We organized categories and themes found during data analysis in a flow diagram, plotted in Figure 1.
After an initial period of experimenting with drugs during adolescence, all participants in our study evolved through cycles of substance use, treatment, desistance, recovery, and relapse before starting the current MAT program. Internal (i.e., cognitive and affective) processes, the social environment, and different events that occurred in the participants’ lives during the pre-treatment stage motivated them to abstain from drug intake, while the treatment motivated them to sustain recovery. Two opposing driving forces were buried deep inside the participants during their substance use career and at the initial stages of treatment. On one side, there was a desire to make lifestyle changes, enhanced by the vision of returning to a functional life, while on the other side, the drug cravings were constantly pulling them back. By a functional life, we mean the ability to secure housing and employment and to reestablish severed ties with family and friends. The participants perceived that under the current MAT, a transformation started to occur, a change in their life course consistent with Elder’s conceptualization of turning points . The transformation that produced the eagerness to sustain recovery was mainly related to the satisfaction of certain psychological needs such as safety, love and belonging, or esteem postulated by Maslow’s motivational theory [29, 30, 31]. The participants did not perceive MAT as an isolated event in their lives, but rather a process occurring within a specific social context. They deemed the structural factors and the sense of acceptance and belonging as essential to supporting the transformation. Additionally, the social context and the perceived warmth displayed by the clinical professionals were considered of great importance for treatment success.
From the participants’ perspective, MAT promoted a positive self-evolution, the possibility to resettle social bonds, and, subsequently, the reconstruction of a new personal and social identity. The level at which this transformation is attained might contribute to determining the recovery or, conversely, future relapse. We analyzed the factors that promoted abstinence from illegal drug use and the perspective of treatment as a turning point separately.
3.1 Factors contributing to abstinence of illegal drug use and sustained recovery
There were circumstances in the participants’ lives before they started the current MAT, which progressively strengthened their motivation to stop abusing drugs and seek treatment.
3.1.1 Pre-treatment stage
Before they entered the current MAT, the participants’ daily lives were dominated by illegal drug use and their struggle to find the resources to nurture their addiction. The participants reported that individuals with an OUD are never satiated. Although opioids provided many pleasant feelings and sensations, the withdrawal symptoms and unpleasant emotions produced if drugs were not available dominated the individual’s inner lives and pushed them to an almost continuous search for more drugs and resources to buy them. During their substance use careers, there were moments when the participants perceived their lifestyle as almost unbearable and impossible to continue for long. “Kevin” explained:
‘You wake up in the morning and you feel really bad, so you have to get hold of money to buy it [heroin]. Then you have to walk around and steal, or commit a burglary... often [I] was shoplifting during the day... and you sell it [the stolen merchandise] to get money, then you get drugs, then you take it, then it started all over again. A fucking squirrel wheel.’
As the participants kept using opioids illegally, they started to develop many physical and psychological symptoms, which created a significant strain that became difficult to manage. They revealed that they did not perceive that they were in control of their behavior and had developed feelings of helplessness. At the same time, the participants hid their addiction from those in their immediate environment who could have ultimately served as social support. Overwhelming feelings of guilt and shame dominated their emotional life, leading them to sever all bonds with relatives and friends. “Matts” decided to leave home when he started taking drugs:
‘I wouldn’t care about having a good life, I just wanted to feel good, but I wouldn’t ever expose my mother to the turmoil and the torments ... she has been so worried about me, and I feel bad about that.’
Isolation from normative social groups was a problem identified by all the participants during the period in which they were using illegal drugs. A bidirectional causal relationship resulted wherein the participants turned away from family and friends because they were taking drugs, and then they took drugs because they could not bear the feeling of loneliness. Besides those with whom the participants shared the drug-related environment, they became more secluded, trapped in a progressively more unsustainable lifestyle. The loss of jobs and other normative sources of income, the lack of resources to maintain a high level of drug consumption, and the absence of social support all contributed to their psychological strain. They informed us how social isolation carves hard within the individual not only while they are using illegal drugs, but it is also carried like a heavy burden when enrolling in treatment. “Markus” pointed out:
‘The first thing I did was to break with everyone. I threw away the phone for a whole year. I think that was what saved me... you get a little lonely when you become drug-free, at the beginning.’
Because support networks have been found to play a crucial role in sustaining recovery [47, 48], they should be considered when the individual starts treatment.
Their unbearable life situation and the social isolation led the participants to an increasingly strong desire to modify their lifestyle to achieve a certain level of normative social functioning. All participants described initial drug use during early adolescence, mainly with alcohol and cannabis, with a quick escalation to using other substances such as opioids. They reported that when dependency struck, the desire for change grew stronger, reinforcing positive attitudes toward treatment and furthering the motivation or intention to quit using illegal drugs. In some cases, an event that had significant meaning for the individual triggered or reinforced the desire for change. In the case of “David,” it was the illness of his mother:
‘When my mom was lying in bed at the hospital I thought I had to do something about it [drug addiction]; she just can’t die knowing that I, yes, I’m doing it [taking drugs]’
As the motivation to cease illegal drug use grew, the participants highlighted that they started seeking treatment. All the individuals in our study disclosed having been involved in treatment several times before starting the current MAT. Some of them perceived the experience of recurring cycles of drug use-treatment-relapse as a personal failure, contributing to the feeling that abstinence was not under their control. “Robert” informed us:
‘I have tried many treatments... In the end, I just felt that I can’t bear it anymore, [to] begin treatment after treatment.’
The mechanisms triggered by the treatment that made sustaining recovery possible seem complex. All the participants had tried different types of abstinence-oriented programs, which they perceived as riskier for relapse than MAT. In effect, some of the participants never achieved total abstinence while under other types of treatment, such as the 12-Step program. While the peculiar characteristics of MAT generally seem to increase the motivation to cease illegal drug intake completely, some participants reported relapsing after previous MAT experiences. The medication was not enough if an internal conversion was not achieved. “Per Olof,” who had started the current treatment five months earlier, had tried MAT for the first time a year before the interview but eventually relapsed. He informed us:
‘I went into the program, I received the medication (...) I had not been there before. I thought with the medication everything would be solved magically, but it was not so. I still felt bad inside [...] I had methadone, changed to buprenorphine... It was only a waste of time.’
Some participants reported taking the same substance that doctors prescribed to them for treatment purposes (i.e., buprenorphine) before they started the current MAT as their main drug of abuse because it was more readily available and cheaper in the illegal drug market than other types of opioids. However, before they started treatment, they were unable to achieve all the changes that treatment facilitated because they had adopted a criminal lifestyle to find resources to buy the drugs. While the level of motivation or the intention to stop using illegal drugs might have eventually varied from one individual to another, a certain level seems necessary to sustain recovery. Increasing the level of self-control also played an important role in remaining abstinent . In this regard, “Peter” told us:
‘It is not possible to turn off just because you get enrolled [into treatment]. You still have it [the addiction]. You get a small dose to help cope with it [withdrawal symptoms], but yes. I mean, just because you get in [treatment] you aren’t clean. It’s a daily work. You work every day with yourself to stay clean.’
In sum, the participants in our study reported how the life situation and the desire for change added up to a certain level of motivation that shaped their intention to cease illegal drug use and drove them to seek treatment. Sustaining recovery depends partially on factors related to treatment and partially on achieving a sense of acceptance and belonging to normative social groups.
3.1.2 Treatment stage
The participants deemed the medication essential in reducing withdrawal symptoms and recurrent anxiety produced by the perspective of feeling the symptoms if opioids were not available. The medication reduced drug cravings, which facilitated that the attention focus on searching for and obtaining drugs was diverted. In this way, the participants perceived an enhancement in their psychological wellbeing. “Ellias” explained:
‘The dose I have keeps me healthy around the clock... and that helps psychologically too.’
However, MAT’s power to keep participants away from illegal drug use lay not only in the medication. Besides the physical dependency, OUD seems to imply certain psychological effects from the participants’ perspective that are important to consider during treatment. “David” referred to the cognitive and affective processes necessary to complement the medication:
‘[Treatment] is about working with yourself. The medication is just a small part of the treatment itself. It’s not that you come here and take the medication and then life is OK, it doesn’t work like that.’
All the participants in our study emphasized the importance of social interaction, critical because, as we saw earlier, social isolation was nearly always present in the individuals’ lives during their substance use career and at the beginning of treatment. “Johanna” stated:
‘The medication is just a small piece of what you get here because here there are people you can talk to...’
The participants regarded rules such as the prohibition of using any type of illegal drug and compulsory urine testing as hard, but necessary and positive for treatment success. However, to be willing to accept the rules, the individuals thought it was important they were equally applied to everyone and displayed in the context of warm relationships with the program staff. It was important that the participants not perceive the staff as guards, but rather as friendly professionals. The participants highly valued relapse prevention. The cognitive-behavioral therapy strategies taught during the sessions helped the participants change negative thinking and develop coping skills, just as they are intended to work . Learning such strategies provided the individuals with important tools to manage not only their addiction to opioids but, more generally, the addictive behavior. “Kevin” explained:
‘After four sessions [in the relapse prevention program] things started to happen within me. After 10 weeks... I have totally redone my way of thinking... quit taking a lot of medicines. I try not to find my happiness in chemicals anymore.’
Besides any new knowledge the participants may have acquired during the relapse prevention sessions, they perceived the repetitive practice of identifying the clues that trigger the drugs cravings and the rehearsal of behavioral strategies to handle these tense situations until achieving a certain level of automatic response, as having a therapeutic effect.
Interestingly, MAT has other components than the content of the treatment that the participants perceived as fundamental to its success. These other components are related to the feeling of acceptance and belonging, very close to the essential human psychological needs identified by Maslow  as motivators of behavior. The participants valued the current MAT because the professionals in the clinic covered these needs for them in some way, solving the problem of social isolation built under a relatively lengthy substance use career. From the individuals’ perspective, it was not only about social interaction, but also about feeling that someone cared and was concerned, and about finding attachment figures among the clinical professionals and eventually among other clients of the MAT program. The quality of the relationships established between the clinical staff and the participants, beyond the strictly professional requirements, ultimately produced feelings of care and acceptance similar to those we find in primary social groups like the family. “Johanna” explained:
‘Here, there are people you can talk to, people who works here, who listen to you, and understand why you feel like you do, and that is of great value. One must be able to talk to someone without being treated like an idiot.’
Because MAT is generally viewed in Sweden as a “drugs provided by the state” program, the participants experienced strong stigmatization not only during their substance use career but also when entering treatment. The individuals perceived that they were continuously subjected to detrimental judgment in many social situations. Furthermore, previous treatment experiences might have contributed to generalizations about the treatment setting and the feeling of constantly being judged. Finding a group in which the individual felt accepted as it has occurred in the current MAT program reinforced the motivation to secure the place in such environment. The social climate that the participants in our study experienced in the MAT clinic was in clear contrast with what they had experienced in the past in other environments, including other MAT scenarios. “Kevin” informed us:
‘They [the clinical staff] see me as a human being and not as an addict... I have experienced it over the years like, yes, people looking down on me.’
In short, during the treatment stage, there were factors directly related to the MAT characteristics such as the medication, the rules, and the relapse prevention sessions that the participants perceived as necessary for sustaining recovery. However, the warm relationships that the participants established with the clinical staff and the sense of belonging to a social group in which they felt they were accepted independently of their life course were valued as highly as the treatment in preventing relapse.
3.2 MAT as a turning point in individuals’ lives
The second level of analysis, to determine what existential changes participants perceived were fostered by the MAT, revealed three themes.
The first theme was “Perceived positive self-evolution.” The participants thought about themselves as if they were walking a path to achieve a constructive personal existence. They described a process of change that they believed would make possible what they most yearned for, a functional life. The individuals viewed MAT as a lock mechanism that opened the doors to this path, and they thought they must cross it by themselves. “Johanna” declared:
‘I think that the program is a damn good thing... I want a productive life... and I want a healthy life... and if you want, they will gladly help you.’
To a certain extent, the participants reported feeling they were again responsible for their lives, in contrast with their previously perceived lack of control. Participants referred to a new lifestyle that clearly broke from their lifestyle while using drugs. In this sense, they described how MAT represented that point in the life course when aspects that could be classified as socially disadvantaged or even antisocial changed to socially accepted. Some of the older participants had experienced this before in their multiple experiences of abstinence and rehabilitation. However, we found that they had the same idealized expectations about the future as the younger participants who had never been fully employed or had never lived independently from their parents. They were not anticipating the burdens that a prosocial lifestyle entails, perhaps because they were just too much jaded about them while using illegal drugs. “Leif” stated:
‘The goal is that you have to come out to work, yes, get a new life, or get an apartment, get out to work. That’s what I see is the most important right now.’
However, the individuals recognized that the process of change was not easy and that it would take time. Due to their past experiences with other treatment programs and relapse, participants were convinced that the achievements that MAT facilitates required effort from them and that it would not be easy to deal with the negative emotionality that had been easily relieved through drug intake in the past. Especially during the first months of treatment, the participants reported cycles of mood swings that could destabilize their motivation to sustain recovery. “Markus” revealed:
‘You have been doing drugs for 10-15 years. It’s not easy to quit just like that. There is a period when you are up and down.’
In this process of change, participants had to deal with mechanisms of positive reinforcement to maintain abstinence that were delayed in time, were occasionally not immediately evident for them, and occasionally alternated with negative reinforcement by the environment and by undesirable psychological strain and physical pain. This was the opposite of the immediate reinforcement the individuals obtained when taking drugs. “Mats” revealed:
‘It really depends on you. You have to come to an insight into what you want in life.’
Therefore, learning what triggers drug cravings and impulse control (i.e., relapse prevention) was imperative for them. Moreover, the lack of social skills and stigmatization was a doubly disadvantaged starting point for the process of self-evolution, which also required learning and training. “Markus” reported:
‘It’s a damn break from how you used to live. You have to learn new things. The worst is, after all, this social part, as well as coming out again [socially] in a new way. I still have a hard time talking to people. It takes time, everything.’
MAT boosted personal growth. The individuals reported they had a new sense of achievement and dignity that came from a certain sense of self-fulfillment and that they could eventually perceive respect from others. The participants who had been under the current MAT program for a longer time had established a clear difference between how well they felt in general with themselves compared to how they felt while using drugs. “Markus” related:
‘I’m feeling good. When I got into this [treatment]... I’m not thinking about the drugs, I don’t have to worry about the aches anymore. So, yes, I’ve got a whole new life. For me it is. And you don’t want to get rid of that.’
Even those participants who had started MAT more recently, such as Fredrik, described this positive self-evolution:
‘I have been coming here for a year and this year has been so good. Yes, probably I’d never had better years... It’s different [from the previous life while taking drugs] like night and day.’
Although drug addiction has been seen as a chronic health problem, and some individuals might require MAT permanently, many of the participants in our study reported that their goal was to reach a functional life, free of medication. They depicted an inner feeling of freedom and the realization of personal potential. “Per Olof” recounted:
‘I have a dream that sometime in my life, I can wake up one day without having to take pills. But I’m not going to rush, but I’m building it up.’
A second theme found during the analysis of MAT as a turning point was the “resettlement of social bonds.” Most participants in our study had severed bonds with their families at one time or another during their substance use career. While some informed us that their families “gave up” on them, others decided to hide their substance use and cut relations unilaterally to prevent family members from suffering. Upon starting treatment, they viewed the resettlement of these bonds as a primary necessity. Beyond the feelings of love and belonging, the family represented a means of establishing an environment where the individuals felt safe and secure and experienced acceptance, order, and control over their lives. In sum, familial relationships created a social comfort zone. “Eva” reported:
‘For me, the family is a support in my life because help to continue to recover and not go into drugs again. Yes, they help me both mentally and physically. It is a support for me anyway.’
However, the individuals were susceptible to how family members perceived and felt about them. The quality of the relationship had been severely affected by the drug use for most of the participants, and at the beginning, family members were suspicious of the individuals’ behavior. On the other hand, they were susceptible to family behaviors that they ultimately perceived as dismissive. However, the continuation in MAT facilitated the reinstatement of trust and confidence, and the participants informed us that it was of great relief and joy when they finally achieved them. Only then was it possible to construct truly supportive relationships. “Joseph” reported:
‘It’s great [the family relationship] right now, now that things have gone well for so long. They started to trust me now that everything starts to work well [because of the treatment]. They are very happy... It became a completely different relationship. If you take drugs, it’s not possible to have any relationship, so it’s a huge difference.’
Besides the family, the participants highly valued the warm therapeutic relationship established with the MAT clinical staff. Some participants, who had been in MAT before in other clinics and who did not, for whatever reason, develop the same kind of relationship, pointed it out as an adjuvant factor for treatment success. When re-establishing bonds with the family was not possible, the clinical staff functioned as a substitute for the primary social group. Communication with the clinical professionals and a warm affective climate was deemed so important that some participants decided to continue treatment in the clinic even when they were eligible to access their medication through the pharmacy distribution net. “Mats” said:
‘I like them [the clinical staff]. It’s very nice to meet them. It’s people who take part in me, in my well-being, and how I feel, and that makes me like to come here to get the medication.’
While the reinstatement of relationships with primary social groups was deemed fundamental, establishing relationships with peers and peripheral social groups differed depending on individual preferences. Most of the participants informed us that they enjoyed making relationships with other clients in the clinic who helped them construct a sense of inclusiveness. “Leif” told us:
‘I think it’s fun to just sit and talk with everyone here while taking the medication... also with the staff.’
In comparison, “Markus,” who had been in treatment at the clinic for one and a half years at the time of the interview, preferred to stay away from other clients because he identified them as a risk factor for relapse:
‘I don’t hang out with anyone that comes here... don’t want to get dragged into any fucking shit. I have to keep that distance for myself... Often those who come here they talk only about drugs and it’s not so fucking fun. That’s what I’m trying to get away from. I don’t hang out with anyone, just with the kids, mother, dad, brother, sister...’
For some, establishing bonds with others was challenging, and despite all the other components of treatment, unattended feelings of isolation and loneliness could remain, which individuals perceived as a threat of relapse. “Dan” revealed:
‘The biggest problem is that you don’t have any friends. Then it is normal that you turn to your old friends... It is very difficult as an adult to get new friends, which is probably the biggest problem.’
In this sense, affective necessities should be evaluated and prioritized structurally during the treatment, and it should not be left to chance for individuals to manage these necessities on their own.
The third theme found when analyzing MAT as a turning point was the “reconstruction of personal and social identity.” Individuals who abstained from taking illegal drugs and endured the recovery referred to themselves as completely different people compared to the time when the illegal drug use dominated their lives. The sense of self-fulfillment and social functioning, and the new lifestyle created a new identity. The participants reportedly replaced the “hooked on opioids person,” as they used to see themselves, with a friendlier and more pleasant person, which was a matter of pride for them. “Anders” reported:
‘[I went] from being a junkie who walked around the street and maybe scared people to sitting in town and talk to any lady or old man. It’s a huge difference.’
The new identity contained aspects related to the realization of personal potential, including parenthood, successful marital relationships, and success in the workplace. “Kevin” reported:
‘Now I have a partner, two children, a permanent job. Yes, life works like life should work... great.’
However, because the misconception persists that MAT is about sate-provided drugs, the individuals constantly struggled with the new identity they were trying to construct and the image of an active drug user, as society classified and labeled them. MAT may be a turning point for the individuals, but not so for others in society. “Estelle” told us:
‘It feels like people don’t like it... I know people who think we are drug abusers, that we are not drug-free. So it’s terrible, terrible.’
The participants informed us that opposing forces against MAT transpired not only from the general public but also from specific social groups. They indicated, for example, that advocates of abstinence-oriented treatments shared the stigmatization bias. “Maria” reported:
‘There are people who have the opinion that it [medication] is a drug from the state. Also, the 12-Step movement thinks like that. Many people think we come here because we get drugs for free.’
They also perceived stigmatization from other social groups considered “deviant.” “Per Olof” revealed:
‘There is a motorcycle club that is alcohol and drug free. I am not welcome there because I take medication and they think I am an addict then.’
Despite their struggle against stigma, the participants in our study perceived they were finding a place in society, facilitated by their new identity. They felt as if they achieved a status like other sick people who need treatment. According to “Adam”:
‘It’s just like any disease. If you have a blood disease or something, then you have to take medication. It’s the same here [with MAT].’