment’ in Nova Scotia (Province of Nova Scotia, 2021). No publicly available data for Prince Edward Island could be located.

Methods

Our study was developed as a partnership between a number of community knowledge users and researchers. Most of the community knowledge users were executive directors of community-based harm reduction programs or AIDS service organizations. One knowledge user was the executive director of a low-threshold methadone maintenance program. A couple members of the research team reported having lived experience of substance use.

One-on-one interviews were conducted with people who use substances, and participants were asked about their experiences of access to and retention in government-funded detoxification or withdrawal management programs, and OAT programs. Participants were eligible to participate if they injected drugs (e.g. opioids) and/or smoked such drugs as crack cocaine, were 19 years of age or older, and had tried to access or had accessed a detoxification program and/or OAT in Atlantic Canada within approximately the previous 2 years. Participants were excluded if they only used alcohol or cannabis. All participants also had to be comfortable being interviewed in English.

Participants were recruited through seven community-based organizations or what are referred to as ‘sites’ located across the four Atlantic provinces with at least one site located in each province. At each site a community knowledge user approached individuals who they believed to be eligible for the study and shared the study recruitment poster. The community knowledge users purposively approached individuals from a variety of backgrounds (e.g. different gender identities and age groups) to help ensure a diverse participant population. If individuals were interested and eligible, an interview time was scheduled. At six of the sites, some individuals did not schedule an appointment but were interviewed because they were at the community-based organization on a day when interviews were taking place and asked if they could participate. All interviews were conducted by the research coordinator who reviewed the consent form including eligibility criteria and answered any questions prior to the interview. Participants provided verbal informed consent prior to the interview, and the interviewer documented participants’ consent. Individuals were made aware that participation was voluntary and would not affect their access to services through the community-based organization. They were also made aware that the executive director of the organization where interviews were conducted was a member of the research team. A $20 cash honorarium was provided to thank participants for their time. Prior to data collection, the protocol for this study was approved by the relevant institutional research ethics boards.

Data collection

Face-to-face semi-structured interviews were conducted with 55 participants between January and April 2019. At the end of each interview, participants were asked a few questions about their sociodemographic background (e.g. gender identity, age range). Prior to the interviews, the interview guide was reviewed by the research team and pre-tested with two members of the research team who have knowledge and experience working with people who use substances. Based on the team members’ feedback, minor adjustments were made to the phrasing of questions and probes. Interview questions centered on understanding what was helpful or not helpful about treatment programs in terms of ‘trying to get in’, ‘getting in and not staying’ and ‘staying in’. For example, for the time period when a participant was trying to get into a program (detoxification and/or OAT) they were asked, ‘Can you tell me anything that was helpful about the program?’, and probes were used if necessary (e.g. supportive staff). Participants were also asked if there was anything that was not helpful about the program (with probes used if necessary), how this made them feel, and any changes to their substance use. Questions about any changes to their sexual health practices were also asked but are not reported here. The interview guide was not modified during the data collection process.

The interviews lasted between 20 and 50 minutes, and participants had the choice of having their interview audio-recorded (n = 44) or notes taken by hand (n = 11). Audio-recordings were transcribed verbatim, and transcripts checked for accuracy by the research coordinator. Handwritten notes of interviews where an individual did not want to be audio-recorded were typed into a word-processing program.

Data analysis

Transcribed interviews were entered into ATLAS.ti, a qualitative software program, and read and re-read together with the typed interviews by two members of the team. Codes were developed inductively by engaging in a process of comparing and contrasting key concepts within and across the interviews as per the analytic techniques of constructivist grounded theory (Mills et al., 2006; Strauss & Corbin, 1998). As codes were developed they were discussed with members of the research team, and all interviews were coded using the established coding scheme. The coded data were read and re-read by two members of the team, often returning to the full interviews to understand the contexts of the coded data. Key themes and sub-themes were developed through this process, and are presented below.

Results

The majority of the 55 participants self-identified as men (n = 32, 58.2%), white (n = 47, 85.5%), were under the age of 40 (n = 37, 67.3%), and reported that they lived in a city (n = 44, 80.0%). Over half of the participants indicated that they had used substances for 11 years or more (n = 33, 60.0%), and approximately half did not have enough money to meet their day-to-day needs in the previous two years (n = 27, 49.1%) (See Table 1).

Table 1. Sociodemographic characteristics of study participants (N = 55).

Demographics	N	%
Self-identified gender
Men	32	58.2
Women (not everyone identified as cisgender)	23	41.8
Self-identified ethnicity *
White/Caucasian	47	85.5
African descent	1	1.8
Indigenous	3	5.4
Other (e.g. individuals who self-identified as having multiple ethnic identities)	4	7.3
Age range
19–29 years	19	34.5
30–39 years	18	32.7
40–49 years	15	27.3
50–59 years	3	5.5
Length of time using drugs
Less than 1 year	1	1.8
1–5 years	9	16.4
6–10 years	10	18.2
11 or more years	33	60.0
No information provided	2	3.6
Enough money to meet day-to-day needs over last two years (e.g. food, shelter)
Yes	21	38.2
No	27	49.1
Not sure	6	10.9
No information provided	1	1.8
Place of residence
In city	44	80.0
Outside of city	10	18.2
No information provided	1	1.8

Please note the following:

*We asked participants, ‘Can you tell me your ethnicity?’.

Responses provided may reflect racial identity, and in some instances individuals may have understood the terms ethnicity and racial identity as interchangeable.

A number of participants reported accessing or trying to access a detoxification program on many occasions, and one participant had been to a program ‘upwards of 20 times over the past ten years’ (Site F, P#5). A couple of participants also indicated that they had been off and on OAT multiple times. In a few instances, participants reported that they had experience with accessing a detoxification program or OAT but not both, and some participants spoke about their experiences accessing a detoxification program or OAT over a span of many years.

In some cases, participants spoke about treatment programs as having features that were helpful (facilitators) as well as some features that were not helpful (barriers). Data were collected prior to COVID-19 and it is therefore important to note that participants’ discussions do not include experiences of any changes in programs (e.g. move to virtual care) due to public health restrictions.

Facilitators and barriers are presented below using a slightly revised Rhodes’ risk environment framework, and specifically four types of treatment program environments: policy and practice, physical, social, and resource environments. See Table 2 for a summary of key facilitators and barriers according to these four types of environments. Participant quotes are identified by site (e.g. Site A) and participant number (e.g. P#1).

Table 2. Summary of key facilitators and barriers to access and retention in drug treatment programs.

Type of environment	Facilitators to access and retention (or what was helpful)	Barriers to access and retention (or what was not helpful)
1: Policy and practice environment	Quick and easy intake Accommodations for/acceptance of substance use and specific health needs	Requirements to ‘get in’ to treatment Rigid policies and practices Hours of operation of pharmacies/clinics
2: Physical environment	Ready physical availability Physical layout of pharmacy	Distance to facilities and limited spaces Physical layout of treatment/testing spaces
3: Social environment	Supportive and understanding staff & structured and protective social environment	Judgmental attitudes and negative conversations/social interactions
4: Resource environment	Meetings, ‘good’ food and other amenities	Boredom and poor--quality food

Policy and practice environment

Facilitators within the policy and practice environment or what was experienced as helpful included quick and easy intake, as well as accommodations for/acceptance of individuals’ substance use and specific health needs. Experiences of policies and practices which were barriers or were not helpful were various requirements to get in to a treatment program and included needing a phone to communicate with the program, wait times, and having to rely on others to help withaccess. Rigid program policies and practices, and the hours of operation of some pharmacies/clinics were also experienced as not helpful.

Facilitators

Quick and easy intake

The process for ‘getting in’ to a detoxification program was reported by some participants as helpful when it was quick and easy. For example, a participant argued that, ‘It was pretty easy to get in’ (Site A, P#4), and another commented that, ‘Yeah it was pretty easy, I just made a call. They called me like, two days later. It was pretty quick. And then I just went in’ (Site C, P#1). A participant who indicated that they had been to ‘detox a couple of times’ stated that, ‘Just go to your doctor or go to emergency room and tell them that you’re addicted to drugs. And that you want help. It’s pretty easy to get into [the program]’ (Site F, P#1). According to yet another participant, sometimes they were in treatment ‘in a bed’ ‘in under an hour’ and that ‘it was very fast’ (Site F, P#2), and another participant argued that they did not have to wait ‘more than a couple of days’ the last few times they went to the ‘recovery center’ as an application was completed on the phone and an appointment booked (Site F, P#12).

Speaking about access to OAT, a number of participants also reported a relatively quick and easy process. A participant explained that, ‘So they pretty much gave me my drink that day so it was actually quite easy’ (Site E, P#5), and another participant stated that they were given paperwork to have tests completed, and the next day they met the physician, ‘and bam’ they were started on OAT (Site A, P#7). Various steps in the process of ‘getting on methadone’ were described by a participant including needing to obtain a referral from their physician but the participant’s comments indicated that they experienced the process as relatively quick and easy as they commented that, ‘…once you get your blood work you just bring it back to the doctor. It normally takes a week from there and then boom. Ten days tops you’re on it’ (Site F, P#8).

Accommodations for/acceptance of substance use and specific health needs

A couple of participants spoke about policies and practices which were helpful because they accommodated/accepted some substance use and specific health needs. For example, a participant noted that the methadone program did not ‘kick out’ individuals for their continued substance use stating that:

'… like there are people that still use opioids and everything while they’re still on methadone. They don’t get kicked off they just try and work with them. There’s a social worker over there, her office is right in the whole place and you go talk to her…. So if you can’t put that cigarette down or you can’t put the needle down and you’re on methadone they don’t make you feel like if you’re not off that you’re gone. So it’s awesome like that' (Site E, P#3).

Another participant spoke in positive terms about a detoxification program that provided nicotine substitution in the context of a no smoking policy. This participant did not explicitly indicate that this accommodation facilitated their retention in the program, but their comments suggest that the accommodation played a role as they stated that, ‘And now where [organization] is involved you can’t smoke on the grounds at all. But now they have the nicotine, they have the patch, the gum and all sorts of other things’ (Site F, P#2).

Barriers

Requirements to 'get in' to treatment

Participants’ discussions of policies and practices that were not helpful to accessing a program included phoning a program and waiting. Many individuals indicated that they were very frustrated even angered by phoning, and often waiting for what they experienced as a long period of time. A participant commented that phoning almost daily to determine if there was a detoxification space available was challenging, and they did not have a phone and so they had to use their sister’s phone (Site C, P#7). Another participant spoke about the frustration of calling and waiting stating that, ‘Sometimes they tell me that I should call back within 24 hours. Really? Are you guys even sure you know what you’re dealing with here? Because normally by the time I get to calling detox I’m in hard shape. I need help '(Site F, P#5). For this individual, the wait time has been an impediment. Yet another participant indicated that they had not been in a detoxification program ‘in years’ but they had tried to access a program recently and then gave up ‘because it’s just the same old story’ (i.e. phoning and waiting) which made them feel angry (Site B, P#7). A couple of other participants stated that when you have to wait to get into detox you keep on ‘using’ (Site B, P#1; Site B, P#4), and a participant argued that if a detoxification program calls you after a week it’s ‘too late’ because you have started to use again (Site B, P#7). Another participant reported that they had tried to get into a detoxification program to ‘fix’ a relapse but it was ‘call back, call back, call back’ and the individual stated that they ‘ended up' in jail because they ‘hit rock bottom’ (Site B, P#4).

A couple of participants reported that they had to rely on others to help them access treatment, and one participant indicated that they did not think they were ‘taken seriously’ until their mother called the program. This participant stated that, ‘So then I had to literally get my mom to call. When my mother had called and dealt with them I got in that day… It was like they didn’t really take me seriously. I’m [in their 20 s]… and I had to get my mother to call to get them serious enough for me to get in. That was a little irritable…’ (Site C, P#7).

Rigid policies and practices

Various program policies and practices were expressed by some participants as not helpful because the policy or practice was rigid and did not accommodate individuals’ specific health needs. A couple of individuals indicated, for example, that a no-smoking policy in a detoxification program was not helpful, and one participant stated that they could ‘not stand’ the no smoking policy (Site F, P#1). This participant argued that the policy influenced retention, and maintained the following: ‘…You go in to try to get off one drug and they take smoking away from you down there. And there was a lot of people only stayed [in detox] two days, three days, that’s it. And they had to leave. Leave and they go back to their drugs because they couldn’t stay because they couldn’t have their cigarette’ (Site F, P#1).

Policies and practices which did not recognize or respond to individuals’ socioeconomic circumstances were also described by a couple of participants as not helpful. For example, a participant reported that they were on methadone ‘for a while’ but one day they were unable to travel to access methadone because there was a snow storm and there ‘were no buses running in town’ (Site F, P#11). This participant stated that they went back the next day to see the doctor who said they were 'cut off' because they missed their appointment (Site F, P#11). As a result of not having access to treatment the individual indicated that they ‘went back to using [drugs]’ although they later accessed methadone from another physician (Site F, P#11).

A couple of other participants commented on policies related to take-home doses of OAT or ‘carries’ that did not recognize or fit with their socio-economic circumstances. A participant argued that the carries policy required multiple urine tests, but they had to engage in extensive travel time by bus to obtain the tests. As this participant commented: ‘…if you don’t have a car, you have to get a bus up there, go in for 3 minutes, long enough to use the washroom, and then wait another hour for the next bus to come. It takes 2.5 hours basically. So I’ll skip it. And because …because I haven’t gone consistently for 3 months to urine tests, they won’t give me carries so I don’t have drinks to take home’ (Site A, P#7). Another participant had access to carries but they were only able to obtain carries for a week which they did not perceive as adequate given that they worked full-time and had other responsibilities. This participant stated that, ‘... you can only get carries for a week if you’re really good. That’s horrible. I mean I work a full time job …. I should be able to get carries for a month but I can’t’ (Site C, P#8).

Hours of operation of pharmacies/clinics

For a few participants, the hours of operation of pharmacies/clinics meant delayed access to or missing a dose(s) of OAT. For example, a participant reported that they had regular, steady access to methadone during the week but the clinic hours changed on the weekend resulting in some withdrawal symptoms. This participant explained that, ‘...it’s 8 every morning [during the work week] and I’m up and at the door at 8 and I’m in there ten after 8 or so. But then the weekends, I just find that their hours vary. Like Saturday it’s 9 AM and Sunday it’s 11 AM…. When you’re waiting on the weekend for 11 AM you’re feeling a little symptoms of withdrawal…’ (Site C, P#7). The pharmacy hours in a rural place were also highlighted by a participant who noted that when they stayed in a rural community with a family member they could not access their methadone for a weekend (Site C, P#1). Another participant commented that the hours of operation of the pharmacy were during the times when they were working, and as they explained, ‘It interferes with work. [Pharmacy] doesn’t open until 9. If you got to be at work at 7 and you don’t get off until 7, by the time you get the pharmacy …. Like there’s days where I have to be missing my drink’ (Site F, P#10). Given that the treatment schedule interferes with this individual’s working hours, they are ‘hoping to be off’ methadone shortly (Site F, P#10).

Physical environment

Facilitators in the physical environment of drug treatment programs or what was reported as helpful included ready physical availability to treatment, and the physical layout of a pharmacy that helped to ensure confidentiality when accessing treatment. Distance to program facilities and limited number of treatment facilities/spaces were identified as not helpful, as was the physical layout of treatment/testing spaces when the layout impacted confidentiality.

Facilitators

Ready physical availability

For a few participants, ready physical availability to treatment was discussed as helpful. For example, a participant commented that the last time they went to a detoxification program it was across the street from where they lived so they just ‘walked over and knocked on the door’ (Site F, #2), and another participant stated that getting to the ‘recovery center’ was ‘easy’ because they had a vehicle (Site F, #12). Speaking about accessing carries, a participant commented, ‘I just walk two minutes down the road to get my carries [at pharmacy]…. I don’t have to get on the bus’ (Site F, P#1), and another participant indicated that it was ‘a 15 minute walk’ from where they lived to access their methadone, and thus it was ‘convenient’ (Site F, P#11).

In one community there was, for a period of time, a mobile methadone program, and a participant commented that it was helpful to have this ready physical availability stating that:

‘A lot of the time you don’t have transportation money, or if you’re too sick to get there or you’re pill sick you’re not going to get a bus and travel all day and take a bus from [neighboring city] to [neighboring city] to go to a clinic…. But when I hit rock bottom, and I saw that methadone bus was sitting there on [street] in [neighboring city] I said that’s it I had enough, it’s time to get on there’ (Site B, P#4).

Physical layout of pharmacy

The physical layout of a pharmacy was commented on by one participant as ensuring access to OAT in a confidential space, suggesting that for them the physical layout was helpful. According to this participant, at the pharmacy there was ‘one side for methadone people only’ and no one was allowed in that section of the pharmacy if not accessing methadone, and ‘… All that’s [access to methadone] confidential and that’s what I love about it. But not every drug store is like that’ (Site F, P#11).

Barriers

Distance to facilities and limited spaces

For a few participants, distance to a facility was referred to as not helpful because of the time involved in travelling and/or because of transportation challenges (e.g. lack of transportation, transportation costs). For example, a participant reported that they had to travel to a town half an hour from where they lived to access ‘their prescription’ (Site G, P#2), and another participant commented that access to transportation to go to another neighbourhood for their methadone was ‘difficult’ (Site F, P#8). Yet another participant spoke about transportation challenges to a pharmacy, and indicated that because of this they sometimes missed their dose of treatment (Site F, P#7). A participant who had been on methadone for many years but just ‘got off’ it a few months previously, and was trying to start again, commented that they would ‘...cab it. Or not go. Or walk. I’ve done a lot of the walking... Because I went to the [clinic] and I live way over in [other neighborhood] so it’s quite the walk’ (Site D, P#4). Another participant spoke about the costs if they took a taxi to where they accessed their methadone stating ‘it’s $20.00 over and then it’s $20.00 to taxi back’ (Site F, P#8).

A couple of participants indicated that in their community the detoxification facility prioritized people with alcohol use disorder, and the limited number of spaces for individuals not detoxing from alcohol was a barrier. One participant addressed this barrier by drinking liquor in order to access the program. They stated that they used the ‘excuse of alcohol to get into detox’ and then once in detox they let their ‘demons out’ and said, ‘Okay I’m using needles and stuff like that and I’m not leaving here until I get help from [detox doctor] to get me on Suboxone’ (Site A, P#1). Another participant commented on the limited number of spaces within a detoxification and transition facility arguing that, ‘Way more people want to be there than they have room for people. They need more spaces’ (Site C, P#4), and yet another participant stated that, ‘There’s a lot of people who want to get in there [detoxification program] and can’t get in because there’s no beds available’ (Site F, P#8).

Physical layout of treatment/testing spaces

According to one participant, some treatment and testing spaces have a physical lay out that impacts confidentiality. This lack of confidentiality appeared to cause this individual some distress as suggested by the following comment: ‘A lot of drug stores you walk in and they give you your drink right over the counter and everyone is watching. They don’t even say here’s your drink, they say here’s your methadone and this is how many ml it is…’ (Site F, P#11). Lack of confidentiality at testing sites in the context of a hospital was also noted by this same participant who stated that, ‘There should be specific rooms so you can get your blood work done in privacy. I’m … at the hospital getting my urine done and seeing people I know who are like ‘what are you doing here'? They know that the room I’m going into is for methadone. It says right at the top, methadone patients only... And then people look at you differently’ (Site F, P#11).

Social environment

The social environment of treatment programs, and specifically supportive and understanding relationships with staff, were experienced as helpful by some participants, and a couple of participants spoke about a structured and protective social environment as helpful. Participants reported as not helpful the judgmental attitudes of some staff and other individuals within or close to treatment facilities, and a few individuals spoke about negative conversations/social interactions with both staff and others within treatment facilities as not helpful.

Facilitators

Supportive and understanding staff & structured and protective social environment

A number of participants indicated that some staff in treatment programs were supportive and understanding. Participants used various positive terms when speaking about some staff including ‘awesome doctor’ (Site F, P#11), ‘fantastic’ staff (Site F, P#2), ‘great’ pharmacist (Site G, P#2), and a ‘big family’ referring to the ‘doctor, the secretary, everyone you meet when you go in’ (Site E, P#3). A participant stated that the staff were helpful because they were ‘...always talking to you. They’re caring you know’ (Site F, P#1), and another participant commented that what was helpful, in part, in keeping them on methadone for two years was that the staff changed the dose as necessary (Site F, P#2). One participant believed that it was because of the staff member’s lived experience with addiction that they were supportive (Site C, P#8).

The structured activities and protective social environment in a detoxification and transitions program were spoken of as helpful by one participant, and although the participant did not explicitly state that this helped with retention their comments suggested that the structure and sense of protection may have played a role. According to this participant, ‘It’s so much easier in there. Life seems easier cause you know you’re just going to your meetings. Or you know you have to do that piss test. And that’s fine and dandy and your food is looked after and your housing is looked after…’ (Site C, P#5). Another participant spoke about the structured activity of daily visits to the pharmacy which they viewed positively also suggesting that for them this structure supported retention (Site C, P#1). This participant argued that, ‘I go to the pharmacy every day. I like it that way. My doctor wanted to get me carries but I like going every day. Just because it’s like structured, a routine’ (Site C. P#1).

Barriers

Judgmental attitudes and negative conversations/social interactions

Even though a number of participants spoke in positive terms about staff there were also comments about judgmental attitudes among some staff including staff in pharmacies (Site F, P#10). A couple of participants explicitly indicated that they had at some point in time left a detoxification program because of staff attitudes (Site F, P#7; Site F, P #11), and a participant stated, ‘That’s one place [detoxification program] you should feel comfortable and respected. I felt like I was being judged and downgraded. So I left. It’s pretty bad when you leave detox because of staff’ (Site F, P#11). Judgmental attitudes among individuals within the vicinity of a treatment facility were also reported by a participant as making it difficult to ‘...go in that clinic and get that methadone…. It’s hard because people automatically know, “okay they were drug users”’ (Site E, P#5).

According to one participant, conversations about substance use among clients of a treatment program were not helpful when they were accessing OAT, and this participant commented that, ‘So you hear conversations about how they were still doing benzos or still doing the coke or still doing the crack. And although I personally don’t like crack or coke, it’s the talking about the drugs in general that get your mind wandering. So I really found that to be disappointing’ (Site E, P#5). These types of peer conversations may be experienced differently by others, but for this individual they were not helpful. A couple of other participants recounted negative social interactions with treatment staff, and a participant reported that in a ‘recovery program’ a worker ‘picked on’ some clients (Site C, P#8), and another stated that a receptionist at the methadone program was treating them ‘almost like a criminal’ (Site C, P#6).

Resource environment

The types of resources available when in treatment such as meetings, ‘good’ food and other amenities were commented on by a couple of participants as helpful, and although these resources were not explicitly linked to retention they may have played a part. Boredom was, however, explicitly reported as negatively influencing retention for a couple of individuals, and poor quality food when in treatment was discussed by a few participants as not helpful.

Facilitators

Meetings, ‘good’ food and other amenities

When speaking about the programming at a transition program a participant commented as follows: ‘There’s morning group that’s like four hours long. And you do affirmations and feeling, like the feeling that you have that day. You talk about anything... It’s really great. I miss it. I loved it’ (Site C, P#1). Although it is not clear if the programming was important to retention the individual’s comments suggest that it did play a role. Programming at a treatment centre was also spoken of as helpful by a participant who argued that: ‘Just you know…like a lot of 1-on-1 programs. Like they had these programs, like each day they had a different program you could go into…. I found a lot of stuff like that was very helpful’ (Site A, P#3). Good food at a treatment center was mentioned by one participant (Site F, P#2), as well as a music room which they used daily suggesting that these amenities were helpful, and may have supported retention. This participant stated that, ‘They had a little music room. And I play. I took my guitar out there with me, an old 6 string that I found. And I played every day I was there’ (Site F, P#2).

Barriers

Boredom and poor-quality food

A number of participants spoke about boredom when in a treatment program as not helpful, and a couple of participants explicitly indicated that it influenced retention. The phrase ‘mind numbingly boring,’ was used by a participant who indicated that they typically stayed for the full 6 days of treatment, but also sometimes left ‘a few days early’ in part because of the boredom (Site F, P#5). Another participant who had been to a detoxification program ‘several times’ spoke about the intensity of boredom as follows:

‘…But the boredom. The pure boredom. I mean, they got books, they got movies, they got all that down there. But I’m telling you it’s just really, really boring. I’ve gone in there and I’ve seen people just so sickeningly bored that they’ve had to leave. I got up there one time. I got up after 48 hours, 2 days, and went straight down to the liquor store. I had to get out of there. I really had to get out of there. It was the worst place I’ve ever been in my life. Ever. And I’ve done the shelters, I’ve done prisons… it’s so frigging boring I wanted to pull my own head off. If there was a way of doing that’ (Site F, P#4).

According to yet another participant there was little to do at the ‘recovery center’ and therefore they had ‘too much time to think’ so started to think ‘…well I might want a fix right now’. There's a lot of people leave because of that. Too much time’ (Site F, P#1). For another participant, boredom when in a detoxification program was a ‘big trigger’ (Site B, P#5).

A couple of participants also spoke about the poor-quality food in programs they attended as not helpful. According to a participant, ‘… when you’re trying to come down off of drugs and alcohol and you’re committed to staying in this program for a month, the quality of the food should be taken into greater consideration’ (Site C, P#3). Another participant argued that when you are in a detoxification program you need ‘a little bit of comfort’ and that, ‘...if food could be improved a little bit in [that] place that I think could be beneficial’ (Site F, P#12).

Discussion

Our research focused on the experiences of people who use substances when seeking access to government-funded detoxification and/or OAT programs in Atlantic Canada. More specifically, the research explored experiences of program facilitators of access and retention (or what was helpful) as well as barriers (or what was not helpful). Facilitators and barriers were organized in terms of four types of program environments (policy and practice, physical, social and resource environments). Although the barriers did not prevent access or impact retention for many of the participants the barriers did, at times, result in feelings of anger, frustration, or distress. In a few cases, the barriers (e.g. hours of pharmacies/clinics) meant delayed access to treatment or missed doses of OAT. A couple of participants also reported giving up on treatment and returning to substance use or continuing to use substances because of the barriers they experienced, and this type of response has previously been reported in research focused specifically on responses to wait times for treatment (Redko et al., 2006). Within the current Canadian context, delayed access to treatment or not accessing treatment is especially concerning given the potential deadly harms associated with a toxic illicit drug supply.

A number of the policy or practice barriers described by participants in our study (e.g. wait times) have been reported in the research literature for many years (See, for example, Fischer et al., 2002; Powell et al., 2019; Prangnell et al., 2016; Redko et al., 2006). Requirements necessary to ‘get in’ to treatment including needing access to a phone have also been reported, and Powell et al. (2019) describe the phone requirement as a ‘logistical barrier to treatment’ (p. 21). Once in a program, some policies and practices were reported by participants in our study as barriers because they did not align with or fit with individuals’ socio-economic situation including their employment, and this is a finding consistent with the literature (Bourgois, 2000; Fischer et al., 2002). Over 20 years ago, for example, Bourgois' (2000) ethnography of a methadone clinic drew attention to the requirement of daily travel to a methadone clinic for treatment, and profiled an individual who could not return to methadone after a period of time on another treatment because the methadone treatment schedule made him late for work (p. 167). More recent research in New York City has similarly found that policies requiring frequent visits to methadone clinics are ‘impractical and counter-productive’, and serve as a ‘barrier to treatment uptake and retention’ (Frank et al., 2021, p. 2). The researchers note that these policies not only make it difficult for ‘patients to maintain steady employment’ but also to ‘attend school, or manage their daily lives’ (Frank et al., 2021, p. 4).

Frank et al. (2021) maintain that it is important to center the ‘voices and experiences’ of people who use substances ‘especially in light of the long history of ignoring the views of PWUD [people who use drugs] in the design of substance use treatment programs and policies’ (p. 2). Our research and the research of others (e.g. Fischer et al., 2002; Frank et al., 2021; Lyons et al., 2015) provide a voice for people who use substances, and these voices point to the need to address the many barriers to treatment access and retention. Barriers are an injustice, and eliminating barriers must be a priority. This means, as the risk environment framework indicates, going beyond a focus on the microenvironment of treatment programs and changing the macro-level forces that shape many of the barriers to treatment access and retention. Macro-level criminalization policies, for example, shape or influence such treatment practices as the daily dispensing of OAT which can act as a barrier given the time and travel involved in meeting this requirement. Daily dispensing is based (at least in part) on a conceptualization of people who use substances as individuals who cannot be trusted given that they engage in ‘criminal’ activities (e.g. illicit substance use), and as Bourgois (2000) argues the supervised administering of treatment is a form of ‘policing’ (p. 180). The policy of limiting the number of take home doses can act as a barrier to access and retention, and is also a type of policing partly grounded in fears that individuals who are provided take home OAT might divert the medication to the illegal drug market or use take home doses inappropriately when not supervised (e.g. inject the substances) (Bourgois, 2000, p. 179; Kourounis et al., 2016, p. 5).

Global organizations as well as national groups and researchers have questioned the criminalization of substance use because of the many health and social harms associated with this approach (Canadian Drug Policy Coalition, 2021; Global Commission on Drug Policy, 2016; McNeil et al., 2014; Oscapella, 2012). There have been proposals for a ‘health-based’ response to reducing the harms associated with drugs (Oscapella, 2012, p. 17) and for the decriminalizing of substance use (Canadian Drug Policy Coalition, 2021; Parliament of Canada, 2021). Our research also points to a need for the decriminalization of substances for personal use because decriminalization can potentially help to reduce barriers to treatment access and retention. The decriminalization of substance use might assist, for example, in re-framing judgmental attitudes towards people who use substances and thus help to create more supportive and understanding attitudes among treatment staff as well as individuals within the vicinity of treatment programs. Decriminalization may also change staff attitudes within other healthcare settings such as hospitals (Chan Carusone et al., 2019). As Paquette et al. (2018) note, people who use substances experience stigma at ‘every turn’ within healthcare contexts (p. 104), and thus there is clearly a need to change stigmatizing attitudes within these micro-environments.

Decriminalization policies might also help support an increase in government funding to treatment programs given that there would be a reduced need for drug enforcement policies. As Greer (2021) argues, ‘A large proportion of the justice system—police, courts, prisons—are occupied with drug-related crimes’, and decriminalization ‘can reduce the demands and costs to this system’ (p. 3). Reducing the need for enforcement and directing resources to other services, such as harm reduction and treatment, is key to ensuring the many ‘benefits’ of decriminalization (Global Commission on Drug Policy, 2016, p. 19). Increased investments in treatment programs would potentially not only help to reduce wait times (because such investments might increase the number of spaces in programs), but also potentially improve the physical availability of programs or spatial access to programs and thus reduce distance and transportation barriers. Spatial access can be defined as existing when programs are ‘within a local area in a given time period’ (Cooper et al., 2009, p. 219), and although spatial access does not necessarily mean individuals will utilize a treatment program, research on needle distribution and disposal programs as well as supervised consumption sites does suggest that spatial access is important. Research in New York City, for example, found that individuals who ‘lived close’ to a needle distribution and disposal program were more likely to attend a program than those who did not (Rockwell et al., 1999), and a survey of people who use substances living in a region of Ontario (Canada) found that half of the survey respondents (74 of 140, 52.9%) reported that the longest distance they would walk to a supervised consumption site was ‘a maximum of 15 minutes’, and ‘eighty-three per cent (n = 115) reported they would be willing to take public transit, of whom 42.0% (n = 48) reported they would travel a maximum of 15 minutes by bus to access a SCS [supervised consumption site]’ (Region of Peel, 2019, p. 49). Having more treatment programs across communities (both within cities and outside of cities) may be especially critical for those who do not have the resources needed for transportation or who live in places where there is no public bus transportation (e.g. many rural places). Mobile treatment sites (e.g. ‘methadone buses') might also be a strategy for increasing spatial access given the role mobile sites play in providing access to harm reduction resources (Jackson & Strike, 2020).

Increased funding for treatment programs might also help improve the resource environment of treatment programs including programming which may help reduce boredom which reportedly impacts treatment retention, at least for some. In addition, increased funding for treatment programs might support treatment expansion efforts such as the provision of injectable opiate agonist therapy (iOAT). Currently, at least one province in Atlantic Canada offers an iOAT program (River Stone Recovery Centre, 2021).

Challenges to changing macro-level punitive drug policies should not be underestimated given the fears associated with decriminalization (Greer, 2021) but treatment program environments—policy and practice, physical, social and resource environments—must facilitate access and retention. The research of others (e.g. Lyons et al., 2015, p. 4) as well as our research indicate that there are some facilitators to access and retention, but facilitators need to be the norm across treatment programs. Further research is needed to fully understand facilitators and their role in retention given the current limited body of literature on facilitators. At the same time, however, there is a need to maintain and further implement existing facilitators to help support risk reduction for people who use substances.

Limitations

This study has a few limitations which should be noted. First, participants were recruited through community-based organizations, and therefore, only individuals accessing such services were part of the study. Individuals recruited through other venues might have different experiences of government-funded treatment environments, and additional research is needed to obtain the experiences of people who use substances who are not accessing community-based organizations. A second limitation is that the eligibility criteria for our study included having accessed a detoxification and/or OAT program in approximately the last two years, but a number of participants had a longer history with such programs and spoke about their experiences prior to the two-year period. Some of the reported barriers or facilitators may not be part of current programs as there may have been changes in program environments over time. There may also have been changes in treatment program environments because of public health restrictions due to COVID-19 (e.g. virtual appointments) but such changes were not part of our results as we collected data prior to the emergence of the pandemic. A final limitation of our research is that although there were attempts during recruitment to try and recruit a diverse sample, most participants self-identified as white and many reported they lived within a city. The experiences of individuals from diverse ethnic or racialized groups require further in-depth exploration given that these populations may have different or additional experiences of barriers and facilitators not highlighted in our study. There is also a need for further research specifically with individuals living in rural and remote areas to gain a greater understanding of the experiences of these populations.

Conclusions

Study participants reported a number of facilitators and barriers to access and retention in government-funded drug treatment programs in Atlantic Canada. Treatment environments that fully facilitate access and retention need to be the norm across drug treatment programs, and this means that features within the environments that operate as barriers must be eliminated. Given that criminalization policies shape or influence a number of barriers, our research suggests that decriminalizing substances for personal use is needed to move towards environments that fully facilitate access and retention and thus operate to help reduce risks. At the same time, the perspectives of people who use substances should be part of all decisions related to treatment program environments including changes to barriers and the implementation of facilitators.

Acknowledgements

This research was supported by the Canadian Institutes of Health Research HIV/AIDS Community-Based Research Operating Grant under Grant number CBR-156918. The authors wish to thank all the participants for giving of their time and speaking to us about their experiences with drug treatment programs. We would also like to acknowledge and thank the community-based organizations that assisted with recruitment, as well as all past and present members of the research team (known as the Atlantic COAST study team). In addition, we would like to acknowledge and remember fondly the late Dr. Margaret Dechman (2020) who was involved in the early stages of this study.

Disclosure statement

The authors report there are no competing interests to declare.

Data availability statement

Study participants did not agree for their data to be shared publicly, so data are not publicly available.