Commentary on Metcalfe et al.: ‘What works in AOD is when it feels like I am driving’ (Craig W, alcohol and drug peer worker)

Along with beneficence, non-maleficence and justice, autonomy is one of the main ethical principles inherent in clinical medicine [1]. Autonomy in health decision-making is a key to recovery in mental healthcare [2]. Metcalfe et al. [3] have shown in their study of the design and delivery of injectable opioid agonist treatments that clients would prefer more control over medication type, dosage and treatment schedules. These measures can be framed as providing clients with increased autonomy.

Although injectable opioid agonist treatment (iOAT) programs are typically more rigorous and intensive than conventional opioid agonist treatment (OAT), requiring attendance up to three times daily for an in-person clinically observed injection [3], it seems highly plausible that clients on conventional OAT share similar views [4, 5].

The issue of ‘carries,’ ‘take-aways’ or unsupervised doses typically produces the greatest divergence between the views of clients and the clinic [6]. Experience during the coronavirus disease 2019 (COVID-19) pandemic provided a natural experiment where dosing guidelines were suddenly relaxed, greatly increasing the number of unsupervised doses for most clients, including both those on methadone and those on buprenorphine [7]. In some jurisdictions, 13 or more consecutive unsupervised methadone doses were provided [8] while many clients were transferred from sublingual buprenorphine preparations to long-acting buprenorphine injections. It should also be noted that COVID also affected illicit drug markets, disrupting and limiting supply, while quarantine measures restricted freedom of movement.

Promoting patient autonomy is an important goal, enhancing self-efficacy and the prospects of recovery [9, 10]. It is also recognized that a diagnosis of opioid use disorder implies a loss or impairment of control. Reconciling the benefits of autonomy with clients who have impaired control over their substance use may be challenging, yet the COVID-19 pandemic experience suggests that enhancing client autonomy with increased unsupervised dosing is safe and reduces discontinuation [11-13]. Although some clinics have returned to pre-COVID practices, others have maintained a more liberal COVID-experience-informed approach.

However recovery is defined, it is the likely goal for the majority of clients in OAT. Although multiple interacting factors may influence progress towards recovery [14], many are outside the control of OAT providers. What can be managed is the degree of patient autonomy afforded within treatment programs.

Length of time in treatment is an important marker of recovery. Experience shows the more restrictive an opioid treatment program the more likely clients will leave the program prematurely with the attendant risks of relapse, misadventure and overdose death [15]. In real life settings, 1 year treatment retention varies widely, however, retention of 10% to 30% is not unusual, and there is limited data about the fate of those who have left treatment [16]. In discussing factors which may predict or influence retention in treatment, little attention is given to enhancing client autonomy. One study of patient-important measures of success in OAT found key domains such as emotional well-being, decreased unsanctioned opioid use and taking care of daily needs and activities were foremost in measuring recovery [14]. Others have shown barriers to retention in treatment include unstable housing, poor mental health, lack of transport, poor physical health, restrictive treatment program policies and stigma [17]. Increasing client autonomy appears to improve retention in treatment [10, 18].

In the face of the North American opioid epidemic and the growing prevalence of novel opioid substances, programs that respect and enhance patient autonomy should form a central element in the public health response. Adapting to the COVID-19 pandemic has crystalized moves towards greater patient-centered care in OAT. At a recent workshop for people with lived experience to support the planning, design, implementation and delivery of mental health services, Craig, an alcohol and other drugs (AOD) peer support worker, commented ‘What works in AOD is when it feels like I am driving.’ To extend Craig's driving analogy, all drivers must respect road rules and regulations. Increasing client autonomy does not mean services throw caution to the wind (or allow their clients to speed through built-up areas). Instead, by providing clients a greater feeling of control over their destiny (or destination), services can enhance their clients' prospects of retention in treatment and recovery.

In the last 5 years, speaker fees from Camurus, Indivior, Janssen, Lundbeck, Servier and Pharmacy Guild have been gifted to ALIMA (a humanitarian charity).