HEROIN DEPENDENCE RECOVERY THEORIES

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CHAPTER FOUR RESEARCH DESIGN

INTRODUCTION

Qualitative research techniques are now a commonly used and accepted means of social enquiry, particularly in the field of mental health behaviour. Although survey methods remain dominant, there is recognition that qualitative research methods have the capacity to inform survey designs and to complement findings. Importantly and in their own right, they provide a means of interpreting behaviours which might otherwise seem inexplicable. This is particularly the case among ‘hidden’ or ‘hard-to-reach’ populations – such as heroin users – where there exist practical and methodological difficulties in the use of large scale quantitative surveys (Dos Santos & Van Staden, 2008; Dos Santos, 2006; Breakwell, Hammond, & Fife-Shaw, 1995). While there is evidence of an emerging interest in qualitative studies on a range of aspects of drug using lifestyles since the 1980s, this has largely focused on local drug markets, crime and drug use ‘careers’. The public health imperative to reduce HIV infection associated with heroin use brought about renewed interest in the use of qualitative methods in the field of illicit drug use research in some countries. It was the recognition of a lack of knowledge about risk behaviours associated with heroin / drug injecting which initially spurred interest abroad in undertaking small scale qualitative projects to specifically investigate needle sharing and sexual risk behaviour (Hughs, 2004). Rather than being understood from the perspective of the individual alone, risk behaviours have been shown to be best understood as highly sensitive to the relationships of heroin / drug injectors with each other in the context of the social circumstances and environments in which they find themselves (Wechsberg, Luseno, Lam, Parry & Morojele, 2006; Hughs, 2004). In countries where a tradition of qualitative research exists, such methods have emerged as particularly well suited to studies of risk associated with drug injecting, and are particularly valuable in the development of public health interventions (Brook, Morojele, Zhang, & Brook, 2006). Yet it is important to recognise that the increased receptivity to the use of qualitative methods since the advent of HIV/AIDS is not indicative of a long-standing or major shift in the relative status or dominance of ‘positivist’ or ‘interpretive’ research paradigms. Such divides still tend to impede the combined use of quantitative and qualitative methods in the substance use disorder field (McKeganey, 1995). Instead, the increased interest in qualitative research reflects the practical as well as the methodological utility of qualitative methods in understanding and responding to public health problems among hidden populations. The present analysis, at the purely descriptive level, primarily concerns itself with the experience and expertise of specialists in the field of heroin use disorder intervention. These findings will be contrasted / compared with those of the long-term voluntarily abstinent heroin dependents in the previous study conducted by the present author (Dos Santos & Van Staden, 2008; Dos Santos, 2006).

RESEARCH DESIGN

Methodological paradigm

A qualitative descriptive research approach has been used for the specialist participant interviews. One of the strengths of qualitative research is the comprehensiveness of the perspective it provides. This research design, then, is especially, though not exclusively, appropriate to research topics and social studies that appear to defy simple quantification. Qualitative researchers may recognise nuances of attitude and behaviour that might escape researchers using other methods. Another advantage of qualitative research is that it allows for the modifying of the research plan at any time and the adaptation of methodology, time frame and other specifics of the study to suit the objectives of the study, which not only increases the validity of findings, but allows for more control and freedom in the research process (Babbie & Mouton, 2002). The chief shortcoming of the chosen methodology is that it may not provide conclusive answers to the research objectives, but may allude to the answer and could furnish insights into the research methods that might provide more definitive answers. The analysis of material is potentially subject to researcher bias. Ultimately, however, the aim of the study is to provide an explorative and descriptive account of the recovery process stemming from interviews with heroin use disorder specialists. To this end, because the participants interviewed are regarded as specialists in their discipline and in the field of heroin use disorders, the information collected seems likely to offer a high level of corroboration.

 Measurement

4.2.2.1 Sampling procedure and data collection
Purpose sampling / interviews were conducted with ten specialist participants in the field of heroin use disorder intervention. This sampling method was chosen based on the objectives of the study, that is, the participants were recruited on the basis of their reputation / specialisation within the said South African field. Although shortcomings in representatives may be evident since the specialist participants represent different professional disciples (as various professional disciplines are involved in heroin use disorder intervention), the most easily identifiable persons were approached based on the author’s judgement, which has been established after ten years of professional experience within the heroin use disorder intervention discipline (Babbie & Mouton, 2002). The interviews were conducted from April 2004 to March 2008. No incentive was offered to the specialist participants during recruitment. Before the interview commenced, a standardised plan of the interview was read out to each specialist participant and they were assured of confidentiality and anonymity. These participants were also informed that they were under no obligation to answer any questions with which they were uncomfortable, and that they were free to pause for a break or terminate the interview at any time. The biographical particulars of the specialist participants were documented by the author, after which an interview with each such specialist participant was tape recorded.
Specialist 1 is a director and founder of an established rehabilitation centre, and is also registered as a National Association of Alcoholism and Drug Abuse Councillors (NAADAC) counsellor. The specialist is also a long-term abstinent heroin dependant (the individual was dependent on heroin for twelve years, and is now thirteen years abstinate). The specialist has been involved in the substance use disorder rehabilitation field for the last twelve years.
Specialist 2 is head of a university psychiatry department and was formerly involved on a leading level within the Central Drug Authority. The specialist possesses extensive international experience within the substance use disorder field, specifically with regards to heroin use disorder assessment and intervention, having worked in Singapore, Hong Kong, Canada, Australia, the SADC region, Western and Central Africa, Thailand, the United Kingdom and the United States. The specialist is also a board member of the South African Medical Research Council and of the International Council on Alcohol and Addictions (ICAA).
Specialist 3 is an Executive Director of an organisation that specialises in substance use disorder research, advocacy and policy formulation for state departments. The specialist holds a diploma in drug and alcohol policy and intervention from the University of London, and has over seventeen years of experience within this specialised field. The specialist is also a recovering heroin dependant (the individual was dependent on heroin for six years, and is now twenty-nine years heroin abstinate).
Specialist 4 is a social worker from the National Department of Social Development who has worked for over fifteen years within the substance use disorder field, specifically with heroin dependent committals for rehabilitation. The specialist is also an honorary member of Narcotics Anonymous and renders a facilitator role within Nar-Anon.
Specialist 5 is a social worker who formerly worked for a state hospital. The specialist managed an outpatient programme for heroin dependents for five years and also worked in the United Kingdom with heroin dependents.
Specialist 6 is a board member of ToughLove South Africa. The specialist has dealt with the many families of heroin dependents for the last fifteen years.
Specialist 7 is a medical sister, specialising in psychiatry, who was employed within the SANCA network for seventeen years, and has medically attended to many withdrawing heroin dependents since the surge of heroin use disorders in 1995.
Specialist 8 is also a medical sister who has been employed within the SANCA network for twelve years. The specialist has been involved in the assessment and medical intervention of heroin dependents since 1995.
Specialist 9 is a general medical practitioner who has for the last five years, in a private practice capacity as well as at a private psychiatric institution, practised within the field of heroin use disorder intervention. The specialist has also undergone training with regard to buprenorphine maintenance intervention regimes.
Specialist 10 is a clinical psychologist, also qualified and experienced as an anthropologist, who has worked in private practice for twenty-three years. The specialist, who also runs offices at Vista Clinic (a private psychiatric clinic), has dealt clinically with clients presenting with heroin use disorders since the onset of the heroin dependence syndrome in South Africa in 1995.
4.2.2.2 Semi-structured interviews
Semi-structured individual interviews were conducted with the heroin use disorder specialists in order to gain a detailed picture of their perspective with regard to heroin use disorder intervention and recovery. According to Babbie and Mouton (2002) this method provides much more flexibility than the more conventional structured interview, questionnaire or survey, because the participant offers a fuller picture and the researcher is free to follow up interesting avenues that emerge in the interview. Babbie and Mouton (2002) also describe the ‘natural fit’ that exists between semi-structured interviewing and qualitative analysis. By employing qualitative analysis an attempt is made to capture the richness of the emerging themes rather than reducing the responses to quantitative categories, and wasting the opportunity provided by the detail of the verbatim interview data (Babbie & Mouton, 2002). The inductive nature of this approach is unique in that it assumes an openness and flexibility of approach that allows a conceptual framework to emerge from the data.
The semi-structured interviews with heroin use disorder specialists were tape-recorded. The interview between the author and specialist participant followed a general plan of enquiry, and an interview schedule with relevant ‘probes’ was utilised. The specialist participants were asked the following initiating question:
‘What interventions, both psychosocial and pharmacological / medical, are in your opinion the most effective in treating heroin dependence?’
Various ‘probes’ were employed in order to further investigate their views regarding various aspects associated with heroin use disorder intervention. These probes were derived from diverse sources such as the professional experience of the author, the literature review, and from the findings of Dos Santos and Van Staden’s (2008) study regarding heroin dependence recovery.
Is there a difference between treating heroin use disorder compared to other types of psychoactive substances?
What is your view with regards to the length of treatment / intervention?
Do you think that harm-reduction approaches, such as needle exchange programmes and methadone maintenance programmes, are beneficial or not within the recovery process?
Are you of the opinion that any specific type of psychosocial intervention is the most appropriate for treating heroin use disorders?
If you are of the opinion that medication should be prescribed, what medications for (a) withdrawal symptoms (b) cravings, are most conducive toward heroin dependence recovery?
4.2.2.3 Interview analysis
The interview recordings, which ranged from 14 to 42 minutes, were subsequently transcribed. Grounded theory analysis was employed to analyse the interview information. Grounded theory holds as a basic tenet that qualitative researchers do not go around testing a hypothesis to add to an already existing body of knowledge, but rather that they ‘do not know what it is that they do not know’ (Babbie & Mouton, 2002:449). This was especially important considering the scarcity of research within the heroin use disorder intervention discipline in South Africa. When the principles of grounded theory are followed, the researcher formulates a theory, either substantiative (setting specific) or formal, about the phenomena they are studying that can be evaluated (Glaser, 1992; Strauss, 1987). Adriaan Van Kaam’s ‘The Addictive Personality’ subscribes to an existential-phenomenological approach to understanding substance use disorders, in which substance dependence is described as a mode of existence, that embodies its own fundamental attitude and way of relating to the world (Van Kaam, 1966). Grounded theory, in accord with the existential-phenomenological approach, is one that is inductively derived from the study of the phenomenon it represents. That is, it is discovered, developed, and provisionally verified through systematic data collection and analysis of data pertaining to that phenomenon. Therefore, data collection, analysis and theory stand in a reciprocal relationship with each other. A theory is not established from the outset of the study and subsequently an attempt to prove the theory embarked on, but rather an area of study is initiated and what is relevant is allowed to emerge (Babbie & Mouton, 2002, Breakwell; Hammond, & Fife-Shaw, 1995). Transcribed interviews were read, subjected to grounded theory analysis, and discussed by the study’s promoter and author / researcher in order to determine the usability of the material and the categorising of themes within the interviews; this increased the inter-rater reliability of the study. Interviews were then purged of all connecting words in order to separate out words containing meaning versus words lacking significance (Elgie, 1998). In order to authenticate the interpretations, conclusions regarding the interviews were taken back to all the specialist participants for possible enrichment and verification of interpretations / significance (Breakwell et al., 1995).
The interview comprised separate meaning units. These units were determined by phrases or paragraphs that were able to stand on their own and generate meaning. The translation of interviews into such units involved using the participants’ own language in order to best generate a true meaning of their language. Categories were established by removing the meaning units from the rest of the interview and applying phrases that would encompass several of these units at once in their totality. These categories were coded in order to identify the regularities. Categories that were clustered together became themes (Elgie, 1998).
The discussion of the findings was organised in the following way:
* the themes that were derived from the interviews of ten heroin use disorder specialists were explored in order to discover the explicit factors deemed necessary in facilitating heroin use disorder intervention and recovery;
* the presumption with regard to the themes is discussed and compared to the actual data that was derived from interviews; and
* the themes and their meanings were compared with the findings of an earlier study regarding heroin dependence recovery by Dos Santos and Van Staden (2008) and Dos Santos (2006), as well as with the existing literature regarding this subject.
It is anticipated that the views / input from the heroin use disorder specialists will contribute to the advancement and planning of heroin use disorder intervention services / programmes.

ETHICAL CONSIDERATIONS

* The principle of informed consent was adhered to in the study. The specialist participants were fully informed with regards to all aspects in the study that might reasonably be expected to have influenced their willingness to participate in the study (Zechmeister & Shaughnessy, 1992). All specialist participants were also informed of the author’s / researcher’s status as a doctoral student studying heroin use disorder intervention.
* Understandable language was utilised when obtaining the appropriate informed consent. Each specialist participant’s consent was appropriately documented (The Professional Board of Psychology, Health Professions Council of South Africa, Ethical Code of Professional Conduct, 2002).
* Informed consent was obtained from each specialist participant for the recording for the interviews (The Professional Board of Psychology, Health Professions Council of South Africa, Ethical Code of Professional Conduct, 2002).
* Input from all specialist participants was treated in confidence, although due to the nature of the method of data collection (interviews), the participants cannot be considered to be anonymous since the interviewer collected the information from an identifiable participant (Babbie & Mouton, 2002). However, all information contributed was regarded as confidential and is only identified by numbers. No identifying information was included in the thesis itself, and conclusions in the study were not ascribed to any particular specialist participant.
* The welfare of the specialist participants in the study was addressed at all times. The harm to someone who participated in the study was not greater than the risk that the specialist participant would normally have encountered (Breakwell et al., 1995). Due to the explorative nature of the study and characteristics of the participants, it is not anticipated that this ethical consideration would have been contravened.
* No form of deception was utilised within the study. Due to the explorative nature of the study, all specialist participants were fully informed with regards to the nature of the study (Babbie & Mouton, 2002).
* From the outset of the study it was made clear to the specialist participants that they had the right to withdraw from the study at any time without any negative effects for them (The Professional Board of Psychology, Health Professions Council of South Africa, Ethical Code of Professional Conduct, 2002; Breakwell et al., 1995).
* It was made clear to the specialist participants that there was no form of direct benefit from participating in the study (Elgie, 1998).
* The contact numbers of the author / researcher and the UNISA Psychology Department Ethics Committee were provided on the consent form for any questions or comments regarding the conduct of the study.
* All findings have been reported and will be made known to the scientific community. Technical shortcomings have been indicated; limitations of the study and methodological restraints that determine the validity of the study has also been specified (Babbie & Mouton, 2002).

SUMMARY

The overall aim of the study was to conduct qualitative research, exploring in detail the views of specialists in the field of heroin use disorder intervention. The findings of this study have subsequently been recorded in the following two chapters.

CONTENTS
ACKNOWLEDGEMENTS
KEY TERMS
SUMMARY
CONTENTS
TABLES
CHAPTER ONE  INTRODUCTION      
1.1 BACKGROUND
1.2 RESEARCH OBJECTIVES
1.3 CHAPTER CONTENTS
1.4 SUMMARY
CHAPTER TWO DEFEATING THE DRAGON: HEROIN DEPENDENCE RECOVERY 
2.1 BACKGROUND
2.2 HEROIN DEPENDENCE RECOVERY THEORIES
2.3 OBJECTIVES OF THE STUDY
2.4 RESEARCH DESIGN
2.5 RESULTS
2.6 DISCUSSION
2.7 SUMMARY
CHAPTER THREE HEROIN USE DISORDER MYTHS AND PRIMARY INTERVENTION MODALITIES 
3.1 HEROIN USE DISORDER MYTHS
3.2 PRIMARY THERAPEUTIC INTERVENTION MODALITIES
3.3 PRIMARY PHARMACOLOGICAL INTERVENTIONS
3.4 RESTORATIVE JUSTICE / DIVERSION PROGRAMMES
3.5 NEEDLE EXCHANGE PROGRAMMES
3.6 SUMMARY
CHAPTER FOUR    RESEARCH DESIGN      
4.1 INTRODUCTION
4.2 RESEARCH DESIGN
4.3 ETHICAL CONSIDERATIONS
4.4 SUMMARY
CHAPTER FIVE RESULTS      
5.1. THE GLOBAL EMERGENCE OF HEROIN USE DISORDERS
5.2 THE IMPACT OF HEROIN USE DISORDERS ON SOUTH AFRICA
5.3 INTERVENTION
5.4 SUMMARY
CHAPTER SIX DISCUSSION AND CONCLUSION  
6.1. PROHIBITION VERSUS DECRIMINALISATION / LEGALISATION
6.2 HEROIN USE DISORDER INTERVENTION WITHIN THE SOUTH AFRICAN CONTEXT 126
6.3 HEROIN USE DISORDER ASSESSMENT AND INTERVENTION
6.4 HEROIN USE DISORDER INTERVENTION
6.5 INTERVENTION SERVICE PERSONNEL
6.6 HEROIN USE DISORDER INTERVENTION EFFICACY
6.7 PRACTICE, POLICY AND FUTURE RESEARCH IMPLICATIONS
REFERENCES

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