QMJC May 2020 - “Like being put on an ice floe and shoved away”: A qualitative study of the impacts of opioid-related policy changes on people who take opioids

First published: 01/06/2020 | Last updated: June 1st, 2020

Article: Tony Antoniou, Kari Ala-Leppilampi, Dana Shearer, Janet A. Parsons, Mina Tadrous, Tara Gomes. (2019). “Like being put on an ice floe and shoved away”: A qualitative study of the impacts of opioid-related policy changes on people who take opioids. International Journal of Drug Policy, 66 (2019):15–22.

Link: https://www.sciencedirect.com/science/article/pii/S0955395919300234

Toronto reading group – May meeting: Carol Strike; Katherine Rudzinski; Andrea Bowra; David Kryszajtys; Cathy Long; Melissa Perri; Rose Schmidt; Sarah Switzer; Tara Marie Watson; Jessica Xavier (Dalla Lana School of Public Health, University of Toronto)

Meeting summary:

In May 2020, members of Qualitative Methods Journal Club (QMJC) reviewed Antoniou et al.’s paper. “Like being put on an ice floe and shoved away”: A qualitative study of the impacts of opioid-related policy changes on people who take opioids. The authors conducted eight focus groups with 48 adults who take opioids in Ontario, Canada in order to understand how patients experienced the effects of recent policy changes. Using stigma theory to assist with data interpretation, the authors examined how the implementation of opioid-related policies may have unintentionally created “conditions in which stigma could be enacted”, the consequences of labelling and stereotyping, and how participants used and/or resisted specific discourses when describing their experiences (p.16).

Antoniou et al. found several unintended consequences of the recently enacted policy changes which they present across three main themes. Findings showed that participants felt that ‘addict’ had displaced ‘patient’ as the dominant social identity for people who use opioids, relationships with service providers (e.g., physicians, pharmacists) had become strained and patients perceived themselves to be powerless in clinical decisions regarding their care. The authors identified several negative repercussions as a result of these changes, specifically with respect to help-seeking and exposing additional structural vulnerabilities (e.g., poverty, unstable housing, criminalization) for people who take opioids. As a result the authors’ propose potential measures for mitigating these consequences including ensuring that people who take opioids are involved in all aspects of policy development and implementation, incorporating peer workers into the care of this population, and recognizing the importance of patient agency when decisions about clinical care, pain management, and opioid use are made.

We discussed how the authors did an exceptional job of depicting how policy gets enacted in really complex ways. Often in the literature quantitative methods are used to assess the impact of drug policies. Consequently, we appreciated how the authors used qualitative methods to effectively examine the impact of specific changes to prescribing practices, and to showcase how these policy changes were lived by people who use opioids.

We valued that the authors were explicit about their theoretical framework and clear about how this lens was applied in their work. Antoniou et al. were upfront about how theory came into their project – not as a guiding framework for defining and implementing their project, but rather drawing on work by Goffman and Link and Phelan on stigma at the later stages of their research as useful for data interpretation. The authors made a point to discuss how this is a legitimate way to use theory in qualitative research.

The use of theory is this paper was accessible and well integrated throughout. Antoniou et al. did a skillful job of setting out the guiding questions of their data analysis plan, which allowed them to justify their theoretical framework while also providing an excellent way to direct the reader through the paper. The authors deliver a nuanced qualitative analysis and effectively use theory, interweaving it throughout the results and discussion. The authors provide definitions of key concepts (e.g., identity engulfment) where necessary, and use their results section as an opportunity to talk about where the findings were illuminated by, or diverge from, the theory. The authors introduced and used theory throughout the article effectively to contextualize their findings. For example, they use the following except to connect the theory back to their data and to what this means in a wider context:  “These experiences are exemplars of Link and Phelan’s argument that stigma is dependent on power, such that those with social, economic and/or political capital are best positioned to create conditions in which stigma and its discriminatory consequences can unfold” (p.18). Although it is challenging to weave theory with results, when done well, as is the case in this article, it ultimately makes for a more engaging paper.

It was interesting that the authors decided to split up the focus groups between people who were using opioids for chronic pain and those who used opioids for other reasons (e.g., had an opioid use disorder, recreational, other). The journal club spent some time discussing this. On the one hand, there is the need to avoid backlash/allow different groups to feel safe in sharing their opinions in focus groups. On the other hand we wanted to consider what the implications of these types of dichotomies are. We were left with many questions about such dichotomies:  Who makes the decision how patients are split in the dichotomy (e.g., self-identified vs. researcher defined)? What happens when there is an overlap in the reasons for use (as seemed to be the case in this article)? What are the implications of such dichotomies for how communities define themselves (e.g., delegitimizes certain kinds of pain, reinforces negative stereotypes)? In light of this, we agreed that researchers need to be transparent in how they define, recruit, and separate different groups because the implications of these decisions are important, especially if we are trying to draw comparisons.

We liked how the authors used a meaningful quotation from a study participant in the article’s title. This worked particularly well in this case since there was a very strong connection between the chosen quote and the content of the paper – in that the quotation effortlessly conveyed the main finding of the paper. Moreover, we felt that the authors’ use of quotations throughout the paper was powerful and effective. The quotes were a vivid, if not at times devastating, use of participants own language to describe how recently enacted policy changes affect patients.

The authors were clear in their limitations regarding their study population (e.g., potentially leaving out people who did not regularly use healthcare services) and their data analysis (e.g., did not explore the impact of race and gender on their findings). This discussion inspired us to consider what a gender analysis of opiate-related policy changes could look like (e.g., examining the impacts of new guidelines on opioid use and pregnancy/early parenting/motherhood).

We often hear about the need for population-based research – whereas these authors underline the importance of focusing on individuals: “By focusing on individuals rather than populations, we demonstrate that the implementation of such policies can create conditions in which stigma and its negative repercussions can be re/produced” (p.21). By using qualitative methods the authors were adept at showing how we can understand the mechanisms of how these policies are enacted and experienced on the ground.

Additional reading:

  • Kennedy-Hendricks, A., Busch, S. H., McGinty, E. E., Bachhuber, M. A., Niederdeppe, J., Gollust, S. E., et al. (2016). Primary care physicians’ perspectives on the prescription opioid epidemic. Drug and Alcohol Dependence, 165, 61–70.
  • Al Achkar, M., Revere, D., Dennis, B., MacKie, P., Gupta, S., & Grannis, S. (2017). Exploring perceptions and experiences of patients who have chronic pain as state prescription opioid policies change: A qualitative study in Indiana. BMJ Open, 7 e015083.
  • Goffman, E. (1963). Stigma; notes on the management of spoiled identity. Englewood Cliffs, N.J: Prentice-Hall.
  • Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363–385.