Challenges Patients Face in an Opioid Agonist Maintenance Program in North Macedonia. How to Respond?

Abstract

Introduction: Republic of North Macedonia faces many challenges in opioid agonist treatment responses that are complicated by abuse and diversion of opioid agonist therapy (OAT), lack of resources and not coherent activities. According to the data of the 2017 bio behavioural study, people who injecting drugs most commonly have injected methadone in combination with diazepam (60.0%; CI95%=51.6-71.3%). Additionally, 22.0% of people who injecting drugs had injected methadone in the last month. In OAT programs patients also inject methadone in combination with benzodiazepines. This situation is worrying and requires an analysis in order to find a strategy that will improve the situation. The aim of this paper is to analyse roots and effects of the injection of OAT and benzodiazepines by patients on an OAT and the factors for and against the proposed change for solving this problem. Methods: For this propose we used Problem tree Force field analysis. "Problem Tree" was used to identify the focal problem and the associated causes and consequences with aim to identify solutions to the problem by mapping out the anatomy of causes and consequences. By rephrasing each of the problems into desirable outcomes, root causes and consequences were turn into solutions. Then objectives for change were used in the "Force Field Analysis" to identify the factors and pressures for and against the proposed change. Results: The analysis showed that the black market near the OAT service and opportunity to sell take home therapy to provide finance and "borrowed therapy" with "interest", poverty, unemployment, non-integration into the community, lack of social support, incoherent harm reduction interventions, exchange of injection equipment in front of the service, lack of education of out-reach workers and lack of staff are some of the reasons for abuse and diversion of the OAT which leads to a poor treatment outcome with all the consequences for patient’s health, staff, environment and contributes to violence, stigma and makes recovery impossible. Drivers and resistors were also analysed, which helps to conclude which decisions are needed and possible. Identified resistors were: black market; existing organizational structures; financial implications; legislation and fears regarding consumption rooms, and not educated CSO's out-reach workers as unintended resistors. Identified drivers were: staff from treatment service; Ministry of Health; CSO’s executive management; patients/parents; neighbourhood; the municipality where the service is located and pharmaceutical industry with new – depot formulations of OAT that can prevent abuse and diversion of the therapy. The highest rated drivers were the staff working with OAT as well as OAT depot formulation, and the highest rated resistance was the black market. Other drivers and resistances are much less influential according to the author. Conclusion: This tool shows reality, helps to see the possibilities for achieving the proposed change and helps to guide treatment policy and practice. Luck of staff, pour outcome, quality of live of patients and staff can be improved with extended-release buprenorphine as an additional treatment option if it is available in the country. Stigma, violence and aggression can be decreased as well.