Opioid Crisis: A Qualitative Analysis of Financial Influences and Addiction

The province of Ontario is currently engaged in a public health crisis centered around the use of opioids. As the number of opioid-related harms continues to grow, reports have identified a need for further investigation and understanding of opioid use.  The purpose of this qualitative study was to examine the differences in motives for opioid use amongst a diverse population. Data collection occurred by interviewing 14 participants at an Addictions Treatment Centre in Northern Ontario. Theoretical thematic analysis and an interpretive framework were used to analyze participants’ lived experiences with opioid use.  Analysis of the results revealed the theme of financial influence in addiction and recovery.  These insights are helpful in strengthening effective prevention and treatment strategies.  


Introduction
The province of Ontario is currently engaged in a public health crisis centered around the use of prescription and illicit opioids. According to a report from Public Health Ontario (2018), the number of harms related to opioid misuse has risen steadily in Ontario for over a decade. The rate of apparent opioid related deaths increased rapidly from 6.2 to 10.6 per 100,000 Ontarians

Methods Ethics
Ethical approval to conduct this study was sought and granted through the Research and Ethics Board of Laurentian University.

Setting and Sample
This research study was conducted at an Addictions Treatment Centre in Northern Ontario. One of the main priorities of this centre was the treatment of opioid addiction through methadone and suboxone programs. At the time of the study there were approximately 50 patients receiving treatment daily. The study relied on purposive sampling. Eligibility criteria included having personal experience with the use of prescription or illicit opioids, the ability to speak and understand English, and the ability to provide informed consent. The study did not exclude participants on the attribute of age, ethnicity, or culture. Participants were given the option to interview before or after receiving their scheduled dose of methadone or suboxone. Previous studies indicate that participants' treatment of methadone or suboxone should not affect their cognitive ability to accurately respond to interview questions (Anderson & McNair, 2018).

Data Collection
Recruitment for the study occurred over a span of three weeks. Paper copies of the invitation to participate were posted on a message board at the centre and left at the front desk for potential participants to take home. This process provided individuals with time to consider if they were eligible and willing to participate in the study.
The researchers interviewed participants who responded to the invitation to participate and met the eligibility criteria. Data was collected utilizing semi-structured interviews over a total of four days. Members of the research team met with participants in a private setting in the centre. The interview process began by reaffirming consent with the participant followed by the collection of demographic data which included age, gender, culture, and/or ethnicity. All interviews were audio recorded. The research team created and used an interview guide with open-ended questions derived from relevant literature to determine participant beliefs and personal motives for opioid use. For example, one question inquired about the participant's initial use with opioids. All participants were interviewed once. The interview durations ranged from 15 to 30 minutes, however, they were not limited to a specific time period. At no time did a participant indicate the need to withdraw from an interview. The research team continued to interview participants until data saturation was reached. The interviews were then transcribed verbatim by the research team.
Participant confidentiality was maintained at all times throughout the study. Participants were able to withdraw from the study or decline to respond to questions without consequence to their treatment.

Interview Safety Precautions
During the interview process, specific steps were taken to ensure the safety of participants. The first step required language sensitivity. Following the suggestions of Clark Diversity of Research in Health Journal / Revue de la Diversité de la Recherche en Santé Vol 4, January / Janvier 2021 - ISSN: 2561-1666DOI : 10.28984/drhj.v4i2.321 (2017, the research team avoided the use of language that could label the participants in order to support positive well-being. The second step to maintain participant safety was centred around modifying the interview process. Given the sensitive nature of the interview questions, there was a need to address potential risk for emotional distress and relapse. Based on the literature, the research team developed plans to manage emotional distress and triggers (Dempsey, Dowling, Larkin, & Murphy, 2016). The decision was made to conduct interviews at the centre on days when it was fully staffed to ensure the safety of all participants. The centre had healthcare professionals on site who were aware of the study and were prepared to provide immediate assistance if required as they had specialized training in addiction and supportive treatment. A question addressing participants' current mental well-being and desire to use opioids was included at the end of the interview. If a participant felt triggered to use opioids, they were encouraged to discuss it immediately with the healthcare professionals at the centre. Participants were also provided with a list of external resources which they could access at any time. The resources addressed addiction, trauma, and mental health.
The research team also developed a distress protocol which detailed instructions in the event that a participant experienced any form of distress. The protocol was adapted from literature on managing distress in qualitative interviewing (Dempsey et al., 2016;Drauker, Martsolf, & Poole, 2009;Haigh & Witham, 2015). The protocol addressed elements such as grounds for interview termination, reasons to initiate the protocol, and methods to manage immediate and continued responses.
An additional initial step taken by the research team was to develop their own knowledge of the sensitive interview process. Dempsey et al. (2016) provide guidelines for sensitive interviewing in qualitative research which include methods such as empathetic listening, developing trusting rapport with participants, having thorough knowledge of interview questions to allow for free-flowing conversation, and maintaining anonymity and confidentiality.
Another issue that was addressed by the research team was duty to report. Duty to report refers to the ethical responsibility of immediately articulate information regarding harm to oneself or others to the respective authority (Paquette & Ross, 2014). All information was kept confidential with the exception of statements that required a duty to report. A statement was included in the consent form which addressed the information requiring a duty to report.

Data Analysis
This paper presents a component of a larger research project examining motives for the use of opioids. To analyze the data, the research team utilized Braun and Clarke's (2006) inductive thematic analysis to serve as a guide for data collection and categorization of themes within the participants' narratives. In addition, Polio, Henley, and Thompson's (2006) approach to existential phenomenology was utilized to as the interpretive framework. The research team opted to use this dual approach, inductive thematic analysis and existential phenomenology, as a means to enhance the qualitative rigor of the study.
Diversity of Research in Health Journal / Revue de la Diversité de la Recherche en Santé Vol 4, January / Janvier 2021 -ISSN: 2561 -1666 DOI : 10.28984/drhj.v4i2.321 Following Polio et al.'s (2006) approach, it was essential for the research team to ensure that interpretation of the data remained close to the participants' narratives. To ensure these criteria were met, the research team utilized two techniques suggested by Polio et al. (2006) prior to data analysis. The first involved a bracketing technique in which members of the research team came together and openly reflected upon their potential biases, perspectives, and clarified any preconceptions regarding opioid use. The background of the research team consisted of nursing and sciences in which individual perspectives varied amongst members. The second technique involved the research team conducting an interpretive research group in which transcripts were selected at random, read aloud, and then discussed amongst the members of the group. By following these techniques, the research team ensured the focus remained on participants' narratives thus increasing the qualitative rigor of the study.
The research team then utilized Braun and Clarke's (2006) inductive thematic analysis to identify themes and patterns within the data. As inductive thematic analysis is driven by the data (Braun & Clarke, 2006), participants' narratives were coded without trying to fit them into existing frames. Therefore, the research team individually read the transcripts line-by-line and grouped excerpts into equivalent or related trends. Once this step was completed the research team met to collate pertinent excerpts from the participants' narratives. A final third reading of the data occurred to ensure the data formed coherent themes and patterns. Where there was disagreement regarding whether a data excerpt aligned with a specific theme, it was discussed amongst the research team until consensus was reached.

Findings Description of Participants
Participants were patients of the centre seeking either methadone or suboxone treatment. The final sample included a total of 14 participants. Nine participants identified as female and five identified as male. Participant ages ranged from 26-58 years old. Participants self-identified as Indigenous, Caucasian, French Canadian, and Italian.

Presentation of Results
Thematic analysis segmentation resulted in 19 excerpts which yielded a theme of financial influence throughout the lived experience of opioid addiction and recovery of participants. The excerpts were analyzed further and grouped into patterns representing the different roles financial influence played throughout the participants' experience with opioids as presented in Figure 1. This theme was sub-divided into four patterns: Funds As a Motive to Seek Methadone or Suboxone Treatment, Funds As a Motive to Continue to Use Opioids, Funds As a Motive to Maintain Compliance with Treatment, and Funds As a Motive to Seek Alternate Substances. Pattern 1. The first pattern was Funds As a Motive to Seek Methadone or Suboxone Treatment. During interviews the participants easily provided descriptions about the financial burden of maintaining their opioid addiction and the associated stress. Participants shared that they no longer had the resources to purchase opioids and therefore were motivated to seek treatment as a last resort. I003: "Once you start running low on money or food you know, it's like you can't buy it [opioids], you physically can't." Some participants stated that their reason for seeking treatment was the realization of how high the cost of maintaining their opioid addiction was becoming. These participants continued to describe the stress related to this reality.

I014:
"If it wasn't so expensive […] I probably would've kept on [abusing opioids]." I004: "Just my life was like becoming unmanageable […] Financially and mentally." Other participants expressed the view that their motivation to seek treatment stemmed from the emotional burden of being financially dependent on either family members or friends to maintain their addiction. Some participants also expressed guilt as they believed they financially burdened their family and or friends.

I001
[Mom] was living with me and every time I was sick and needed money for a pill all my money was gone so I would turn to her. She would offer to help but I shouldn't have took it because I would make her broke. And everyone around me, family too.
In contrast, a few participants revealed that their motivator to seek treatment was the mental burden of financially supporting their own opioid addiction in addition to other dependants.
I012: "I actually had a complete mental breakdown, I was actually working and supporting three other people… I couldn't take it anymore. I just had a complete mental breakdown." Pattern 2. The second pattern was Funds as a Motive to Continue to Use Opioids. Participants discussed how having the financial resources to fund their addiction was a motivator to seek and use opioids. For some participants the availability of money provoked them to use opioids.
I003: "So like if they do have money, they, they will want to go out and use like it is so hard to explain." I008: "Right now I can't have money. I can't hold on to money… It's one trigger lately I've been having hard time with money… just 20 bucks and I want to go run." Some participants also suggested that if money was replaced with resources such as food, clothes, and stable housing the motive to seek or use opioids would be removed.

I003:
If people are committed and they have the mindset to stay off, it will help them. It will. But if they get you know, money in their hands, they're going to go out and use. Like let's say they win the lottery for five grand, it's going to drugs. Whether they are on this program or not. So like you have to almost take away everyone's money, put them on the system, and they will do good.
Some participants were aware of their spending habits, while others did not realize how much they were spending until after seeking methadone or suboxone treatment.
I009: "I didn't realize then like how much money was getting spent on drugs and… Yeah they were a lot." I003: "They know that they can waste $2000 on it [opioids] … I was spending $120 a day on fentanyl patches." Pattern 3. The third pattern was Funds as Motive to Maintain Compliance with Methadone or Suboxone Treatment. The low cost of methadone and suboxone treatment acted as a motive for some participants to continue receiving treatment. Several participants stated that after they began with methadone or suboxone, the financial toll of their addiction was greatly reduced.
Diversity of Research in Health Journal / Revue de la Diversité de la Recherche en Santé Vol 4, January / Janvier 2021 -ISSN: 2561 -1666 DOI : 10.28984/drhj.v4i2.321 Participants were pleased that they no longer had to continue with behaviours in order to fund their addiction.
I014: "I think it's lifesaving for a lot of people… you don't suffer the negative things in life of … no money and what you have to do for money in order to get the stuff which is ridiculously expensive..." In addition, no longer having to fund an addiction allowed participants to begin to stabilize other aspects of their lives. Participants also found the psychological strain of knowing they must take part in undesirable activities to get money to buy opioids was also alleviated after receiving treatment. Pattern 4. The final pattern was Funds As a Motive to Seek Alternate Substances. Several participants explained how the cost of different substances acted as a motive for them to seek cost-efficient substances. Participants noted that the long lasting effect of opioids compared to the short lived effects of other similarly priced substances such as stimulants was a reason they continued to use opioids. In this sense, many participants viewed opioids as cost effective which was a reason they gravitated towards these types of substances.
I011: "Cocaine is $100 a gram too. It's not cheap. I mean I can do three to four hundred worth of cocaine injection in a night […] whereas no one can do that much heroin in a night." Additionally, some participants found that the varying costs of different opioids was a motive to try new opioids, especially if they were less expensive. The cost of opioids also acted as a motive to try using different routes of intake in order to achieve greater effects for the same cost.

Discussion
Based on participant narratives, it was clear that financial influence was apparent throughout their lived experiences involving opioid addiction and recovery. This theme was unexpected by the research team. Despite none of the interview prompts alluding to finances, this topic was commonly brought up by participants. Although financial influence is mentioned in previous substance abuse and opioid literature, it is seldom presented as a motive for the use of opioids. The unexpectedness of this finding may be related to the qualitative nature of the research work. Qualitative methods provide the context for researchers to examine participant experiences as a whole rather than a specific aspect of the experience (Ivey, 2012). Through a qualitative methodology the researchers determined that finances influence participants' experiences with opioids. Based on this study's findings the authors suggest that financial factors may influence multiple aspects of the experience such as seeking and using opioids, choosing types of opioids and routes of administration, making decisions to seek treatment, and remaining compliant with treatment.
The findings also demonstrate how finance can influence individuals who use opioids to seek methadone or suboxone treatment. This finding supports previous literature which highlights how the cost of opioids can act as a motivating factor to initially seek treatment (Amini-Rarani, Khedmati Morasae, Pashaei, & Moeeni, 2020; Bansal, Sidana, & Mehta, 2019;Andrews, Kramer, Klumper, & Barrington, 2012;Parmar, Patil, Sarkar, & Rao, 2018). In addition to demonstrating how a lack of funds can motivate opioid users to seek treatment initially, the findings also suggest that finance influences opioid users to continue with treatment. This suggests that the role finance plays in addiction should be examined throughout the entirety of the recovery process. Methadone and suboxone treatment are more affordable than illicit opioids in Ontario (Zaric, Brennan, Varenbut & Daiter, 2012). The authors of this study believe it is of interest to explore how the role of finance changes in locations where methadone and suboxone treatment is more expensive.
The pattern of findings demonstrating Funds as a Motive to Continue to Use Opioids describes how some participants viewed the availability of money as a motivator or trigger to seek and use opioids. This finding is supportive of previous substance abuse literature on the association between finance and drug use. One phenomenon suggested by previous literature is termed the "check effect" which was described as an increase in illicit substance use and related harms at times in which individuals receive income assistance (Hoj, Jacka, Minoyan, Bussiere, & Bruneau, 2020;Otterstatter, Amlani, Guan, Richardson, Buxton, 2016;Rosen, 2011). While some authors (Rosen, 2011) suggest that income assistance has little impact on overall drug use, other authors contend that any sudden financial gain may be a cue for individuals to use drugs (Hamilton & Potenza, 2012;Obrien, Childress, McLellan, & Ehrman, 1990). The findings from the current study support financial gain as a cue to use opioids as participants stated that receiving any form of money was a motivator to seek and use opioids. As a result, the authors suggest that the availability of money plays a vital role in opioid use and methadone and suboxone treatment. Furthermore, individuals should have continued access to funding supports Diversity of Research in Health Journal / Revue de la Diversité de la Recherche en Santé Vol 4, January / Janvier 2021 - ISSN: 2561-1666 as well as increased ongoing assistance from healthcare services. Another finding was that some participants in this study were aware of their association of financial gain and opioid use. Increased awareness of this personal association may provide individuals in methadone or suboxone treatment with the opportunity to self-identify and report to friends, family, or healthcare professionals for assistance when they are at an increased risk for relapse.
Another relevant process is "delay discounting" which is described in literature as the process where an individual places high value on immediate short-term rewards and "discounts" the value of long-term rewards (Daugherty & Brase, 2010;Hamilton & Potenza, 2012). Previous studies have suggested that those who abuse substances are more likely to delay discount than non-abusing controls (Black & Rosen, 2011;Daugherty & Brase, 2010;Hamilton & Potenza, 2012). This phenomenon has also held true in studies specific to opioid use (Giordano, Bickel, Loewenstein, Jacobs, Marsch, Badger, 2002;Robles, Huang, Simpson, & McMillan, 2011). Many studies have suggested a positive association between delay discounting and financial mismanagement in substance abusers (Black & Rosen, 2011;Hamilton & Potenza, 2012). The findings of the current study support the existing literature as some of the participants did not recognize the long-term consequences of their spending until their financial situation became unmanageable.
Given the findings supporting delay discounting and the overall theme of financial influence, the researchers question how individuals who use opioids would be affected by the social determinants of health. It is understandable that financial influence is directly related to income and socioeconomic status. Previous literature has suggested that wealthier individuals may be less likely to delay discount (Hamilton & Potenza, 2012). Therefore, it may be possible that individuals who use opioids and are of low income are more likely to associate the availability of money as a cue for drug use. Social and economic factors are also known to exacerbate risk behavior and affect the overall health of drug users (Galea & Vlahov, 2002). According to Van Draanen, Tsang, Mitra, Karamouzian and Richardson (2020), socioeconomic marginalization is associated with an increased likelihood of overdose. Socioeconomic factors such as income and housing have also been suggested to amplify the previously mentioned check effect phenomenon, leading to increased negative health and financial outcomes (Goedel, Green, Viner-Brown, Rich, & Marshall, 2019). As displayed by the findings of this study, opioid addiction can heavily affect an individual's socioeconomic status. Therefore, the risk of delay discounting and opioid related harm may change over an individual's life as their socioeconomic status changes. The researchers suggest a need for further research on the connections between the social determinants of health, financial influence, and opioid-related use and harms. The researchers also recommend a need for further investigation regarding the efficacy of programs focused on improving financial management specific to opioid misuse. Finally, the authors of this study emphasize the need of effective interventions that serve to reduce potential health inequities associated with financial influence.
Recent Canadian reports have detailed a dramatic increase in opioid related harms since government mandated quarantines began in March of 2020 as a result of COVID-19 (Canadian Centre on Substance Use and Addiction, 2020; Public Health Agency of Canada, 2020). Additionally, the Canadian economy has been greatly affected with current employment down approximately 1.3 million as result of the pandemic (Statistics Canada, 2020). The government has created initiatives to financially support Canadian citizens such as the Canadian Emergency Response Benefit (Government of Canada, 2020). Given the findings of this study and supporting evidence in the literature such as delay discounting and the social determinants of health, it is unknown how the availability of money and socioeconomic status will affect individuals who use opioids. A recent report from the Canadian Centre on Substance Use and Addiction (2020) found that individuals who use substances such as opioids have reported a loss of social connection and support as well as an increase in isolation and anxiety during the COVID-19 pandemic (Canadian Centre on Substance Use and Addiction, 2020). Based on the current evidence and the findings of this study, the authors contend there is an urgent need to discover interventions to effectively support individuals who use opioids during the COVID-19 pandemic.

Limitations
Participants' responses may have been affected by a passage of time as they spoke of past experiences. The sample population in this study included individuals from one treatment centre and thus reflects the lived experience of one sample. However, the findings may not be generalizable to other treatment Centres.

Conclusions
Using interviews to collect data was found to be an effective method of obtaining information on participants' experiences with opioids. All participants shared that they were comfortable with the interview process. Several participants also explained that they found the process to be therapeutic and rewarding and stated they were thankful for the opportunity to articulate their story. Using a qualitative approach with precautions and supports can create a safe environment to collect data. Similar qualitative approaches should continue to be used synergistically with quantitative data to understand the motives for opioid use and treatment.
This qualitative research study interviewed individuals seeking methadone and suboxone treatment at an Addictions Treatment Centre in Northern Ontario. Analysis of participants' experiences with opioids revealed financial influence as a recurring theme throughout their addiction and recovery. The theme of financial influence was subdivided into four patterns: Funds As a Motive to Seek Methadone or Suboxone Treatment, Funds As a Motive to Continue to Use Opioids, Funds As a Motive to Maintain Compliance with Treatment, and Funds As a Motive to Seek Alternate Substances. These findings will contribute to a larger body of empirical knowledge that can be beneficial in preventing and treating opioid addiction. There is a progressive need for future studies to gain a better understanding of individuals and opioid crises.