‘I just thought that was the best thing for me to do at this point’: Exploring patient experiences with depot buprenorphine and their motivations to discontinue

Background Conventional systematic review techniques have limitations when the aim of a review is to construct a critical analysis of a complex body of literature. This article offers a reflexive account of an attempt to conduct an interpretive review of the literature on access to healthcare by vulnerable groups in the UK Methods This project involved the development and use of the method of Critical Interpretive Synthesis (CIS). This approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances in methods for interpretive synthesis. Results Many analyses of equity of access have rested on measures of utilisation of health services, but these are problematic both methodologically and conceptually. A more useful means of understanding access is offered by the synthetic construct of candidacy. Candidacy describes how people's eligibility for healthcare is determined between themselves and health services. It is a continually negotiated property of individuals, subject to multiple influences arising both from people and their social contexts and from macro-level influences on allocation of resources and configuration of services. Health services are continually constituting and seeking to define the appropriate objects of medical attention and intervention, while at the same time people are engaged in constituting and defining what they understand to be the appropriate objects of medical attention and intervention. Access represents a dynamic interplay between these simultaneous, iterative and mutually reinforcing processes. By attending to how vulnerabilities arise in relation to candidacy, the phenomenon of access can be better understood, and more appropriate recommendations made for policy, practice and future research. Discussion By innovating with existing methods for interpretive synthesis, it was possible to produce not only new methods for conducting what we have termed critical interpretive synthesis, but also a new theoretical conceptualisation of access to healthcare. This theoretical account of access is distinct from models already extant in the literature, and is the result of combining diverse constructs and evidence into a coherent whole. Both the method and the model should be evaluated in other contexts.

This paper summarises evidence for medicinal uses of opioids; harms related to the extra-medical use and dependence upon these drugs, and for a wide range of interventions to address the harms related to extra-medical opioid use. Finally, we use mathematical modelling to estimate harms and explore the overall health benefits of opioid agonist treatment (OAT) in a range of settings that vary in levels of opioid use and associated harms (overdose, HIV, HCV, suicide, accidental injuries) and responses. Estimates in 2017 suggest 40.5 million people were dependent upon opioids (40.5 million people, 95%UI 34.3–47.9 million) and 109,500 people died from opioid overdose (10.5,800–113,600). OAT can be highly effective in reducing illicit opioid use and improving multiple health and social outcomes, including reduced overall mortality and key causes of death including overdose, suicide, and other injuries. Modelling suggested scaling-up and retaining people in OAT, including providing OAT in prison, could avert a median of 7.7%, 14.5% and 25.9% deaths over the next 20 years (compared to scenarios without OAT) in Kentucky, Kyiv and Tehran, with more impact achieved in Tehran and Kyiv due to the added benefits on HIV mortality.. Other pharmacological and non-pharmacological treatments have varying levels of evidence for effectiveness and patient acceptability. Other effective interventions are those focused on preventing harms associated with problematic opioid use. Despite strong evidence for the effectiveness of a range of interventions to improve the health and well-being of people who are dependent on opioids, coverage is low even in high income countries. Treatment quality may be less than desirable, and considerable human, social, and economic harms arise from the criminalisation of illicit opioid use and dependence. Alternative policy frameworks are recommended that adopt a human rights and public health-based approach, do not make drug use a criminal behaviour and seek to reduce drug related harm at the population level.