Abstract

The complexity of the problems related to the harmful use of substances requires regular questioning of practices. This article aims to explore the acceptability and applicability of an intervention programme for patients with problematic substance use. Qualitative study. Data collection, through a focus group with 6 nurses and 6 semi-structured interviews with patients under treatment. We have used lexicographic textual analysis. From the focus group, 151 text segments were analysed, retaining 85.8% of the total for the creation of five classes. An analysis of similarity led to the formation of two central nuclei, represented by the words “Nursing” and “Intervention”. From interviews, 252 text segments were analysed, retaining 71.83% for the creation of 5 classes. An analysis of similarity led to the formation of three central nuclei, represented by the words “want”, “programme” and “see”. Nurses recognise the need for a more structured and flexible approach focused on people’s needs. Users also affirm the need for flexible interventions, without a pre-established time frame, that promote labour integration, therapeutic support for abstinence and management of comorbidities.

Key words:
Substance related disorders; Alcoholism; Program development; Perception; Nursing

Introduction

About 1.2 million people in Europe are currently under treatment for illicit substance use¹1 European Monitoring Centre for Drugs and Drug Addiction. European Drug Report 2018: Trends and Developments [Internet]. Luxembourg: Publications Office of the European Union; 2018 [cited 2021 dez 12]. Available from: https://www.emcdda.europa.eu/publications/edr/trends-developments/2018.. In Portugal, a policy was implemented in the year of 2000, aiming at decentralisation, national coverage, proximity responses, with a humanistic orientation of harm reduction and decriminalisation of public or private use, acquisition, and possession of any drug. This policy has contributed to the creation of many specialised outpatient support units with multidisciplinary teams, integrating a psychosocial support network articulated with basic health care. These public health policies have reduced the prevalence of problematic substance use, compared to other countries in Europe, lowered rates of infectious diseases, reduced penalties for drug-related crime and made it clear that this was a social problem of extensive impact²2 Rêgo X, Oliveira MJ, Lameira C, Cruz OS. 20 years of Portuguese drug policy: developments, challenges and the quest for human rights. Subst Abus Treat Prev Policy 2021; 16(1):1-11.. Among the various outcomes associated with this approach, the users’ survival and consequent ageing stand out. From this perspective, and given the users’ complex health needs, the importance of nursing care stands out, since it has a key role in the development of structured responses to the problems caused by substance abuse. Users call for a more active role of nurses in their monitoring processes, that value their care and shared decision on care plans³3 Comiskey C, Galligan K, Flanagan J, Deegan J, Farnann J, Hall A. Clients' views on the importance of a nurse-led approach and nurse prescribing in the development of the healthy addiction treatment recovery model. J Addict Nurs. 2019; 30(3):169-176.. Nursing can play a leading role with interventions aimed at reducing stigma, increasing users’ knowledge, promoting recovery, responding to the needs of older people, and helping to empower them to self-manage their addictions. However, regarding “nursing intervention programmes” for patients with substance addiction, evidence is still scarce³3 Comiskey C, Galligan K, Flanagan J, Deegan J, Farnann J, Hall A. Clients' views on the importance of a nurse-led approach and nurse prescribing in the development of the healthy addiction treatment recovery model. J Addict Nurs. 2019; 30(3):169-176.. Nurses work closely with drug-based programmes⁴4 Pearson C. Perceptions and experiences of methadone maintenance treatment. J Addict Nurs 2019; 30(4):248-253., through appointments and programme management. However, nurses should seek new systematised approaches in response to people’s needs and increase the level of evidence of the interventions they perform, which should have a multidisciplinary matrix⁵5 Louie E, Barrett EL, Baillie A, Haber P, Morley KC. Implementation of evidence-based practice for alcohol and substance use disorders: Protocol for systematic review. Syst Rev 2020; 9(1):1-6..

In many chronic illness situations, such as drug abuse, people need programmes to train and develop a better capacity for self-management of their health situation⁶6 Van de Velde D, Zutter F, Satink T, Cost U, Janquart S, Senn D, De Vriendt P. Delineating the concept of self-management in chronic conditions: a concept analysis. BMJ Open 2019; 9(7):e027775.. It is for this reason that a set of interventions or strategies may be included in an “Intervention Programme”, defined as a set of activities, structured in organized sessions, and aiming at a certain objective. Some authors place these programmes to develop social competencies and acquire confidence and should be supportive and stimulating contexts⁷7 Sousa L, Sequeira C. Conceção de um programa de intervenção na memória para idosos com défice cognitivo ligeiro. Rev Port Enferm Saúde Ment 2012; 8:7-15.. Many of these programmes differ in structure, content, target population and type of response⁸8 Seabra P, Boska G, Sequeira R, Sequeira A, Simões A, Nunes I, Sequeira, C. Structured programs for the self-management of substance addiction consequences of adults in outpatient services: A Scoping Review. Curr Psychol [seial on the Internet] 2023 [cited 2021 dez 12]:[about 14 p.]. Available from: https://link.springer.com/article/10.1007/s12144-023-04267-z#citeas.
https://link.springer.com/article/10.100... and their indiscriminate use cannot be considered adequate. When opting to create a “new” programme, the cultural characteristics of the population, the health problem, the care to be provided and accessibility must be considered. Both professionals and experts by experience (people with experience of the health problem) should be heard, as they provide essential details about the need for it, comparing it with the existing ones, and adapting it to the context for its development, viability and effectiveness⁹9 Khonsari S, Chandler C, Parker R, Holloway A. Increasing cardiovascular medication adherence: A medical research council complex mhealth intervention mixed-methods feasibility study to inform global practice. J Adv Nurs 2020; 76(10):2670-2684..

In line with what some authors advocate¹⁰10 Clancy C, Kelly P, Loth C. Walls are not the answer! Addiction nurses show the way in cross-national collaboration. J Addict Nurs 2019; 30(3):136-138., this research intends to contribute to greater consistency in the way treatments are implemented, and to the identification of better settings for intervention programmes. Thus, the aim of this study is to explore the acceptability and applicability of an intervention programme for patients with problematic substance use.

Methods

Type of study

Exploratory study, with a qualitative approach, integrated into the development of a complex intervention. It is intended to structure the intervention and to perform the initial analysis of acceptability and applicability by the stakeholders (substance users and nurses) of the context where the intervention may be implemented⁹9 Khonsari S, Chandler C, Parker R, Holloway A. Increasing cardiovascular medication adherence: A medical research council complex mhealth intervention mixed-methods feasibility study to inform global practice. J Adv Nurs 2020; 76(10):2670-2684.^,1111 Rousseau N, Turner KM, Duncan E, O'Cathain A, Croot L, Yardley L, Hoddinott P. Attending to design when developing complex health interventions: A qualitative interview study with intervention developers and associated stakeholders. PLoS One 2019; 14(10):1-20.. Activities were defined for the focus group (FG) phases, planning, preparation, moderation (introduction, development and conclusion), data analysis and dissemination of results¹²12 Morgan D. Basic and advanced focus groups. Los Angeles: SAGE Publications; 2018..

Population, sampling and selection criteria

Convenience sampling. Inclusion criteria: nurses working in public health outpatient units, specialised in addictive behaviours and addictions (ABA), in different regions of the country, for more than 5 years; or in higher education institutions, with experience in ABA and in the development of complex interventions. Users were selected by nurses from a team with the aforementioned characteristics, integrated in a drug-based programme and followed in a nursing consultation; or people discharged from a drug-based programme in the last 6 months.

Data collection and variables

Data collection from nurse participants was conducted through an online FG, using the Zoom platform for audio recording, in February 2021. The FG with 6 nurses was led by the main researcher, with a duration of 1h40min. Since the main researcher and the participants knew each other personally and professionally, due to their shared area of clinical practice and research, special attention was paid to explaining the study and obtaining consent. The FG was recorded, transcribed and the texts were analysed. The questions that guided the FG were: 1. Within the scope of drug support programmes, do you consider that one would benefit from a structured training programme for self-management of the consequences of substance dependence? 2. What should be included in such a programme (interventions, duration, objectives, participants)? 3. How can such a programme be made attractive to people? We also posed questions about age, level of education, profession, length of professional experience in the field of ABA, and previous experience in the development of intervention programmes.

Due to the COVID-19 pandemic, six semi-structured interviews were conducted, between June and August 2021, to collect data from users. The interviews were conducted at the premises of a specialised outpatient public unit in the Greater Lisbon region, recorded on computer in audio format and then transcribed. The interviews, transcription and text analysis were carried out by the main researcher (external to the team and without personal knowledge of participants) as well as by other researchers external to the unit’s team. The average length of the interviews was 22 minutes. The interview questions were: 1. In what way have you been helped to cope with the consequences of your addiction? 2. How do you think teams could better help people coping with the consequences of their addiction? 3. Would you consider that a structured training programme for self-management/self-care of the consequences of substance dependence would be beneficial? In addition, participants were also asked about their age, time of substance use and time of follow-up in medication programmes.

Data processing, data analysis and conceptual framework

The analysis of the data that resulted from both the FG and the interviews were carried out using lexicographic textual analysis, the Descending Hierarchical Classification (DHA) and similarity analysis, through the software IRaMuTeQ - R Interface, following the recommendations of other authors¹³13 Brantes A, Curado A. Percepção dos enfermerios sobre a alimentação do recém-nascido. Texto Context Enferm 2021; 30:e20200597.. This approach does not require any prior coding or classification of the content. No content was sent to participants for validation. The main researcher discussed the data, already anonymised, with the research team. COREQ recommendations regarding the design and reporting of qualitative studies were followed¹⁴14 Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Heal Care 2007; 19(6):349-357..

Ethical aspects

The objectives were explained, doubts were clarified, and participants’ informed consent was obtained. This study received a positive review by the Health Ethics Committee of the Regional Health Administration of Lisbon and Tagus Valley (7211/CES/2020), and all institutional authorisations were obtained.

Results

Five nurses specialised in Mental Health and Psychiatric Nursing and one generalist nurse, aged between 35-54 years (mean 47.3, standard deviation (SD) =7), three men and three women, two with a PhD in Nursing, two with a master’s degree and two with a Bachelor’s degree, participated in the FG. The average time of experience with people with ABA was between 11 and 20 years (mean 18, SD=3.9). Of the 6 participants, 3 had previous experience in having contributed to the development of intervention programmes for people with ABA. Concerning the interviews, participants included 5 men and 1 woman, aged between 45-63 (mean 58.4, SD=7.6); with a mean time of substance use of 27.4 years (SD=14.1) [9-43] and a mean time of permanency in the programs of 11 years (SD=8.8) [2-11]. Three were working regularly, 1 had intermittent work, 1 was retired and 1 was unemployed. They all lived on their own or in rented accommodation, and none was homeless. Only 1 of the participants lived alone.

Regarding the lexicographical analysis, in the CHD the criterion used as a cut-off bridge for the inclusion of the elements in the dendrogram classes, was the value of X²≥3.84, the calculation being defined according to a significance level of 95%. All words included present an X² higher than the reference value and a p-value<0.0001. In the analysis of the focus corpus and the interview corpus, it was not always possible to apply the criterion double the average frequency, possibly due to the number of texts (16 texts in the FG and 6 texts in the interviews). In the FG analysis, the double of the average frequency was 18 (2*9) and in the interviews it was 12 (2*6). The lexicographic textual analysis from the FG revealed 6381 occurrences of words, distributed by 715 forms, with an average of 9 words for each form.

Through the CHD, 151 text segments were analysed, retaining 85.8% of the total for the creation of 5 classes resulting from the participation of the content regarding the Nurses’ perception of the need and structure of an intervention programme (Table 1).

The vocabulary in class 1 allowed us to call it “Model of the intervention”, being responsible for 15.9% of the text segments analysed in the corpus. The words change, need, theoretical, status, nursing, help understanding the vision shared by the participants, agreeing on the benefit of a change in the form of intervention. This intervention should be centred on people and their behaviour, based on nursing diagnoses and on a defined theoretical framework. The need to be able to perform a structured intervention focused on empowerment for self-management of the consequences of drug addiction achieved consensus and acceptability, and nursing knowledge was inherent.

The excerpts of the participants’ discourse, show that, by analysing their practices, nurses consider the discussion, construction, and creation of a structured model of intervention to be beneficial:

In all classes, it was possible to identify words that appeared in 100% of the text segments of class 1, although with reference values without statistical significance (p>0.001), but with semantic proximity to those included in the class (significance to the lexical conception). In this class 1, the words diagnosis, help, need may relate to an intervention model with a final focus on promoting well-being and meeting needs.

Class 2 was entitled “Participants” justified by 21.2% of the textual data analysed. The words technician, reference, person, reveal the comprehensiveness of the participants’ reflection on the actors involved. Professionals with different disciplinary backgrounds such as facilitators/therapists, the people being cared for and the relationship as a bond emerged as the reference matrix to delimit the active actors in this process. The participants’ competence is perhaps the main reference for dynamization, in addition to the active role of the caregivers:

From the complementary analysis of the words that appeared in the text segments, the following words stand out: therapist, psychologist, nurse, physician, competence, user, relationship. They show a departure from the single concept of who is the most suitable professional for the intervention and suggest an association between different knowledge. The performance by only one nurse was unanimously considered possible, but the indication of a generalist nurse or a specialist in Mental Health and Psychiatric Nursing was questioned.

Class 3 was designated as “Structure of the intervention”, totalling 25.8% of the analysed corpus, and the main words emerged as: individual, group, month. When reflecting on such a complex issue, most participants had difficulties in being direct and objective in reflecting on the structure, which was observed in the lexical vocabulary of the class, since an intervention of this nature may have different structures:

In addition, the words durability, limited, integrate, programme, intervention, and nursing appointment contribute to a reflection on the therapeutic integrality and intentionality of a program.

Class 4 represents 17.2% of the textual segments and was designated “Focus of intervention”, as it contains the words consequences, problem, training, self-management, approach, stop, consumption. This class focuses on the need for help to deal with the consequences of drug addiction, the empowerment for self-management of the problem, and quitting the consumption, as can be seen in the following excerpts:

The word advantage demonstrates the consensus in the creation of an intervention model. The words addiction and structured, are related to the focus of the intervention, orienting towards the structure adapted to the focus and present a significance to the lexical conception. The word familiar broadens the view of the client who is the target of care.

Class 5 was assigned the name “Indicators for the operationalization of the programme”, covering 19.9% of the analysed corpus, with the words difficulties, create, assess, which are articulated in process and result indicators, essential for the creation and how the programme is run:

With this class, it became clear that there is a need for indicators for this intervention and that participants have difficulty in anticipating the scope and course of implementation of this program, as suggested by the words be, systematise, predict and intervention.

The analysis of similarity, referring to the FG data analysis, led to the composition of two central nucleus (Figure 1) represented by the words intervention and nurse. The interconnection between these two concepts is strong, and their connection with the word think reveals the exploratory nature of the FG but reinforces the conviction that intervention should and can be led by nurses, and that needs can be advantageously met by nurses. In the nucleus of intervention, the branches with greater connectedness are: focus, want, consumption, stop, area, help, different, important, thing, which, as mentioned in classes 1 and 4, the focus of the intervention should consider people’s multiple needs. There is also connectedness with class 5 and the difficulties inherent to an implementation. As for the nucleus of nurse, the branches with greater connectedness are technician, user, work, need and change, which refers to class 2 and the role of the various professionals’ skills, together with the users, in the development of a change approach. This connection extends to classes 1 and 3, with the reflections on the added value of the individual or group approach. With less connectedness emerges the need for change.

The textual analysis performed with the corpus that resulted from the 6 interviews revealed 8,836 words occurrences, distributed by 1,509 forms, with an average of 6 words for each form. Through the CHD, 252 text segments were analysed, retaining 71.83% of the total for the creation of 5 classes resulting from the participation of the content, as shown in Table 2, regarding the users’ perception of the need and structure of an intervention programme. The vocabulary in class 1 allowed us to name it “Expectations regarding the programme”, being responsible for 14.4% of the text segments analysed in the corpus.

The excerpts from the participants’ interviews show that the expectation towards a capacity-building programme will depend on the option for change, between what the person wants in their current reality, and what they want to change in their life (represented by the word door). They reveal the need for people to be helped to clarify what they want, after confronting their present situation, and demonstrate the need to respond to the users’ instability:

Complementarily, the words see, situation, counselling, ask, refer to the consensus on the added value of a programme, the difficulty of setting time rigidly and the need for advice in response to requests and needs.

The words programme, certainty, and want led to the denomination of Class 2 “Programme’s link” with 21.55% of the analysed data. Analysing, it was found the need for the effective bond of users with a structured program, with which they agree and that should be focused on meeting their needs. They consider it necessary that participants have reflected deeply on their option, wanting to effectively change:

The words must, really, good, believe, reinforce the class designation. They are associated with the need to be supported in clarification. They also refer to the recognition of the benefit when linked to a structured programme.

Class 3, entitled “Articulation with a drug-based programme” accounts for 28.18% of the text segments and focuses on the answers provided to people’s concrete requests when they need help. For this population, the articulation with a drug-based programme is considered essential, as can be seen in the following statements:

The words safety, nice, appointment, listen, reinforce the characteristics recognised and necessary in this articulation, for the safety it provides, related to the medication support and the therapeutic space that can be created.

In class 4 entitled “Needs-based support” (20.99%) emerges the expression of support considered fundamental to the needs expressed by the interviewees, related to what they feel helps them the most. From listening to their problems, to help to meet more objective needs:

The words handle, big, need and service, indicate the challenging way users look at the need they have, the help they need to cope and the huge commitment of professionals to articulate with different related services.

Class 5, called “Pillars of dignity” (14.92%), represented by the words home, receive, money, income, allows to verify a more objective relationship to class 4. The analysis allows to uncover the needs considered most pressing, such as having a home and an income, considered factors of individual dignity, essential in the roadmap of a program:

In this class, the words retirement, mother, living, salary are important because they are recognised as sources of financial support, sustenance, fundamental for personal dignity and quality of life. They show the economic dependence on parents and the added value of autonomy is pointed out by all.

The similarity analysis also led to the composition of 3 central nucleus, as observed in Figure 2, represented by the words programme, want and see. In the programa (programme) nucleus, the associated words: help and must sustain the pressing need for a response of support to people, with the commitment of all actors in the duty to intervene and refer to class 2. In this nucleus there is also a connection with the word think, revealing the uncertainty about the intervention in response to the consequences, then the word speak as a necessary and fundamental vehicle, which refers to class 4. We also highlight the connection with the word really, as the motivational positioning to change many variables related to the person’s condition. In the nucleus of want, the branch of walk stands out, which is associated with a behavioural change related to consumption and the word work, a need pointed out as essential for the improvement of the quality of life and facilitator of the motivational wanting, which is connected to class 5. The connection with the word take refers to the need for adherence to drug-based programmes, which emerged in class 3. This nucleus is strongly connected to the nucleus see, which refers to class 1, i.e. about the expectations of a programme with these characteristics. It is interpreted that there are more people in the same situation who need a more structured help (refers to class 2).

Discussion

This study sought to contribute to the identification of better settings for intervention programmes that meet people’s needs.

The substance-using population, especially those dependent on opiates and alcohol, are often integrated into drug-based programmes, and followed by multidisciplinary teams. These programmes try to respond to health needs, related to the severity of comorbidities such as hepatitis C, HIV, and diseases resulting from years of consumption and natural ageing, whether heart, gastric or respiratory⁴4 Pearson C. Perceptions and experiences of methadone maintenance treatment. J Addict Nurs 2019; 30(4):248-253.^,1515 Seabra P, Sequeira A, Filipe F, Amaral P, Simões A, Sequeira R. Substance addiction consequences: Outpatients severity indicators in a medication-based program. Int J Ment Health Addict 2022; 20:1837-1853.. The aim of the program is to help with situations of poorer mental wellbeing, such as depression, anxiety, distress, low self-esteem, cognitive decline¹⁶16 McKowen JW, Isenberg BM, Carrellas NW, Zulauf CA, Ward NE, Fried RS, Wilens TE. Neuropsychological changes in patients with substance use disorder after completion of a one month intensive outpatient treatment program. Am J Addict 2018; 27(8):632-638., and to promote a reduction in consumption and control of risk situations¹⁷17 Wieben ES, Nielsen B, Nielsen AS, Andersen K. Elderly alcoholics compared to middle-aged alcoholics in outpatient treatment-6-month follow-up. Nord J Psychiatry 2018; 72(7):506-511.. The programmes use different cognitive behavioural based interventions¹⁸18 Schuman DL, Slone NC, Reese RJ, Duncan B. Efficacy of client feedback in group psychotherapy with soldiers referred for substance abuse treatment. Psychother Res 2015; 25(4):396-407. with reinforcement of the motivational structure, individually or in groups¹⁹19 Amiri Z, Mirzaee B, Sabet M. Evaluating the efficacy of Regulated 12-Session Matrix Model in reducing susceptibility in methamphetamine-dependent individuals. Int J Med Res Heal Sci 2016; 5(8):77-85., in-person or remotely²⁰20 Tiburcio M, Lara MA, Martínez N, Fernández M, Aguilar A. Web-based intervention to reduce substance abuse and depression: A three arm randomized trial in Mexico. Subst Use Misuse 2018; 53(13):2220-2231..

In this study there was consensus among nurses and users on the benefit of a new structured programme, with moments focused on topics that empower people, as advocated by some authors⁶6 Van de Velde D, Zutter F, Satink T, Cost U, Janquart S, Senn D, De Vriendt P. Delineating the concept of self-management in chronic conditions: a concept analysis. BMJ Open 2019; 9(7):e027775.^,2121 Campbell ANC, Turrigiano E, Moore M, Miele GM, Rieckmann T, Hu MC, Kropp F, Ringor-Carty R, Nunes EV. Acceptability of a web-based community reinforcement approach for substance use disorders with treatment-seeking american indians/Alaska natives. Community Ment Health J 2015; 51(4):393-403.. The classes found in the textual corpus, and the words that integrate and specify their aggregation, reinforce this perspective, which is verified in the relationship between the classes that emerged from the FG and the interviews. There is an approximation in the benefit of a programme, with its actors well defined, with the necessary bond and motivation, centred on basic needs, in order to provide dignity. Flexibility is an essential condition for both groups of participants. This combination may help to build a programme that effectively pays attention to needs, as it is based on a common perspective.

A recent study, which listened to nurses and people undergoing treatment, about an intervention model in ABA found, similarly to this study, that integrated people recognise nurses as not only providing interventions for their physical care, but also as an essential source of psychological support. They also expressed the desire to see their role expanded in the management of methadone treatment and the possibility of nurses articulating and facilitating the connection to other necessary services³3 Comiskey C, Galligan K, Flanagan J, Deegan J, Farnann J, Hall A. Clients' views on the importance of a nurse-led approach and nurse prescribing in the development of the healthy addiction treatment recovery model. J Addict Nurs. 2019; 30(3):169-176..

From the words that were extracted from the participants’ discourse, we can highlight several that provide guidelines for intervention, such as support, listening, social support, money, want, which were also the target of attention in other studies, focusing on a more adequate social interaction, less drug and alcohol use, less psychological distress and increased motivation for therapeutic adherence¹⁹19 Amiri Z, Mirzaee B, Sabet M. Evaluating the efficacy of Regulated 12-Session Matrix Model in reducing susceptibility in methamphetamine-dependent individuals. Int J Med Res Heal Sci 2016; 5(8):77-85.^,2020 Tiburcio M, Lara MA, Martínez N, Fernández M, Aguilar A. Web-based intervention to reduce substance abuse and depression: A three arm randomized trial in Mexico. Subst Use Misuse 2018; 53(13):2220-2231..

The greatest advantage of a group intervention, mentioned as positive by the participants of this study, is the promotion of rehabilitation and social reintegration, as the exchange of experiences is seen as empowering to face factors that promote relapse²²22 Sousa JM, Farinha MG, Silva NS, Caixeta CC, Lucchese R, Esperidião E. Potencialidades das intervenções grupais em Centros de Atenção Psicossocial Álcool e Drogas. Esc Anna Nery 2022; 26:1-10.. The need not to stipulate fixed times of duration is identified, but it is recognised as one of the most effective in promoting capacity for reflection and self-knowledge²³23 Rettie HC, Hogan LM, Cox WM. Identifying the main components of substance-related addiction recovery groups. Subst Use Misuse 2021; 56(6):840-847..

There is a need to articulate professional support, with the support of peers with experience of addiction, which has been demonstrated to be effective²⁴24 Gilbert WC. Voices from the rooms and programs: recovery capital speaks. J Soc Work Pract Addict 2022; 22(1):53-67.. The difficulty in finding work is one of the factors pointed out by users as a problem for treatment adherence and quality of life. They consider it essential to receive help getting a job, as found in previous research with people in drug-based programmes²⁵25 Ware OD, Frey JJ, Cloeren M, Mosby A, Imboden R, Bazell AT, Huffman M, Hochheimer M, Greenblatt A, Sherman S. Examining employment and employment barriers among a sample of patients in medication-assisted treatment in the United States. Addict Disord Their Treat 2021; 20(4):578-586..

The relationship between the findings reinforces what has been found in other studies on the opinion and acceptability of interventions implemented in this area of addictions, where this exercise was carried out during the implementation of the intervention²⁶26 Imani S, Atef Vahid MK, Gharraee B, Noroozi A, Habibi M, Bowen S. Effectiveness of mindfulness-based group therapy compared to the usual opioid dependence treatment. Iran J Psychiatry 2015; 10(3):175-184. or, in a construction phase through participatory research²⁷27 Loth C, Schippers GM, Harm't H, van de Wijngaart G. Enhancing the quality of nursing care in methadone substitute clinics using action research: a process evaluation. J Av Nurse 2007; 57(4):422-431.. We found no other studies of prior collection of the opinion of professionals or experts by experience in this area of health care. This practice is not widely used in the construction of complex interventions¹¹11 Rousseau N, Turner KM, Duncan E, O'Cathain A, Croot L, Yardley L, Hoddinott P. Attending to design when developing complex health interventions: A qualitative interview study with intervention developers and associated stakeholders. PLoS One 2019; 14(10):1-20..

This study contributes to strengthening of the knowledge in the area of health and the specificity of nursing interventions, alerting to the satisfaction of complex needs and refocusing on the need to meet the most basic needs. The flexibility pointed out by nurses, but mainly by users, is a remarkable contribution to the construction of a new programme and challenges the foundations of previously defined interventions/programmes with mandatory contents and sessions for everyone.

This study has the size of the sample interviewed as limitation. Its analysis is directed to the context under study and with the specific objective outlined, and the results cannot be extrapolated to other contexts.

Conclusion

This study aimed to listen to participants’ voices - expert nurses and experts by experience - in a drug addiction follow-up process. People with ABA, assisted in specialised units, have an increasingly higher average age, with several physical and psychological comorbidities and polysubstance use, which reveals the severity of the consequences of drug addiction, with impact on several areas of life.

Based on the assumption that people followed in nursing consultations have benefits from this follow-up, we questioned nurses and users about the added value of a structured intervention programme. The acceptability and agreement to its applicability became clear, flexible, with no set time at the beginning, enabling moments of individual and group interaction, initially focused on the satisfaction of basic human needs and with an emphasis on support to get a job. The spaces for venting emotions and the help to cope with day-to-day situations were also among the most consensual strategies.

The users’ expectations are in line with those of the nurses. They welcome a constructive idea of a programme, recalling the need to create an effective bond with this intervention proposal on the part of the people included. They also stress the need to provide medication-based programmes articulated with this proposal. They indicate the benefit of focusing and centring the programme first on the most fundamental needs, with the subsequent offer of other interventions promoting well-being and less emotional suffering. They also point out that it is a basic human need to have a house to live in, preferably a house where the person can be autonomous and, complementarily, to have a job and an income. The challenges pointed out are enormous, due to the complexity of people’s life situations and the consequences of the problematic use of substances. There is a consensus on the need for and the benefit of a flexible therapeutic structure and strategies of attachment. It is highlighted how everything is articulated in the capacity to communicate and to help the other, listening, interpreting their signs of anguish, uncertainty and difficulty in making decisions. We believe that this perspective may be innovative, responding in a more individualised and holistic way, as opposed to interventions/programmes with modular sequences formatted in a stricter way.

References

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