Negotiating structural vulnerability following regulatory changes to a provincial methadone program in vancouver, canada: A qualitative study
Negotiating structural vulnerability following regulatory changes to a provincial methadone program in vancouver, canada: A qualitative study
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DOI：
10.1016/j.socscimed.2015.04.008
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发表时间：
2015-05-01
影响因子：
5.4
通讯作者：
Small, Will
中科院分区：
文献类型：
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作者：
McNeil, Ryan;Kerr, Thomas;Small, Will
虽然美沙酮维持治疗 (MMT) 的监管框架需要高度严格的治疗计划来塑造治疗结果，但很少有研究探讨这些计划的监管变化对接受治疗的人的影响，并将他们的经历置于社会结构不平等的更广泛背景下。在加拿大不列颠哥伦比亚省（BC），管理MMT的省级法规最近进行了修改，包括：用Methadose（R）（预混合且浓缩10倍）取代现有的美沙酮制剂；禁止药房提供美沙酮；并且，禁止药房奖励美沙酮配药。我们进行这项研究是为了检验这些变化对不列颠哥伦比亚省温哥华参加 MMT 的结构性弱势群体的影响。对参加 MMT 的 34 人进行了定性访谈，这些人是从两项正在进行的观察性前瞻性队列研究中招募的，这些研究的对象是 2014 年监管变化后六个月内的吸毒个体。访谈记录根据“结构性脆弱性”的概念进行了主题分析。调查结果强调了这些监管变化如何扰乱治疗参与，造成相当大的健康和社会危害。 Methadose (R) 的引入导致了戒断症状的增加。由于结构性脆弱性（例如贫困、无家可归）带来的限制，药品配送服务的停止导致 MMT 和共同配发艾滋病毒药物的中断。与此同时，失去药房激励措施限制了参与者获得物质支持的机会，以克服 MMT 的障碍，同时削弱了他们在与药房谈判配药安排时主张一定程度代理权的能力。总的来说，这些变化损害了 MMT 的参与，增加了结构性的伤害脆弱性，包括重新开始注射毒品使用和参与高风险创收战略。在修改 MMT 计划时，需要更多地关注社会结构不平等对 MMT 参与的影响，特别是在其他司法管辖区正在采取类似的变革时。应提供全面的环境支持，以尽量减少过渡时期的不利后果。 (C) 2015 Elsevier Ltd. 保留所有权利。
While regulatory frameworks governing methadone maintenance therapy (MMT) require highly regimented treatment programs that shape treatment outcomes, little research has examined the effects of regulatory changes to these programs on those receiving treatment, and located their experiences within the wider context of social-structural inequities. In British Columbia (BC), Canada, provincial regulations governing MMT have recently been modified, including: replacing the existing methadone formulation with Methadose (R) (pre-mixed and 10 times more concentrated); prohibiting pharmacy delivery of methadone; and, prohibiting pharmacies incentives for methadone dispensation. We undertook this study to examine the impacts of these changes on a structurally vulnerable population enrolled in MMT in Vancouver, BC. Qualitative interviews were conducted with 34 people enrolled in MMT and recruited from two ongoing observational prospective cohort studies comprised of drug-using individuals in the six-month period in 2014 following these regulatory changes. Interview transcripts were analysed thematically, and by drawing on the concept of 'structural vulnerability'. Findings underscore how these regulatory changes disrupted treatment engagement, producing considerable health and social harms. The introduction of Methadose (R) precipitated increased withdrawal symptoms. The discontinuation of pharmacy delivery services led to interruptions in MMT and co-dispensed HIV medications due to constraints stemming from their structural vulnerability (e.g., poverty, homelessness). Meanwhile, the loss of pharmacy incentives limited access to material supports utilized by participants to overcome barriers to MMT, while diminishing their capacity to assert some degree of agency in negotiating dispensation arrangements with pharmacies. Collectively, these changes functioned to compromise MMT engagement and increased structural vulnerability to harm, including re-initiation of injection drug use and participation in high-risk income-generating strategies. Greater attention to the impacts of social-structural inequities on MMT engagement is needed when modifying MMT programs, especially as other jurisdictions are adopting similar changes. Comprehensive environmental supports should be provided to minimize adverse outcomes during transitional periods. (C) 2015 Elsevier Ltd. All rights reserved.