Understanding Opioid Use and Risks

Chapter one

Introduction

Opioids is defined as a class of drugs that used for pain relieving and include heroin, synthetic opioids such as fentanyl and pain relievers that are available legally and have been prescribed by physicians (NMC, 2018). All these types of opioids are chemically related and normally interact with opioid receptors in the nerves on the human body. These drugs are considered safe when ingested for a shorter time as prescribed by a doctor. Misuse of these drugs causes dependence, addiction, overdose accidents and even deaths. Opioid overdose can be reversed with drug naloxone when taken right away; however, Care should be exercised by patients to ensure that the drugs are not misused Opioid addiction has become a global disease manifesting in physical and psychosocial problems that affects the brain. Significant overprescribing of opioid medication and subsequent illicit availability has been reported (Battista et al.2019). Recent evidence on opioid use disorder (OUD) has shown that opioid use has been practiced by institutions with varied demographic and psychosocial groups (Parlier-Ahmad et al.2021).Buprenorphine is a treatment for opioid addiction and is the main focus of this literature review. The Nursing and Midwifery Council (NMC) requires the nurse to deliver care based on the evidence available .Evidence-based practice is an approach that clinical research in combination with clinical experience and patient characteristics are preferred in Oder to make clinical decisions (NMC, 2018). This literature review as an evidence-based study may contribute to practice through the findings and recommendations.

Buprenorphine is a type of medication that is used to treat individuals that have grown fond of the opioid drug. It belongs to a class of drugs that are called mixed opioids agonists-antagonists (Amitava Dasgupta, 2020). These medicine works by preventing withdrawal symptoms that have been caused by stoppage of other opioids. It a common treatment plan for drug abuse such as changes in lifestyle as well as compliance monitoring. This medication should be used as directed by the doctor. These tablets are placed under the tongue as per the prescription and left to dissolve which roughly takes 5-10minutes. This medicine was licensed in France in the year 1996 and in USA its use was advocated for in 20002. It comes in different forms such as, injectibles, pills patch or oral form and therapeutic interventions (Fox et al., 2015). Buprenorphine works best when taken immediately after the signs and symptoms of opioid withdrawal. Abruptly stopping this medication may causes adverse side effects hence it is advisable that a patients should consult their doctors for further directives on how to stop using this drug. Gamma-AminoButyric Acid (GABA), is a neurotransmitter that is produced by the brain and works by blocking impulses between cells in the lower brain (Fields & Margolis, 2015). According to researchers, this chemical has been suspected to boost a person’s mood by calming and relaxing the hypersensitive nerves in the body. Receptors undergo endocytosis and desensitisation causing a blunting effect of emotions (Horsfall & Sprague, 2016). This increase in doses can be a risk for a drug overdose as well as behavioural changes to behaviours such as criminal activities. Heroin and morphine bind to opioid receptors that normally bind to endogenous neurotransmitters like endorphins, so they mimic mechanisms of pain reduction, causing euphoria (Horsfall and Sprague, 2016)). Heroin and methadone are full agonists which have a good fit with the receptor and cause respiratory depression which can lead to a risk of death at high doses. (Cisewski et al., 2019). Buprenorphine negates any effect of subsequent heroin use .Buprenorphine is very effective when used in higher proportions, which is a protective factor and less harmful compared to morphine which has effects of sedation ,respiratory defects, depression and intoxication.

Figure1 Buprenorphine is a partial agonist and does not fully activate the receptor as a full agonist such as heroin does.

1.1 Definition of key terms

The research question was analysed to form and develops the key terms.

The medication Buprenorphine was used as a key term for this dissertation (Bettany-Saltikov and Mcsherry, 2016). Interviews were used in the analysis of buprenorphine treatment and patient’s experiences. Therefore, the key terms perspective, preference, needs, view, experiences, attitudes, opinions, beliefs, satisfaction, outcome, and willingness (Bettany-Saltikov and Mcsherry, 2016). The key term adult is used for patients or people over the age of 18.

1.2 Prevalence and statistics

Opioid use began back in 1775 after it was legalized in United States. It was used during the civil war in 1860s to treat troops that were injured. Since pain was the main issue that made them opt for the opioid drug, many of them became addicted to the drug. Due to adverse side effects of addiction to the opioid drug, the Harrison Narcotics act was developed in 1914 to place restrictions on the use of the drug (Centres for Disease Control and Prevention, 2019) . In 1970, doctors avoided prescribing the drug due to stigmatization and instead opted for surgical procedures that could prevent pain in the human body. Later in the 19180’s and 1990’s, this drug was reintroduced again to aid in the treatment of chronic pain. However, the second wave of reintroduction came in with massive deaths and in 2017; every day recorded a total of 142 opioid-related deaths. Due to the massive deaths associated with the use of the drug, buprenorphine was introduced as a substitute drug for pain relieving (Ayoo et al, 2020). This drug was developed back in 1966 as an alternative time’s standard for morphine. It was designed to relieve pain in patients without putting them through additional struggles. During its inception, it took scientists two years of clinical testing to perfect its use. Historically there have been three waves of opioid overdose deaths in USA, the first wave was in the 1990’s and saw an increase in prescribing of opioids in the USA. The second wave began in 2010 which was caused by a rapid increase in heroin overdoses. The third wave started in 2013 when the use of synthetic opioids was used.

In the UK approximately 5% of the population in 2015 were prescribed opioids. (Smith and McManus, 2017), moreover the pattern of increase in opioids prescription continued to 34% in England between 1998 and 2016. The Office of National Statistics (ONS) publication for England and Wales in 2019) on deaths due to drug poisoning was found out that the rates of deaths related to drug poisoning in the last decade was 5.5 times higher in deprived areas compared to least deprived (ONS.gov.uk).

1.3 Relevant policies and guidance in UK drug use strategy

A regulation on the production, supply and possession of controlled drugs has been covered under the Misuse of Drugs Act (1971) the act categorises drugs into three groups and sets out a criminal offense related to the use and control of these drugs (DoH, 2018). The Three categories of these drugs have maximum penalties on conviction which in most cases is a life imprisonment. The last category comprises of buprenorphine which saw later added in 1989. To allow for a lawful possession and supply of controlled drugs for purposes that are legit, the misuses of drugs regulations 2001 has set out guidelines that have allowed for use of these drugs (DoH, 2018). These guidelines clearly outline how these drugs will be prescribed, administered and stored. Therapeutic usefulness and the potential to cause harm are the main factors that have been considered in listing these substances under regulation. The psychoactive substances act 2016, this act was developed with an aim of filling in the gaps that were present in the previous legislations and policies that guided drug use (Strang, et al, 2007). This act introduced complete ban on production, supply, possession with the intention of supply of these substances. Crime survey for England and Wales in 2017/2018 estimated a 9.0% of people ranging from16-59 years have taken over the past year (DoH, 2018). The trend has remained relatively flat since 2009/10, despite the drop in the number of people taking drugs. The number of men considered to have taken this drugs is twice as much as the past year which was 11.8 while that of women was 6.2%. It is required that substance use assessment should be undertaken as a part of the mental health assessment for adults in contact with the criminal justice system ,Nice guideline [NG66](NICE, 2017). Buprenorphine is identified as an appropriate opioid substitute for heroin dependency to achieve positive outcomes. (Department of Health and Social Care, 2017).

The current buprenorphine treatments NICE guidelines for oral buprenorphine (are found in “Overview | Methadone and Buprenorphine for the Management of Opioid Dependence, Guidance (NICE, 2007) and inject able (ES19) are found in “Key Messages | Opioid Dependence: Buprenorphine Prolonged-Release Injection (Buvidal), Advice (NICE, 2019).

1.4 Summary of existing literature

There is a vast amount of research on buprenorphine used as an analgesic medication (White et al.2018) furthermore there are large numbers of quantitative studies of buprenorphine used for opioid addiction (Lofwall et al. 2018). There is a lack of existing qualitative research and conclusive evidence of patient’s experiences, views and their impact on the choice of opioid treatment therapies. Further research to explore is required to understand patients’ perspectives of buprenorphine as a therapeutic intervention. Gryczynski et al., (2013) reported views of people being treated with buprenorphine that include the satisfaction of treatment, buprenorphine treatment as a choice for recovery and information sources on buprenorphine treatment, which were also identified in Parsons et al., (2020). Another question raised in studies was regarding buprenorphine treatment side effects which have broad consequences to a person prescribed buprenorphine (Parsons et al.,2020) (3Tompkins, Neale and Strang, 2019 (Tompkins and Strang, 2019a).

1.5 rationale

Data from existing literature has been able to prove that there is a gap and the information available is limited. There is need for more informed research that could help new researchers in filling the information gap. This literature review also suggests that there is lack of qualitative studies on the research topic. Since the topic of research is complex and broad. More research is needed to provide a much deeper understanding of users’ views on the service and their experience to inform further research.

1.6 Development of the research question

The research question was developed from attendance of a drug and alcohol community-based clinical placement and interest developed on the use of buprenorphine as a therapeutic intervention for heroin addiction used in this unit.

1.7 Aims and objectives

This dissertation aims to answer the research question “Exploring the views of buprenorphine treatment for individuals with an opioid addiction?".

The objectives are:

Critically review the literature on views of buprenorphine as a therapeutic intervention.

Identify common themes in the literature using thematic analysis.

Recommendations for further research, education, and nursing practice.

This chapter has discussed the current guidelines regarding buprenorphine interventions, and the terms that will be used throughout this dissertation. It has also set out the aims and objectives for this dissertation. The following chapter will explore the method to search for the appropriate literature for the review in this dissertation in respect to the research question.

Chapter Two

2.0 Methodology

This chapter will outline the methods used to identify appropriate research included in this literature review, discuss the chosen critical evaluation tool and the method of analysis. The research question was formulated, and the key terms were identified using the PEO framework (Bettany-Saltikov and Mcsherry, 2016). The key terms were used to search the various databases using EBSCOhost (EBSCOhost, 2019b), to generate the search results using Preferred Reporting Items for Systematic Reviews and Met-analyses to strategize the search for the studies (PRISMA).

2.1 Search strategy

2.1.1 Databases

The databases selected was for arrange of medical and academic content, therefore unsuitable databases searches were eliminated from this research. Furthermore, a variety of databases were used to widen the search and to retrieve a larger search result. The databases used were CINAHL complete, MEDLINE Complete, APA Psyc Info and APA Psyc Articles as they were suitable for identifying nursing research(Aveyard, 2014). The results were checked to identify any duplicates to strengthen the search strategy (Aveyard and Sharp, 2017)

Search Results

CINAHL complete …..

MEDLINE Complete…..

APA PsycInfo, …….

APA PsycArticles……..

2.1.2 Search terms

Key terms used in this research were identified using the PEO framework as part of the search. (Bettany-Saltikov and Mcsherry, 2016). EBSCOhost database search platform was used to complete the searches (EBSCOhost, 2019a). However the PEO framework was the mostly used strategy as it analysed the themes in qualitative research papers effectively as compared to other frameworks.

The PEO database search strategy was used and presented in Table 1, with the three concepts population, exposure and outcome (Bettany-Saltikov and Mcsherry, 2016).

Four searches were carried out separately and the “and” Boolean term was used to combine, reduce, and focus the search results (EBSCOhost, 2019a),(Bettany-Saltikov and Mcsherry, 2016).

The abstract search option was used in selecting papers for this study using the EBSCO host option to ensure that desired results are achieved when retrieving the papers. This will ensure that only relevant information is used in the study and helps in eliminating irrelevant data. Boolean operators were used as tools to navigate the search strategy to broaden, improve and focus results. Truncations were used to capture variations of key terms to ensure a wider selection of results (EBSCOhost, 2019a) (Bettany-Saltikov and Mcsherry, 2016). The first search was “Buprenorphine” as the general medication treatment that was used to give a broad set of results of 9475. The second search terms were views, experiences and perceptions with various iterations to produce 5873237 results. These were combined using the "and”Boolean operator to produce 4138 results. These results had the limiters applied of peer review, English language, between 2011 and 2021 and produced 2940 results. A third search was carried out of the terms qualitative “or “interview, to identify the relevant studies for this review and the limiters were applied and gave 496012 results. These results were combined with the second search results to give a final total of 288 studies. Duplicates were removed leaving a total of 283 studies. The 283 studies were screened for title and abstract and were evaluated for relevance and eligibility for this literature review. The screening was completed by identifying the studies which had appropriate evidence and connection to support the research question .Nine appropriate papers were found, however, three were removed due to a lack of focus on buprenorphine as a single medication in the treatment of opioid addiction (Bettany-Saltikov and Mcsherry, 2016).

Search strategy

S1 Buprenorphine (9475)

S2 Perspective* or preference* or need* or view* or experience* or attitude*or opinion* or belief* or satisfaction* or outcome* or willingness* (5873237)

S1 and S2 (4138) =S3

Limiters were applied to further focus the results.

1Limiters = Peer reviewed, English language, .2011-2021

S4= S3 x 1Limiters= (2940)

S5=qualitative or interview x 1Limiters= (496012)

S5 and S4= 283

2.2 Inclusion and exclusion criteria

The focus of this study was achieved by using these two criteria. These two methodologies of research identifies the study population in a in a consistent, reliable and objective manner. Only relevant information is included in the study while factors that make the recruited population in eligible for study in this research were excluded (Aveyard, 2014).

This enabled the retrieval of results that would be relevant to the research question and eliminate irrelevant studies (Boland, Cherry and R Dickson, 2017)

2.3 Critical appraisal and selected tool with rationale

When reading research papers, there is a set of tools designed for use. These tools are known as critical appraisal tools. These tools are designed for systematic reviews, cohort studies and qualitative studies. In this paper, six papers were reviewed in the literature section as their quality, reliability and validity were clear and their arguments checked out. The qualitative Critical Appraisal Skills Programme (CASP, 2018) tool was used to evaluate the strength of the research papers with only papers being used that indicated good quality and validity. The CASP tool is subdivided into sections of questions to evaluate the strength of papers and indicate false or weak information. Qualitative CASP tool was used to measure the validity and reliability of this research papers by analysing the participants views and evaluating the main themes in this study. Hence the choice of CASP tool used to measure validly was a qualitative CASP tool as opposed to using an alternative tool as a quantitative tool that analyses data and numbers in a research study (Bettany-Saltikov and Mcsherry, 2016). Each paper was analysed using the qualitative CASP tool for validity, reliability, and trustworthiness. These are presented in Appendix 1(CASP, 2018).

2.4 Method of Analysis

Data analysis is a considered a very critical part of research process. It is considered the main engine of study as it informs the entire results and discussion section of a research paper (Braun & Clarke, 2006). It involves collecting, modelling and analyzing data to extract insights that support the final decision made. The choice of a data analysis method in research greatly depends on the method of research. In this research thematic analysis was used as the study was qualitative in nature. Thematic analysis was chosen to identify commonalities within the literature and define themes that were found through the analysis of data. This utilised the six steps method by Braun & Clarke (2006). This provides a structured method to analyse the qualitative papers by familiarising the research data, generating codes, searching for initial themes, reviewing themes, defining themes, and writing up findings. The synthesis of themes from emotions and feelings associated with experiences and views enables a clearer way of identifying themes and connection when dealing with complex data.

2.5 PRISMA flow chart

Summary

This chapter discusses methods used to search for the appropriate literature that informs the research. Six papers were used after exclusion criterion was used to omit the unnecessary information. The exclusion was based on the language and the year published as well as the type of research design used. The six papers were checked for eligibility, validity and reliability. Search strategies that were used in this study included CINAHL, MEDLINE, APApsycInfo and APAPsyc Articles. ‘AND’ was the only Boolean expression used as a search team to obtain information that would inform the research. The CASP tool was qualitative in nature and thematic analysis was used to analyse the quality of the studies and the intended use of thematic analysis to evaluate the selected studies.

Chapter Three

3.0 Findings

This section comprises of the principle outcomes of a research question. It is referred to as the totality of outcomes where conclusions and recommendations are drawn from. Consists of what the project suggested and what it has revealed. Similarities in the six studies conducted in chapter two are identified by use of the thematic analysis method.

3.1 Study characteristics

This review analysed six studies where four of them were from UK (Parsons et al., 2020), (Tompkins, Neale and Strang, 2019), (Neale, Tompkins and Strang, 2019b), (Neale, Tompkins and Strang, 2019a) while the other two were from US (Gryczynski et al., 2013), (Yarborough et al., 2016). All these six papers were qualitative and greatly explored the different views of people on the use of buprenorphine treatment for individuals with opioid addiction. Participants were recruited and selected by various methods however all of them were purposively recruited and from mixed demographics. The cohort studies of the United Kingdom suggested that there were primary care records for people using these opioids as their primary drug for treatment of pain. During the recruitment of participants, patient eligibility was assessed and screening questions were used in selection criteria. Patients were approached and given verbal or written information on the research on buprenorphine. Patients gave consent to be contacted or they contacted the researcher for further information and confirmed eligibility. All the studies used semi-structured interviews using open-ended questioning. These were conducted face to face or on the telephone with some of the interviews being audio recorded. However, one study used a supplementary questionnaire to obtain responses (Yarborough et al., 2016), (Tompkins, Neale and Strang, 2019) used a topic guide. All of the studies were carried out ethically as participants gave informed consent. Participant’s confidentiality was protected when interviews were conducted and the responses transcribed and the data was anonymous. All included studies received approval from the associated Ethical Committee Board or the associated Institutional Review Board (see Appendix 1)

The findings are summarised in table 3.

3.2 Themes

Thematic analysis was completed using the six-step method by Braun & Clarke (2006).The structured method was used to analyse the six studies and synthesise themes by familiarising them with the data, generating codes, searching for initial themes, reviewing themes, defining themes, and writing up findings(Braun & Clarke, 2006).The synthesis of themes from emotions and feelings associated with experiences and views enables a clearer way of identifying themes and connection when dealing with complex data. Six main themes emerge from these studies.

3.2.1 Theme 1 -Treatment satisfaction

This theme of study was in the three studies conducted by Parsons et al., (2020), Gryczynski et al., (2013).Parsons et al (2020) focus on reported outcomes, experiences, and satisfaction as patient views. Overall, it indicated that the vast majority of comments were positive (81%) or benefited from prolonged-release buprenorphine (PRB) therapy. Furthermore, all participants reported positive life changes and having a positive attitude. Hence, they expressed “it was a better way of having treatment”. Moreover, 73% stated that they would recommend PRB treatment to others (Parsons et al., 2020). However this theme has been criticised for failing to account for the exact number of patients who were unsatisfied with the results and did not consider external factors. According to the feedback stated by the participants, treatment was effective, and they were actively engaging with the treatment. 21% of the patients reported to have not been taking the medication daily as which made them feel normal. This treatment reduced cravings, increased clarity of the mind and freedoms, hence “feeling normal”.(Parsons et al., 2020). 36% of the participants had stopped thinking about using other opioids on top as it was ineffective. Buprenorphine was also perceived to benefit patient’s lives and have pharmacological differences such as reduced withdrawal symptoms compared to methadone (Gryczynski et al., 2013).

3.2.2 Theme 2-Recovery

The second theme was more focused on recovery, which was evident in the studies of Parsons et al., (2020), Tompkins, Neale and Strang, (2019), Neale, Tompkins and Strang, (2019a) , Gryczynski et al., (2013) and Yarborough et al., (2016). 86% of the participants who were undertaking the PRB treatment indicated progress of recovery. While 57% claimed that they felt ok and will not use heroin while using buprenorphine as the later had high affinity to the opioid receptors in the brain cells. The treatment enabled positive changes in the quality of life and behaviours such as, ability to work and study, hence the vast majority (86%) expressed their recovery had improved their outlook on life and improved wellbeing and positive attitude. Additional positive effects were having reduced cravings, improved self-esteem and had improved relationship stability with family and friends (Parsons et al., 2020). Moreover, in another study participants expressed that they were willing to receive depot buprenorphine hence ability to live a normal life and to abstain from the use of heroin use becomes ineffective. Recovery was questioned by participants regarding the use of inject able buprenorphine compared to its oral and forms as well as compared to methadone In the study by Gryczynski et al., (2013), 58% of the participants were ready for treatment and exhibited a higher recovery rate. Furthermore, it is established that buprenorphine suppressed withdrawal which was another factor for a treatment choice. Moreover, the recurring theme of normalcy with the use of buprenorphine as opposed to morphine treatment was identified (Gryczynski et al., 2013). The recovery theme was cocidered inefficient as it was more focused on patient recovery other than the effectiveness of the medicines in pain reduction.

3.2.3 Theme 3 -Perceived effectiveness of depot buprenorphine

The Third theme identified in the studies was perceived effectiveness of depot buprenorphine and reported by Tompkins, Neale and Strang, (2019a) and Yarborough et al., (2016) Participants commented that they would have more confidence and understand in buprenorphine treatment and would have received domination on its effectiveness (Yarborough et al., 2016) . It was concluded that buprenorphine was very effective in treatment and positive impacts as compared to used of other drugs such as methadone. If only two papers are referring to perceived effectiveness is this strong enough to emerge as a theme?

3.2.4 Theme 4 - Duration and dosage

The duration and the dosage of buprenorphine injections use in these patients was rought out by the work of Tompkins, Neale and Strang, (2019). These injections had different times of administering which were considered suitable by this patients as it was adjustable, hence an improved willingness in the uptake of treatment. Furthermore, the ability to gradually increase injection durations over time and live a normal life was discussed by participants and was of a greater advantage. Others mentioned injection treatments were daunting and had fears of its medication effects running out early or not long enough. (Tompkins, Neale and Strang, 2019) The down side of this theme was that Although participants were aware that medication would be administered by a health care professional (HCP), some still asked if it could be self-administered, a participant raised questions on how much medication the slow-released injection showed daily as well as how buprenorphine felt at different times throughout the day. This indicates that this patients may be tempted to administer their own dose which ,may pose health risks as these drugs are only administered by care providers l (Neale, Tompkins and Strang, 2019a).

3.2.5 Theme 5- Side effects

Most of the drugs have side effects some which maybe considered potential while others may have minor side effects when ingested. The studies of Parsons et al., (2020), Tompkins, Neale and Strang, (2019) and Neale, Tompkins and Strang, (2019a). Revealed that intake of buprenorphine had side effects. (29%) of PRB patients experienced unwanted side effects such as grinding teeth during sleep, disturbance to their ability to sleep, constipation, or dehydration. These patients however preferred to cope with the side effects of taking these drugs other than not receiving treatment at all as the benefits of the treatments were more than the side effects (Parsons et al.2020). Other study participants stated that they were not influenced to take buprenorphine injections by the side effects as it was viewed as not a great issue in comparison to the positive outcomes of the treatment. However, it also mentioned that preferences to injection site would be in areas more discrete such as the buttocks to cover up any reactions (Tompkins, Neale and Strang, 2019). Questions were raised as to whether buprenorphine was a safe medication including issues of overdosing or whether it is addictive. Other physical side effects concerns were scarring, pain, itching, lumping or redness on the injection site. Other worries included weight, libido, heart rate, sleep hygiene and appetite.(Neale, Tompkins and Strang, 2019a)

3.2.6 Theme 6 –Treatment information

The Sixth theme of treatment information was found in Neale, Tompkins and Strang, (2019a) Gryczynski et al., (2013) , Yarborough et al., (2016). There were strong views that depot buprenorphine information should come from people who have authority and were trusted and unbiased. Participants also expressed that sources of information should be from people who have experience of the treatment and would be able to give independent honest advice which could inspire and give confidence in the buprenorphine treatment (Neale, Tompkins and Strang, 2019a). Participants stated that their knowledge was learned from a variety of sources such as family members or friends under treatment Yarborough et al., (2016), indicated that there was a lack of information provided for treatment alternatives addressing opioid dependency or given a choice of treatments. The participant's lack of knowledge limited their understanding of choices, to have medication comparisons and preferences (Yarborough et al., 2016). These theme has also been criticised for failure to account for other nations in the treatment information obtained, hence biasness as different responses from different nations would be effective in comparative studies on the same topic of study.

3.3Critical evaluation of findings

This paper has been able to identify that buprenorphine is effective in treatment of opioid use disorder. Most of the patients with this disorder use buprenorphine and prefer injectable formulations that may decrease risk of diversions. This research has been able to prove that more than 26 million people globally have been affected by this disorder. The disorder is more prevalent in high income countries of the North America. There have been significant mortality rates that have stemmed from opioid addiction. The treatment for this disorder has been recommended by the WHO and the food and drug administration. Participants stated that their knowledge was learned from a variety of sources such as family members or friends under treatment Yarborough et al., (2016), indicated that there was a lack of information provided for treatment alternatives addressing opioid dependency or given a choice of treatments. The participant's lack of knowledge limited their understanding of choices, to have medication comparisons and preferences (Yarborough et al., 2016). This theme has been criticised for failure to account for other nations in the treatment information obtained. The theme of treatment satisfaction was clearly brought out by this report. Participants stated that they were satisfied with the treatment of opioid disorder. The number of recovery rates was higher when using therapy and buprenorphine. There were positive changes in the quality of life as 86% of the patients had recovered and improve their outlook on life. Patients preferred using injections as compared to oral forms. Depot buprenorphine use was effective in treatment and patients expressed more confidence when using it. The duration and dosage of this medicine were had positive views as it was considered flexible hence willingness in uptake and treatment. Potential for side effects in using this medicine was found in the studies Tompkins, Neale and Strang 2019. 29%of the patients experienced unwanted side effects and preferred to cope with these side effects than receiving treatment at all.

3.4 Evaluation of reliability, validity, transferability and trustworthiness

The quality of research papers are determined by the validity, reliability and transferability of the data collected and the methods used in evaluation. There is consistency in measurement and validity of data hence accurate. Reliability of this paper is evident in the method of research design used when writing the paper. Qualitative research design was used in writing this paper; all measurements done in this research paper were reliable and valid. Symptom questioners were used to diagnose these patients. Different diagnosis was used to same patients with different doctors. This research is valid as the results produced correspond to real life properties and variations in the physical world. Different versions of the same measurements were used to inform this research hence the research is estimated to be reliable. Scholarly articles on the same topic were assessed and results from respondents compared. The element of transferability in this research paper has been identified by the different evidence from different scholars.

Summary

The above chapter discusses the six themes that were identified from the reviewed literature, by stating the characteristics of the study population as well as the feedback obtained from the respondents. All the themes summed up to a conclusion that administration of these drugs in treatment of opioid addiction was effective and patients preferred them despite the side effects as their benefits estimated from its use was more compared to the side effects. The result from this discussion informs the next chapter of research which discusses these findings in detail. However these themes were criticised as most of them failed to identify critical gaps in research that required more ideal knowledge.

Chapter Four

4.0 Discussion

This chapter will discuss the identified themes and findings concerning current literature and practice guidelines. Six themes were identified in the six papers of experiences of buprenorphine treatment for individuals with opioid addiction. These were treatment satisfaction, recovery, perceived effectiveness of buprenorphine, duration and dosage, side effects, and information.

4.1 Discussion

4.1.1 Treatment satisfaction

There was strong evidence to support this theme as the qualitative research being analysed indicated that consistent views of the people were positive and majority of them benefited from PRB treatment (Gryczynski et al., 2013),(Parsons et al., 2020). Only a small percentage of the people had different views on the subject matter that helped in understanding the choices and preferences made by these patients. (Parsons et al., 2020). In situations where opioid treatment therapy is preferred, a patients experience and expectations need to be critically examined. (Madden et al.,2008)r research from other scholars was concise and precise and stated that stated that a specific tool such as SASMAT–Buprenorphine-Naloxone for Heroin addiction (SASMAT-BUNHER) can be is used to measure satisfaction and therefore an alternative method could be used to measure satisfaction for buprenorphine treatment (Pérez de los Cobos et al.,2020). Buprenorphine was viewed as a life changing medicine that was considered effective in the treatment of opioid addictions. This views created positivisms in this patients and hence made it easy to recommend treatment to newbies. (Parsons et al., 2020). However research from Australia displayed negative results in the use of buprenorphine in treatment satisfaction. This is because people expressed fear in the dosage administration as well as the mode of operation of the drug hindering patient preferences. (Larance et al.2020). There was limited availability of these buprenorphine drugs as the socio economic status of these people hindered them fro accessing private health care. This drugs were only available to those who could afford it hence information obtained on its use especially in the united states is considered biased (Mitchell et al.2019).

4.1.2 Recovery

The recovery theme was identified by the works of (Parsons et al., 2020) (Tompkins, Neale and Strang, 2019) (Neale, Tompkins and Strang, 2019a) (Gryczynski et al., 2013) (Yarborough et al., 2016). Improved withdrawal symptoms supported the work of these researchers. The findings of Parsons et al., (2020) stated that recovery progress was indicated to have an 86% progress to recovery and reduction in cravings, and furthermore readiness for treatment and recovery was 58.8% (Gryczynski et al., 2013). However green et al (2014) evidenced those buprenorphine treatments gave concerns to clinicians as a highly effective treatment leaving patients feeling cured, to the extent of them feeling normal. This rapid transition removed motivation to learn recovery and support skills and resilience in life-changing situations. However, there is a reported reduction in the withdrawal rates on the use of buprenorphine treatment (Tompkins, Neale and Strang, 2019), which has been used as contradictory treatment measure for withdrawal and craving. There was evidence of stress in the recovery program due to reduction rates in the number of patients engaged in the treatment plan. This in turn may result in relapses. (Truong et al.2019). There is often a great deal of misapprehension and anxiety associated with the stigma of recovery (Gryczynski et al., 2013, (Olsen and Sharfstein, 2014)). Recovery with abstinence is regarded in the community as true recovery whilst recovery with medication has a negative connotation, hence influencing treatment choices by patients (White, 2011). Furthermore, patients under-recovery felt the need for abstinence and being off medication to feel truly clean (Monico et al, 2015).

4.1.3 Perceived effectiveness of buprenorphine

Prior

It is vital for a medical practitioner to make a full understanding of the effectiveness of administering buprenorphine as a treatment form.(Tompkins, Neale and Strang, 2019).This was further supported by another study where the treatment explanation was given and had a 68% of the patient sample perceived buprenorphine a good treatment (Larance et al.2020). According to Hutchinson et al.,2014, his study criticised the findings of these theme and it reported that only 28% of patients had the prescribed treatment plans as lack of institutional and mental health support were the greatest barriers in administering treatment. Another challenge that presented itself from this study was lack of effective training for the HCP to deliver information on buprenorphine treatment as an alternative patient treatment (Haffajee et al.). Patient decisions of treatment choice are influenced by the previous negative experience of opioid treatments such as methadone (Yarborough et al., 2016). Furthermore, prior experiences of buprenorphine indicated better retention with treatment therapies. This exposure to buprenorphine is common as an illicit or prescribed form in the USA and has implications on clinical and health outcomes (Cunningham et al., 2013). Another study, Alford et al., (2011) support the findings that previous use of illicit buprenorphine had a higher treatment retention rate or tapering off of buprenorphine but contradicted the findings that previously prescribed buprenorphine had no impact on treatment outcomes (Gilman et al., 2018).

4.1.4 Duration and dosage of buprenorphine

Having a stable treatment regime with varied dosage availability gave patients flexibility and increase the duration between doses. This gave a positive view and willingness to uptake treatment and feelings of living and normal life. (Tompkins, Neale and Strang, 2019). Neale et al. (2018) study discussed the findings of patients views that agreed with these positive aspects, however, it also highlights the disparity of views that were negative to buprenorphine depot stable daily dose. Patients did not like the way they were continually using the same dose, lacked control, and felt powerless. These were contrary experiences of daily prescribed methadone. Participants described enjoying the daily routine involved with street drugs to feel humans alive and different. They expressed the not wanting to feel flat, boring, or not being stoned for the month (Neale et al., 2018).Furthermore, views of wanting to self-medicated buprenorphine treatment were discussed by participants which indicated the desire to control medication regime (Neale, Tompkins and Strang, 2019a). Unprescribed buprenorphine was used for illicit use for short durations as a substitute for other opioid addictions such as heroin. This habitual use was used as a stopgap on bad days or lack of funds to use instead of heroin. Alternatively, whilst using illicit use of opioids, buprenorphine was used instead for longer durations such as being fit for periods of employment (Ling et al., 2020).

4.1.5Potential for side effects

Participants discussed views on common side effects such as sleep hygiene, constipation, dehydration and appetite (Parsons et al., (2020)(4Neale, Tompkins and Strang, 2019a). Sexual dysfunction due to buprenorphine treatment is indicated as a high percentage at 83 % (Ramdurg et al., 2015) and in a second study 64.2% (Baykara and Alban, 2020). Furthermore, this linked to a reduction in serum levels of testosterone among men using opiates (Mendelson et al., 1976, Mendelson and Mello, 1975). Current evidence by Zheng et al (2017) suggested that starting buprenorphine treatment had improved sleep hygiene for the participants. However, research completed by Baykara and Alban (2020) found that buprenorphine treatment was effective on sleep hygiene which was inconclusive on the study. Sedation, drowsiness, and constipation are side effects that participants in study experienced (Parsons et al. (2020) and had views of coping with prescribed buprenorphine as they stated that the treatment benefits outweighed the side effects. Furthermore, these side effects were identified as being expected due to biochemical changes in the brain with opioid agonist activity (Lange et al.1990).

4.1.6Treatment Information

Neale et al., (2018) discussed that participant’s views indicated that they may know of buprenorphine treatments but showed a keen interest and sought further information regarding the treatment. The questions raised were specific uncertainties that they did not have prior knowledge due to the lack of treatment knowledge and skills (Neale, Tompkins and Strang, 2019a). These aspects impact the limited understanding of choices and preferences for the patient (Yarborough et al., 2016). Patients gain medical information and are informed from various resources such as the internet (Henwood et al.2003) (Hardey, 1999) but socio-economic status affects availability and ability to gain access to medical information (Rooks et al.2012). It is important to offer assessable information and support whilst being mindful of the gap that exists in socio-demographic factors specifically amongst people who use non prescribed opioids (March et al.2006).

4.2 Recommendations for further research, education, and nursing practice

4.2.1 Further research

Further research is required for larger populated studies to gain broader insight into participants experience when under buprenorphine treatments to include wider multi-racial and socioeconomic status studies. Using a broader choice of interview question may identify sub groups such as socio-demographic characteristics such as sex, age, race, education, recovery status and the identified themes (Parsons et al., 2020). Having a global populated research study will enable the production of information-rich data and the potential for generalizability (Grbich 1999).

Further qualitative research is needed on a population who have used prolonged-release OAT to explore their experiences and understand characteristics of prolonged-release treatments, such as the pharmaceutical drug, dose, delivery system, and dispersal mechanism.

Qualitative and quantitative research should be carried out on patient wiliness to receive buprenorphine treatment and how it translates into adherence and uptake.

4.2.2 Education

The health practitioner needs access to effective training to deliver informed clear, evidence-based information on buprenorphine treatment. This would enable the nurse to give guidance and support with confidence and reassurance offering a broader choice to patients when making treatment preferences and choices (Yarborough et al., 2016).

Education resources should be developed for training utilising the lived experience of buprenorphine patients to give an informed view of buprenorphine treatments and understanding. This could lead to the production of information materials and videos that the nurse and MDT can use to potentially allay anxiety, increase patient confidence and uptake of treatment.

Nurses need specialist training and education in the delivery of buprenorphine treatment, opioid addiction, and opioid treatment options. This would enable the nurse to have effective knowledge and skills to support and empower patients competently to make informed choices.

4.2.3 Nursing practice.

The following measures should be recommended in buprenorphine treatments:

Nurses need clear guidelines and transparency of treatments to educate the patient group to enable patients and families to make informed choices and improve service satisfaction. This may involve explanations such as duration and dosage of buprenorphine treatment.

Nurses need effective specialist training in opioid addiction and need to consider the impact of patient’s perceived views and their previous opioid histories. This insight will aid the Nurse to support treatment choices and improving clinical outcomes.

Nurses need to have the training to advice and support patients with the side effects of buprenorphine treatments before and during therapeutic interventions.

Nurses need to gain insight into the recovery process for patients under buprenorphine therapy. The patient may have varied physical and psychological experiences such as withdrawal and cravings, the unusual rapid transition to feeling normal and the day-to-day uncertainties which may hinder their recovery process.

4.3 Limitations of literature review

The main limitation of this literature review was the gaps in information that were indentified from the six papers that were reviewed. This suggests that only limited results were expressed and the search strategy used eliminated relevant data that could otherwise have filled in the identified gaps. This is because the search was mostly limited to nations from the United Kingdom and English were the major consideration. Geographical location and language barrier were the limitation of the search strategy. Another limitation arose from the date and time of the articles published. This research only covered database that was published as from 2012. This was considered biased in reporting the finding as relevant information might have been omitted during the filtration. It was found that qualitative studies in the research topic were limited in number on views of patients of buprenorphine treatments. Having a ten-year limiter constrained the research further to only include Up To Date topic-focused studies .A further limitation of the review was that the studies chosen had a small population of participants reducing the transferability and reliability of the results (Holloway et al, 2017). The studies chosen were conducted in two counties which limited the findings and impacting the transferability and reliability. Other countries such as France and Australia have used buprenorphine treatments for a significant number of years but were not found in the search for studies.

Summary

This chapter has discussed the identified themes and findings with respect to current literature and practice guidelines. The limitations of this literature review have also been identified.

The next chapter will provide an overview of the literature review, discuss recommendations, and conclude the review.

Chapter Five

5.0 Conclusion

The above discussion analyses the effectiveness of using buprenorphine as an opioid replacement. Buprenorphine is a medication that has been approved by the food and drug administration for use in the treatment of patients with opioid addictions. This drug is preferred for use immediately after the side the addiction symptoms of using opioid starts kicking in. It is preferred for shorter term used and doctor’s prescription is required when using the drug. It includes the overall comprehensive plan that involves therapy as well as and counselling. It is the first medication that has been prescribed in the treatment of OUD by physicians. Qualified practitioners have been given a go ahead by the drug addition treatment act of 2000 as well as the substance use-disorder prevention opioid recovery and treatment for patients and communities.

The review of the studies indicated that the nurse’s role is important to guide, support and inform patients who are looking to engage with opioid treatments. The use of buprenorphine as an opioid replacement and the stabilising drug has significantly increased its use around the world in the last decade opioid addiction has become an epidemic leading to n many parts of the world with consequences on health provision and availability of treatments. Buprenorphine provides an additional choice of treatment to patients for nurse to individualise care plans and recovery.

The disparities of socio-economic (Rooks et al.2012) status limit the access to the treatment as some studies were carried out with participants from private health care units and furthermore, the gap to access information was limited by socio-demographic factors amongst people who used non prescribed opioids(March et al.2006).

The findings of these six studies conducted on the effectiveness of using buprenorphine treatment of opioid disorder indicates that the drug was effective and from the responses gathered, patients prefer using the drug despite the side effects as the benefits associated with its use are more compared to the side effects.

The recommendations from this review for further research is needed to gain a comprehensive view and the scale of opioid addiction and buprenorphine replacement and stabilising drug therapy to complete a broader analysis and result to plan access to a larger population. Secondly, Education in opioid addiction is essential for the nurse and equally the patient and families to optimise engagement, success in the treatment uptake and recovery processes. This can be delivered through undertaking specialist opioid addiction training and access to a multitude of technological resources.

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