"I still can feel the sickness": Withdrawal experiences of people on methadone maintenance treatment.

Introduction: Opioid withdrawal is a regular occurrence for many people who use illicit opioids (PWUIO) involving acute physical and psychological pain. Yet, there is very little data on the withdrawal experience of people in methadone maintenance treatment (MMT) and almost none from the patients' experience. Learning more about patients' withdrawal experiences can help to inform policies and practices that are better suited to address withdrawal and may improve patient satisfaction as well as uptake and retention.

Methods: This article is based on 29 semi-structured interviews with people who use illicit opioids who reported recent withdrawal experience. The study conducted interviews remotely via Zoom between April and August 2022 and later transcribed them professionally. The study team then coded data thematically using Atlas.ti, based on a combination of inductive and deductive coding strategies and informed by the literature and study aims.

Results: Participants described withdrawal as a significant issue that negatively impacts their treatment experience and increases the likelihood of treatment cessation. Their accounts of withdrawal were complex and often involved multiple factors; however, feeling underdosed and missing clinic dosing hours were seen as important vectors that led to their withdrawal experiences. Importantly, participants framed feeling underdosed and missing clinic dosing hours as institutional problems, resulting primarily from clinic policies, practices, and culture rather than from patients' decisions or individual behavior. Specifically, they cited restricted access to take-home doses, limited hours of operation, and a punitive focus on complete abstinence as factors that made withdrawal difficult to avoid.

Conclusions: Patients' accounts demonstrate a disconnect between providers' focus on promoting complete abstinence and patients, who were often using MMT for more pragmatic reasons that did not include complete abstinence from all drugs. These findings support growing calls for the integration of MMT into the mainstream healthcare system by making it available via prescription from office-based medical settings and dispensed through pharmacies.