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. Author manuscript; available in PMC: 2023 Sep 1.
Published in final edited form as: Int J Drug Policy. 2022 Jun 30;107:103773. doi: 10.1016/j.drugpo.2022.103773

NAVIGATING OPIOID AGONIST THERAPY AMONG YOUNG PEOPLE WHO USE ILLICIT OPIOIDS IN VANCOUVER, CANADA

Andreas Pilarinos a,b, Yandi Kwa c, Ronald Joe c, Madison Thulien a, Jane A Buxton d, Kora DeBeck a,e, Danya Fast a,f
PMCID: PMC9872974  NIHMSID: NIHMS1866799  PMID: 35780565

Abstract

Background

Opioid agonist therapy (OAT) has been shown to reduce opioid use and related harms. However, many young people are not accessing OAT. This study sought to explore how young people navigated OAT over time, including periods of engagement, disengagement, and avoidance.

Methods

Semi-structured, in-depth qualitative interviews were conducted between January 2018 and August 2020 with 56 young people in Vancouver, Canada who reported illicit, intensive heroin and/or fentanyl use. Following the verbatim transcription of longitudinal interviews, an iterative thematic analysis was used to extrapolate key themes.

Results

Young people contemplating OAT expressed fears about its addictiveness. Many experienced pressure from providers and family members to initiate buprenorphine-naloxone, despite a desire to explore other treatment options such as methadone. Once young people initiated OAT, staying on it was difficult and complicated by daily witnessed dosing requirements and strict rules around repeated missed doses, especially for those receiving methadone. Most young people envisioned tapering off OAT in the not-too-distant future.

Conclusions

Findings underscore the importance of working collaboratively with young people to develop treatment plans and timelines, and suggest that OAT engagement and retention among young people could be improved by expanding access to the full range of OAT; updating clinical guidelines to improve access to safer prescription alternatives to the increasingly poisonous, unregulated drug supply; addressing treatment gaps arising from missed doses and take-home dosing; and providing a clear pathway to OAT tapering.

Keywords: opioid agonist therapy, young people, COVID-19 pandemic, opioid use disorder, overdose

BACKGROUND

The increasingly poisonous, unregulated drug supply has significantly impacted the health and well-being of adolescents and young adults (hereafter referred to as “young people”) between the ages of 10 and 30 years of age (Eurostat, 2017; Statistics Canada, 2019; United Nations, 2020; World Health Organization, 2021). This is particularly true in North America, where there have been significant increases in overdoses among young people in recent years, largely due to the presence of illicitly-manufactured fentanyl and related analogues in the local drug supply (Gaither et al., 2018; Hadland, 2019; Hedegaard et al., 2020; Public Health Agency of Canada, 2021). Opioid agonist therapy (OAT) is recognized as a critical tool for reducing harms among young people diagnosed with opioid use disorder (OUD) and is currently recommended by pediatric clinical guidelines for the treatment of OUD across North America (British Columbia Centre on Substance Use, 2018; Committee On Substance Use Prevention, 2016).

Despite existing recommendations and the demonstrated effectiveness of OAT (British Columbia Centre on Substance Use, 2018; Committee On Substance Use Prevention, 2016), some evidence suggests that young people in the USA and Canada are significantly less likely to access OAT in comparison to adult populations (Pilarinos et al., 2022). More specifically, a recent systematic review demonstrated that, firstly, young people are less likely to receive OAT than adult populations, and, secondly, are more likely to be prescribed partial opioid agonists such as buprenorphine-naloxone rather than full agonists such as methadone and slow-release oral morphine (Pilarinos et al., 2022). The latter is noteworthy given the important differences between partial and full opioid agonists, which have been shown to influence young people’s treatment decision-making and access to OAT (Giang et al., 2020).

Partial opioid agonists, such as buprenorphine-naloxone, require abstinence from all opioids for 12 to 48 hours prior to treatment induction to reduce the risk of precipitated withdrawal symptoms, which can be a barrier to treatment initiation, including among young people (British Columbia Centre on Substance Use, 2017, 2018; British Columbia Ministry of Health, 2017; Giang et al., 2020; Maremmani & Gerra, 2010). Nevertheless, partial opioid agonists are deemed safer than full opioid agonists because of how they displace and block opioids consumed concurrently at the mu-opioid receptor site, thus reducing the risk for drug poisoning and death when compared to full opioid agonists (British Columbia Centre on Substance Use, 2018). This improved safety profile has allowed for greater flexibility in the provision of partial opioid agonists, including longer durations of take-home dosing (Carney et al., 2018). Additionally, partial opioid agonists such as buprenorphine-naloxone produce less euphoria in comparison to full agonists such as methadone, which is believed to reduce the risk of diversion (Kumar et al., 2021).

Alternatively, there is no requirement of abstinence prior to full opioid agonist induction, and treatments such as methadone and slow-release oral morphine produce a more euphoric effect in comparison to partial opioid agonists (British Columbia Centre on Substance Use, 2018; Kumar et al., 2021). There are safety concerns regarding full opioid agonists for young people as they do not have a blocking effect when taken concurrently with other opioids, which heightens the potential for drug poisoning and death (British Columbia Centre on Substance Use, 2018). These concerns are reflected in the various restrictions surrounding how these medications are administered (British Columbia Centre on Substance Use, 2018; British Columbia Ministry of Health, 2017). For example, methadone typically requires daily witnessed dispensation (British Columbia Centre on Substance Use, 2018; British Columbia Ministry of Health, 2017). In some pediatric clinical guidelines, full agonists are indicated as a second line treatment that is only appropriate for young people who are unsuccessful with partial opioid agonists, or for those who report high-intensity opioid use (British Columbia Centre on Substance Use, 2018; British Columbia Ministry of Health, 2017).

In the province of British Columbia (BC), Canada, where the present study is situated, unintentional illicit drug toxicity deaths are the leading cause of preventable death, and young people under the age of 30 accounted for approximately 20% of overdose fatalities between 2011 and 2022 (British Columbia Coroners Service, 2022). In response, there have been growing calls in this setting for immediate investments to improve the accessibility of treatment programs for young people who use drugs, including OAT (Representative for Children and Youth, 2020). In our setting, OAT includes full opioid agonists such as methadone and slow-release oral morphine (brand name Kadian), as well as partial opioid agonists like buprenorphine-naloxone (brand name Suboxone©) (Camenga et al., 2019; Viera et al., 2020).

There is evidence that OAT can be effective in reducing opioid-related overdose deaths locally (Irvine et al., 2019). In order to improve access to this potentially life-saving treatment modality, in 2017 researchers and policy-makers established provincial OUD treatment guidelines that reiterated the importance of OAT and provided clinicians with guidance on how to prescribe these medications (British Columbia Ministry of Health, 2017). A corresponding youth supplement was released in 2018 that lists buprenorphine-naloxone as a first line treatment for young people experiencing OUD, emphasizing the improved safety profile and flexible take-home dosing of buprenorphine-naloxone when compared to methadone (British Columbia Centre on Substance Use, 2018). Additionally, at the onset of the COVID-19 pandemic, the government of BC implemented interim Risk Mitigation Guidelines, which decreased barriers to OAT and facilitated access to prescribed alternatives to the increasingly poisonous, unregulated drug supply, such as hydromorphone and dextroamphetamine tablets (British Columbia Centre on Substance Use et al., 2022; Vancouver Coastal Health, 2020). The Risk Mitigation Guidelines were intended to promote physical distancing and reduce overdose risk during the COVID-19 pandemic and have demonstrated promising results in Canada (Brothers et al., 2022).

Despite expanding access to OAT locally, recent evidence raises concerns that many young people are not accessing or may even be avoiding these therapies in our setting (Fast, 2021; Giang et al., 2020; Krebs et al., 2021; Pilarinos et al., 2022). For example, research has demonstrated that a lower proportion of young people are accessing or being prescribed OAT in comparison to adults (Krebs et al., 2021), and some young people are highly ambivalent towards OAT and in particular buprenorphine-naloxone (Fast, 2021; Giang et al., 2020). One qualitative study showed that young people who did access OAT often viewed its longer-term use as incompatible with their goal of achieving complete abstinence from licit and illicit opioids (Giang et al., 2020). They often only accessed OAT as a short-term intervention to mediate withdrawal symptoms during in-patient treatment and detoxification and while in hospital (Giang et al., 2020).

Both the risk environment (Rhodes, 2002) and patient-centered healthcare accessibility (Levesque et al., 2013) frameworks point to potential social, structural, and environmental risk factors operating at micro-, meso-, and macro-levels, including healthcare system-related barriers, that may influence young people’s perspectives on and willingness and ability to engage with OAT. For example, one study conducted among adults found that stigma towards OAT at the macro-level results in meso-level policies that exclude people on OAT from accessing treatment and recovery services (Paquette et al., 2018). Specifically, participants described being excluded from sober living and Narcotics Anonymous programs because they were deemed to be “actively using” drugs and therefore ineligible for these programs (Paquette et al., 2018). Adding to this, entrenched poverty, homelessness, and marginalization among young people experiencing street-involvement create upstream barriers that make it difficult for them to effectively access healthcare services and engage with OAT (Smye et al., 2011).

Drawing on the risk environment and patient-centered accessibility frameworks, our study builds on this previous work to more closely examine how young people contemplated, engaged, disengaged, and in some cases avoided OAT over time. Our purpose is to identify policy-related factors that can be addressed to improve OAT experiences and outcomes among young people, and we provide new insights into how OAT programming can be optimized to meet young people’s needs and goals.

METHODS

Most participants were recruited from the At-Risk Youth Study (ARYS), an open, prospective cohort of street-involved young people in Vancouver, Canada (Wood et al., 2006). To be eligible to enrol in ARYS, young people need to be between ages 14 and 26 at the time of recruitment, report any illicit drug use during the past 30 days, and be accessing health or social services for young people experiencing unstable housing and homelessness. Additionally, some participants who were not enrolled in the ARYS study were recruited from various local drug treatment settings (e.g., youth-dedicated detoxification and treatment centers, safe houses). Recruitment occurred on a rolling basis over the duration of the study period.

For this qualitative study, all participants had used heroin/fentanyl intensively (2 or more times per week by injection, inhalation, and/or ingestion) and undergone some form of drug treatment (e.g., OAT, in-patient detoxification and recovery programs, out-patient Twelve Step programs) in the previous 6 months at the time of their first interview. While some young people still referred to using “heroin,” or stated more generally that they used “down” (a slang term for illicit opioids), it is generally recognized that illicit opioids obtained in Vancouver’s street-based drug markets now consist primarily of, or are heavily adulterated with, illicitly-manufactured fentanyl (it is for this reason that we use the term “heroin/fentanyl”) (Karamouzian et al., 2018; Tupper et al., 2018). All young people had encountered some form of OAT over the course of their treatment trajectories, whether in the sense that it had been explicitly offered to them by a care provider or they had simply heard about it while attending in- or out-patient treatment. The majority of participants had initiated and discontinued OAT multiple times across the study period.

A semi-structured interview guide developed by a medical anthropologist (DF) was used during interviews to elicit explanations of young people’s engagement with OAT across time and healthcare settings in Greater Vancouver. This interview guide was developed in collaboration with a Youth Advisory Council (YAC), a group of 8 young people with lived and living experience of street-involvement, substance use, and mental health concerns. YAC members were actively involved in the creation of the interview guide and advised the research team on relevant lines of inquiry regarding OAT engagement among young people, but they were not involved in the analysis and interpretation of the data in the case of this manuscript (see Giang et al., 2020 for a related paper that includes YAC member co-authors).

The interview guide was divided into nine topic areas, including current living situation and drug use trajectories, accessing drug treatment and other kinds of substance use services, and experiences with OAT. For the OAT topic area, questions centered on participants’ experiences with different forms of OAT. Questions included: Who was involved in the decision to begin OAT? Have you ever switched from one type of OAT to another? What were the challenges of getting on this form of OAT? What were the benefits? After you went on it, how did things change? We also asked young people about how daily adherence to OAT impacted other areas of their lives, including relationships with family, caregivers, friends, romantic partners, and healthcare professionals. Follow-up interviews focused on how things may or may not have changed for young people since their previous interview(s) and delved deeper into young people’s understandings of their drug use and treatment trajectories.

Interviews began in 2018, and participants were then invited to complete follow-up interviews at 6-month intervals. While we attempted to follow up with each participant approximately every 6 months, this was not always possible due to the circumstances of young people’s lives (e.g., chronic unstable housing and homelessness). Alternatively, when the conditions of young people’s lives stabilized for periods of time, they sometimes expressed interest in more regular follow-up interviews (e.g., every 3 months). Participants who were seen for follow-up interviews contributed between two to six interviews over the study period.

Co-authors DF and MT conducted in-person and telephone interviews in accordance with COVID-19 safety protocols, which took approximately 60 to 90 minutes to complete. Written informed consent was collected from participants prior to the commencement of their first interview and participants were reimbursed with a $30 CAD honorarium for each interview. Once completed, interviews were transcribed verbatim, deidentified, and reviewed to ensure that the transcripts corresponded with interview recordings. Transcripts were then uploaded to NVivo 12 software (QSR International, 1999) where all data pertaining to OAT (i.e., buprenorphine-naloxone, methadone, slow-release oral morphine) was coded and retrieved for thematic analysis.

Once OAT-specific content was identified and extracted, a preliminary codebook was developed by AP in consultation with MT and DF. This began with an inductive thematic analysis (Guest et al., 2011), whereby we identified overarching themes as they related to the risk environment (Rhodes, 2002) and patient-centered accessibility (Levesque et al., 2013) frameworks. We then subsequently refined these through the identification and inclusion of more detailed codes to provide a more nuanced understanding of young people’s OAT experiences and trajectories. This thematic analysis was an iterative process that involved multiple discussions between the research team on the interpretation of the findings and their implications in the context of an increasingly poisonous, unregulated drug supply. Pseudonyms are used in the place of participants’ names to protect their confidentiality.

RESULTS

One hundred and seven semi-structured, in-depth interviews were conducted with 56 young people in Vancouver between January 2018 and August 2020, of which 30 young people participated in one or more follow-up interviews. Participants ranged in age from 14 to 25 years and included 36 men, 18 women, and two non-binary participants. A majority identified as white (n=42) followed by Indigenous (n=13), Asian-Canadian (n=5), and African-Canadian (n=3), with some participants providing multiple responses. An additional two participants chose not to disclose their race.

Thematic analysis of interviews highlighted how young people contemplated, engaged, disengaged, and in some cases avoided OAT over time. Findings demonstrate social and policy factors that influence young people’s perceptions of, experiences with, and willingness to engage with OAT, including those contributing to frequent re-attempts at OAT. Results point to areas where existing treatment guidelines and services can be improved to meet the diverse needs of young people in and beyond our setting.

OAT contemplation and initiation

As they contemplated trying it, many young people expressed negative perceptions of OAT, which, in some instances, resulted in avoidance. Joanne, a 14-year-old white woman, shared her hesitations around substituting illicit opioids with methadone, which she viewed as being as highly addictive as fentanyl and potentially causing the same cravings for opioids:

“I know for a fact that if I had something like methadone – because it still gives you kind of a high – I’ll want to take more. And then I’m back in that cycle, and me being here [in residential treatment] will just be a waste of time because [methadone is] going to make me want to use again.”

Some participants detailed the influence of friends on delaying or avoiding seeking OAT. Nicky, a 20-year-old non-binary person of mixed Indigenous Ancestry, was initially hesitant to try methadone at the outset of the study. They discussed in their first interview how witnessing the negative side effects of methadone experienced by a friend was especially influential when they were initially contemplating it:

“I have a friend […] in her mid-thirties and she’s been on methadone for the past 15 years. And she can barely think straight. She’s so fucking out of it all the time - just, like, spaced out - and she was never like that before she got onto methadone.”

In addition to concerns about addictiveness, ongoing cravings, and side effects, participants described how friends’ negative experiences with tapering off OAT shaped their perspectives. Tina, a 23-year-old woman, decided to cease methadone due to the burden of daily witnessed dispensation and having to re-initiate methadone at a lower dose when she missed three doses in a row. But her friend’s experiences also powerfully informed this decision: “[My] best friend was on, like, 80 mils [mililitres of methadone] and spent two months up north [in northern Canada] getting off of it and almost died. […] It gives me nightmares thinking about it.”

While negative perceptions of OAT could lead some participants to avoid OAT altogether across the study period, for others the result was a delay in seeking OAT, or particular forms of OAT. A number of participants moved between different kinds of OAT as they attempted to figure out what form might work best for them in relation to their treatment and recovery goals. For example, while Nicky was initially hesitant to try methadone, over the course of the study period they navigated multiple forms of OAT. After trying Kadian for a period of time and finding that it did not sufficiently mediate cravings, Nicky tried methadone despite their initial hesitations and had some success with it. Similarly, over the course of the study period, Tina eventually returned to methadone despite identifying a number of negative aspects of this treatment.

Some participants reported unwelcome pressure from family members to go on OAT, while others reported that their families attempted to dissuade them from OAT. For example, Cory, a 21-year-old white man, explained how several members of his family expressed to him that they “didn’t like who [he was] on methadone.” A number of young people also reported their parents’ direct involvement in their treatment decision-making. Julia, a 17-year-old white woman, had been on methadone in the past at the outset of the study but told us that she had discontinued use because she lived far away from her methadone clinic and ultimately decided not to renew her prescription. Upon ceasing methadone, she experienced significant pressure from her father to initiate buprenorphine-naloxone:

“My dad was like, ‘You gotta get on Suboxone©.’ But I don’t like the idea of Suboxone©. He just thought that if I was on Suboxone© that I was not gonna do drugs at all anymore ‘cause I wouldn’t be able to get high [due to the blocking effect of partial opioid agonists].”

In addition to experiencing pressure from family members surrounding OAT decision-making, participants also commonly reported feeling pressured or even coerced by healthcare providers when contemplating OAT, including which kind to try. Specifically, participants felt that providers were pushing them to try buprenorphine-naloxone rather than methadone, even when they indicated that they had previously tried and preferred methadone. As Julia recounted during her initial interview, she had experienced significant challenges finding a healthcare professional to prescribe her methadone instead of buprenorphine-naloxone:

“I went to go see a doctor and the doctor was like, ‘No, we’re not gonna put you on methadone because you’re young.’ People have died from methadone, I guess? And they don’t want to, like, overdose me, which I understand completely, but I also felt that they should have understood that I didn’t feel comfortable with Suboxone©.”

Being pressured into taking buprenorphine-naloxone and denied methadone was an extremely frustrating experience for many participants. Tina shared that, during a period of time when she was considering initiating OAT, at one clinic visit she was repeatedly offered buprenorphine-naloxone instead of the full range of OAT. This led her to leave the clinic “without anything because [she] was so frustrated and didn’t want to have that conversation with the doctor.” Alternatively, participants who were able to access their preferred form of OAT – usually methadone – described the positive impacts that this had on their trajectories. For example, Angel, a 16-year-old white woman who had previously tried but then discontinued buprenorphine-naloxone, described her satisfaction when she was finally able to access a form of OAT that worked for her:

“I was on Suboxone© before, but I hated it. I just didn’t like the taste. Currently, I have been on methadone for about seven months and it’s unbelievable how much it’s helped me.”

In some cases, the provision of OAT as part of what was offered at wrap-around service “hubs” for young people was itself perceived as coercive. Trevor, a 20-year-old Indigenous man, noted at his initial interview that he had accessed a hub looking for food but quickly felt that providers there were pressuring him to go on OAT:

“I went there because they had food and they’re like, ‘You have to be a client here [to get food].’ They’re like, ‘Do you do down [heroin/fentanyl]?’ And I’m like, ‘Yeah.’ And then, like, ‘Do you wanna get off of it?’ I’m like, ‘Yeah.’ And they’re like, ‘Sign this form.’ And I got food and then they’re like, ‘Wait, you have more [forms to fill out].’ And the next thing I know I was in a doctor’s office, and I was like, ‘Whoa, what happened?’ And yeah, that’s how [getting on OAT] kinda started. It’s manipulative.”

Trevor eventually accessed Kadian at another clinic. However, a sense of being pressured to take OAT and being excluded from treatment decision-making led several participants to disengage from care for extended periods of time.

OAT maintenance and retention

For participants who went on OAT, staying on it was complicated by the everyday demands of navigating the broader risk environment. In the context of daily struggles to meet basic needs, participants questioned the value of OAT and its potential to impact their lives. During a follow up interview with Nicky that occurred during a period of time when they had recently discontinued methadone, they reflected on how the required daily witnessed dispensation of methadone was unrealistic and burdensome when navigating the complexities of street-involvement, poverty, and other health challenges:

“You know it’s like, well, what’s the point in trying it at the end of the day? Like, especially when you’re not stable. I’ve got, you know, other doctor’s appointments. I’m homeless so I’ve gotta figure out food in a day. I’ve got to figure out fucking shelter. I’ve gotta figure out how to help my partner, […] you know?”

Young people also pointed out that, in the context of a drug supply that is heavily adulterated with highly potent fentanyl and related analogues, even high doses of OAT might “barely touch” (as Nicky put it) or manage their cravings and withdrawal symptoms. As Nicky elaborated, the inability of OAT to adequately mediate cravings and withdrawal symptoms – especially initially, while patients are being titrated to a higher dose – encourages treatment disengagement:

“People just – eventually they give up because they’re like, ‘fuck this shit, why would I try [OAT] if all that’s gonna happen is I’m gonna get nothing, you know, to even help me?’”

Some participants shared how existing guidelines around missed doses, whereby those who have missed three or more consecutive days of OAT are required to re-initiate OAT at a lower dose, discouraged retention. As Marcus, a 21-year-old man of mixed Indigenous Ancestry, explained, it took him approximately two months to achieve a longer period of retention on methadone due to repeatedly missing doses:

“[When I started OAT] it took about two months, and they were pretty rough. […] I had a mess-up when I got out of the hospital [and my OAT was cut-off]. Say you’re at, like, 90 or 100 [millilitres] or whatever, well, you miss three days and they start you back at 30, at the beginning dose again. And then you’re really screwed – which I’ve had that happen to me already. Twice.”

Other young people indicated that their experiences around missed doses resulted in treatment disengagement and eventual relapse. As Robby, a 24-year-old white man, recollected:

“It was already, like, five days since I’d had my Kadian, so they couldn’t – once you miss your dose for, like, more than three days, they have to restart you back at the lowest dose possible and then slowly raise you up again. So I was on, like, 600 miligrams of Kadian and I asked to go back on it and they were like, ‘Well, we can start you at 30,’ or whatever and that was, like – to me that wouldn’t even put a dent in [my cravings and withdrawal symptoms]. So it was, like, really upsetting and I barely made it home. And then I ended up relapsing ‘cause I was – I just felt, like, so terrible, I had to.”

The requirement of daily witnessed dosing at a pharmacy weighed heavily on some participants. This was especially true for those who had secured employment while on OAT, only to find that their treatment regimen conflicted with their work schedule or requirements. Missed doses because of scheduling conflicts could also lead to relapse. Julia explained why she had discontinued methadone yet again during a follow up interview:

“I have trouble keeping a job because I work from this time to that time, and I need to take my methadone from this time to this time. I need to be able to get to the pharmacy and take [my methadone]. And then, like, when I was on the way to my job, [the pharmacy] wasn’t open, and sometimes they’d make me work later and by the time I got back, it was closed. So, I’d be withdrawing, and I’d have to go get drugs. It was just, like – I couldn’t keep a job because of it.”

Another participant who was employed shared their challenges with getting enough “carries” (take-home doses of OAT) so that they could travel for work for extended periods of time. Adam, a 24-year-old man, described his preference for Kadian over buprenorphine-naloxone and methadone during his initial interview. At a follow-up interview, he described how the length of a work trip exceeded his maximum allowable duration for Kadian carries and he experienced difficulties receiving an emergency refill. Having experienced numerous difficulties with missing doses of Kadian previously that required re-initiating at a lower dose, he was very concerned about losing access as his work trip was extended beyond the anticipated end date. In this case, the implementation of interim Risk Mitigation Guidelines across BC, which eased restrictions around the provision of take-home doses, was a positive development:

“I went out to [a rural community] and I got carries for the whole time that I was there. I was actually really lucky because I tried to call my pharmacy to get more carries, and they were like, ‘No.’ But then I tried calling all the pharmacies around there and the one pharmacy – the only reason that they were even able to give me my Kadian was because of COVID. So, if it wasn’t for COVID, I never would have been able to get my meds and I would have had to leave the job site and miss out on, like, another $1000 worth of work.”

Finally, a number of participants cited aging out of youth services and the transition to adult services as a moment when disengagement from OAT became more likely. Participants worried about building relationships and trust with new prescribers so that they would be provided with adequate, and in some cases take-home, doses. Tricia, a 25-year-old woman, described her hesitancy to access an adult clinic in order to secure Suboxone© carries:

“I’m scared to death to get my Suboxone© from, um, [an adult clinic] in Surrey. When I was 18, 19, 20, whatever, I went to an adult Suboxone©/methadone clinic and I told myself, ‘I’m never coming back here.’ Like, I got treated like I was the young one and it’s just like, I saw things I did not need to see in Surrey at that clinic. And now I’m going to have to go back to adult services and I’m just – they’re just a lot stricter, you know what I mean? Like, I’m worried now that I’m gonna have to go back to witnessed doses, when I’ve been on carries for years.”

Tapering off and OAT discontinuation

Consistent with previous research (Giang et al., 2020), many participants viewed OAT as a short-term intervention to mediate cravings and withdrawal symptoms and expressed a desire to discontinue use shortly after discharge from detoxification, residential treatment, and hospital settings. As described above, several participants experienced pressure and even coercion from prescribers to go and stay on OAT, and in particular buprenorphine-naloxone. However, there were also cases in which providers and programs encouraged young people to taper off of OAT after relatively short periods of time, despite guidelines that strongly caution against this approach. As Kenny, a 21-year-old white man, explained:

“Basically, when I got intaked [sic] at a treatment centre they were like, ‘We want to see you in, like, the next month or two tapering off of [buprenorphine-naloxone],’ right? And, like, I didn’t really care at that point because I didn’t really have a whole lot of experience. I was just like, ‘Okay, if you guys think that me tapering off this is a good idea, let’s do that,’ right? I was like, yeah, you know what? I don’t want to be on Suboxone©, right? Like, I’m in a treatment centre with support. Like, I don’t feel unsafe at all without this Suboxone© thing in my life. I don’t feel the need for it at all, right?”

While Kenny described wanting to taper off of OAT at that treatment center – or at least not resisting the idea – in hindsight he connected tapering to a subsequent relapse and overdose. During another interview, he shared that he had re-initiated OAT in the hopes that it could protect him from having that happen again. Kenny and other young people described how confusing it could be to navigate conflicting approaches to OAT across providers and programs. While some providers and programs advocate strongly for the longer-term use of OAT, others suggest short-term use and tapering. To complicate things further, young people themselves have shifting ideas about whether OAT is a longer- or shorter-term treatment option. Many participants described wanting to quickly taper off OAT, and then experiencing a relapse following a taper. They identified tapering off OAT too quickly as a contributing factor. As Tricia reflected regarding the first time that she tried to taper off buprenorphine-naloxone when she was an adolescent:

“I think my first taper went really quickly and I wasn’t ready back then. I was still in, like, [residential] treatment and stuff and they were, like, tapering me down. That was way back, [when I was] younger – like, teenager days. So, that didn’t work out. I think it lasted, like, a month and then I ended up using.”

Eventually, Tricia got back on buprenorphine-naloxone and was able to maintain a period of abstinence from illicit opioids. Motivated by her desire to begin a family, Tricia consulted with her doctor and made the decision to initiate another taper. This time, her plan was to taper over a longer period:

“[I said to my doctor] ‘I’m doing so well right now, so let’s just do it slowly.’ I told [my doctor] that I want to stay on 6 miligrams for months before I go down to, like, 4 miligrams. So, this is gonna be quite a bit of a process. It might even take a year or two, who knows, but I just wanted to get it started ‘cause I haven’t tried to taper in years. He’s like, ‘Are you sure that’s gonna be okay?’ And it is a lot different. At nighttime I’m okay, but when I wake up, I feel like I need [buprenorphine-naloxone] right away. Which is fine.”

Like Tricia, many participants expressed uncertainty about how and when to taper off OAT, even as they expressed a strong desire to do so.

DISCUSSION

Our findings point to important micro-, meso-, and macro-level environmental factors that influence young people’s engagement with OAT across time, while also demonstrating how patient-centered accessibility is significantly influenced by the risk environment in which individuals are enmeshed. While many young people who were hesitant to initiate OAT subsequently initiated or re-initiated treatment, our findings demonstrate how micro-level interactions with family members, peers, and clinicians can powerfully influence these trajectories, including extended periods of avoidance. At the macro- and meso-levels, entrenched poverty and burdensome clinical guidelines created difficulties for staying on OAT, as well as challenges when attempting to taper off of OAT. Several young people had to navigate conflicting recommendations regarding when and how to taper off of OAT. The risk environment that young people are navigating must be accounted for in the design of clinical guidelines and programs, including which kinds of OAT to prescribe and requirements surrounding their use (e.g., initiation dose level, dose restart level, witnessed dispensation, tapering).

While we identified several challenges to navigating OAT, participants’ experiences also provide insight into how to improve OAT programming for young people. Specifically, findings suggest that OAT engagement and retention would be improved by expanding access to the full range of OAT while simultaneously addressing real or perceived coercion onto OAT, and in particular buprenorphine-naloxone; updating clinical guidelines to incorporate the interim Risk Mitigation Guidelines introduced during the COVID-19 pandemic; addressing treatment gaps arising from missed doses and take-home dosing, particularly for methadone; supporting young people who are aging out of youth-dedicated services; and providing a clear pathway to OAT tapering for young people when that is something that they indicate they want.

Young people often enter the healthcare system with clear treatment goals and preferences, which can be shaped by family members and other caregivers, friends, and romantic partners. To date, there is some evidence highlighting the potential benefits of including family members in treatment programming and planning, and the positive impact of one’s social network on treatment willingness and engagement (Hogue, Becker, Fishman, et al., 2021; Hornberger & Smith, 2011). Involving caregivers may be particularly effective when young people are actively involved in decision-making around who is involved and how, and when the definition of caregivers extends beyond biological and adoptive family members to include chosen family members (Goodman et al., 2011; Hogue, Becker, Wenzel, et al., 2021). However, we must account for how family members and other caregivers may push young people towards treatment programming that does not align with the latter’s interests and priorities and could even undermine their safety. For example, stigma towards OAT and preference for abstinence-based treatment approaches among family members may push young people towards tapering off of or discontinuing OAT when they do not necessarily want to do so, increasing their risk of drug poisoning upon relapse (Zweben et al., 2021). Family and caregiver involvement in treatment decision-making should be secondary to fostering young people’s self-determination and safety in relation to their treatment and care.

Our findings regarding the role of friends in shaping treatment trajectories is consistent with other similar research in Canadian settings (Brands et al., 2005; Russell et al., 2019), which demonstrates that peers can discourage young people from following up with prescribers and refilling OAT prescriptions. Although friends may discourage OAT initiation and adherence, our findings also demonstrate that social networks are crucial sources of information about OAT. Peer networks have previously been credited with reducing injection-related harms among people who use drugs and warrant further attention in the context of shaping young people’s understandings of OAT (Mackesy-Amiti et al., 2013).

For young people who initiated OAT, the challenges of navigating the everyday emergencies of poverty, homelessness, and unstable housing alongside the demands of OAT programming led many to conclude that it was too burdensome, particularly if dosage levels were inadequate. Study participants identified the clinical guidelines regarding repeated missed OAT doses, which dictate re-starting OAT at a lower dose, and the requirement of witnessed dispensation as major barriers to retention. This was especially true for young people who were employed, for whom the stringent requirements of OAT programming could force them to decide between staying on OAT and maintaining employment. Healthcare providers should work closely and expediently with young people to identify OAT dosage levels that works well for them during treatment initiation (Artenie et al., 2019; González-Saiz et al., 2008; González-Saiz et al., 2018; Viera et al., 2020), including after missed doses. Additionally, findings highlight the need for a continuum of health and social supports for young people, which include providing access to safe, stable, supportive housing and employment and income-related supports (Giang et al., 2020; Simeone et al., 2017; Viera et al., 2020; Zhou et al., 2017). In the absence of these supports, OAT can seem irrelevant to young people’s daily priorities and needs.

With regards to buprenorphine-naloxone specifically, the required precipitated withdrawal prior to treatment initiation is a significant barrier for many young people. However, one approach that could help young people reach an optimal dose of this treatment, including after repeated missed doses, is the use of micro-dosing induction. Micro-dosing induction does not require abstinence from opioids while titrating patients up to an adequate buprenorphine-naloxone dose, thus preventing precipitated withdrawal (Ahmed et al., 2021). Micro-dosing induction does require a longer duration of monitored administration to prevent withdrawal symptoms, and therefore residential detoxification and treatment settings, as well as safe houses and other residential settings frequented by intensive case management teams, may be particularly suitable environments for the initiation of buprenorphine-naloxone via micro-dosing induction.

Rapid methadone induction, and the co-prescription of oral morphine or hydromorphone tablets alongside initial doses of methadone, have also been used in our study setting with some success (Hemmons et al., 2019). This approach better supports patients in reaching an optimal methadone dose within a shorter period of time, and provides patients with more comfort (i.e., reduced cravings and withdrawal symptoms) during methadone induction. The co-prescription of oral morphine or hydromorphone tablets alongside initial doses of methadone is a component of the provincial interim Risk Mitigation Guidelines that sought to promote physical distancing and reduce overdose risk during the COVID-19 pandemic in our setting (British Columbia Centre on Substance Use et al., 2022; Vancouver Coastal Health, 2020). Revising existing youth clinical guidelines to incorporate this component of interim Risk Mitigation Guidelines is warranted.

Revising youth OUD clinical guidelines to align with the most recent evidence may also help reduce the repercussions of missed doses. Crosstown Clinic in Vancouver’s Downtown Eastside has recently trialed and adopted a more flexible, patient-centred approach to addressing missed OAT doses, increasing the missed dose allowance from 3 to 10 days (Macdonald et al., 2020). Potential opportunities to improve OAT retention among young people include increasing the missed dose allowance; including preprint orders on patients’ electronic medical records to ensure continuity of OAT when prescribers are not available; allowing nurses to dispense OAT; improving access to daily OAT delivery services; and dispensing up to half of the original dose that a patient had previously been receiving after missed doses (Macdonald et al., 2020). Prescribers can employ a range of diagnostic criteria – from rapid urine drug testing to accounting for patients’ self-reported illicit drug use patterns, frequency, and expenditures – in order to optimize dosage levels upon treatment initiation or re-initiation (British Columbia Centre on Substance Use et al., 2022; Macdonald et al., 2020; Vancouver Coastal Health, 2020).

Addressing barriers to take-home OAT doses, including the provision of prescription refills, must also be addressed. As one participant described, these barriers were lessened during the COVID-19 pandemic due to the introduction of the Risk Mitigation Guidelines (British Columbia Centre on Substance Use et al., 2022; Brothers et al., 2022; Vancouver Coastal Health, 2020), which allowed clinicians to prescribe longer durations of take-home OAT doses. However, Risk Mitigation Guidelines are temporary and there is no assurance that this flexibility will persist after the pandemic. Given recent evidence that take-home dosing for OAT during the COVID-19 pandemic has been safe and practical (Figgatt et al., 2021), there is a need to review and revise existing youth guidelines in order improve access to take-home dosing and daily OAT delivery services, thereby further reducing the impacts of missed doses on treatment continuation.

Lastly, the challenges experienced by young people when attempting to taper off of OAT highlight the importance of empowering young people in relation to treatment decision-making and adopting a patient-centered approach (Marchand et al., 2019). When young people initially inquire or are approached about OAT, prescribers should at that time communicate relevant information regarding the process of tapering off of OAT, including the benefits longer-term tapering and the risks of short-term tapers. Previous research has suggested that it may be useful to talk to young people about OAT using shorter timelines initially, as the idea of being on OAT for an extended period of time can dissuade some young people from trying it at all (Giang et al., 2020). For young people who communicate an intention to rapidly taper themselves off OAT against medical advice, it is important that prescribers clearly communicate the potential harms of doing so while also assuring young people that they are willing to work with them on a longer-term taper and will support their re-initiation onto OAT at a later time if needed. This scenario further emphasizes the importance of integrating the interim Risk Mitigation Guidelines into youth OUD clinical guidelines (British Columbia Centre on Substance Use et al., 2022; Brothers et al., 2022; Vancouver Coastal Health, 2020), because it is critical to facilitate access to prescribed safer alternatives to the increasingly poisonous, unregulated drug supply among young people who taper themselves off of OAT and subsequently begin using illicit opioids intensively again.

There are several limitations to this qualitative study. Our findings describe OAT engagement among young people in a somewhat unique substance use treatment and policy landscape. Moreover, our findings are most representative of young people experiencing entrenched poverty and unstable housing and homelessness, and who report intensive daily opioid use. Therefore, young people’s experiences in other places are likely to differ in some regards. Additionally, this article does not include the perspective of clinicians and healthcare providers, nor participants’ family members, caregivers, friends, and romantic partners. It therefore does not fully explore how these other social actors shaped young people’s OAT trajectories.

CONCLUSIONS

In conclusion, it is critical that young people be empowered with more control over treatment decision-making and trajectories. They should have access to the full range of OAT, including but not limited to buprenorphine-naloxone. Providers must work collaboratively with young people to develop treatment plans and timelines that can be quickly adapted as young people’s circumstances, needs, and desires change. Given that many young people view OAT as a shorter-term treatment option, it is critical that they are provided with a clear pathway to an OAT taper, as well as a range of additional treatment, health, and social services when they decide to taper off of OAT. For clinicians, this requires viewing OAT as one of many tools available to support young people in realizing their treatment, recovery, and broader life goals. Such an approach will allow clinicians to develop the kinds of trust-based therapeutic relationships that can be lifesaving in the context of an increasingly poisonous, unregulated drug supply.

HIGHLIGHTS.

  • Opioid agonist therapy (OAT) has been shown to reduce opioid use and related harms

  • We need to better understand why many youth do not engage with OAT

  • Family and peer perspectives contributed to young people’s perceptions of OAT

  • Several policy barriers to OAT engagement and adherence were identified

  • Updating existing clinical guidelines may improve OAT engagement among young people

Acknowledgements

We wish to thank the Musqueam, Squamish, and Tsleil-Waututh peoples on whose occupied, ancestral territories the research was conducted upon. We also extend our appreciation to the study participants for their contributions to the research, as well as current and past researchers and staff, including Reith Charlesworth and Cathy Chabot. Lastly, we would like to thank Lizzy Ambler.

Funding sources

This research was supported the Canadian Institutes of Health Research (MOP-286532, PJT-153239), the US National Institutes of Health (U01-DA038886, R01-DA044181), SickKids Foundation (SKF-160823), and Vancouver Foundation (20R01810). AP is supported by a University of British Columbia Four Year Fellowship. KD is supported by a Michael Smith Foundation for Health Research/St. Paul’s Hospital Foundation-Providence Health Care Career Scholar Award. DF is supported by a Michael Smith Foundation for Health Research Scholar Award. The funders were not involved in the design, analysis, or drafting the manuscript for this research.

Footnotes

Ethics approval

This study received ethical approval from the University of British Columbia and Providence Health Care Research Ethics Board (Study ID #: H17–01726; H18–03529).

Declarations of Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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