Adherence tools are often employed to improve our understanding of the practical and perceptual barriers which stand between patients and their medication regimes. Substance misusers are a notoriously difficult-to-treat client group. There is continued debate around whether drug addiction can be classified as an illness. For the purpose of this blog, let’s assume addiction to be an illness. Could applying a Perceptions and Practicalities Approach (PAPA™) help to improve our understanding of why adherence to prescribed heroin substitutes breaks down among this client group?

PAPA™ provides a conceptual framework that explains non-adherence based on the overlapping categories of intentional and un-intentional non-adherence. Unintentional non-adherence can result from barriers, beyond the control of the individual, inhibiting the individual’s ability to adhere. Practical barriers could include, but are not limited to, homelessness, unemployment, and thus a lack of/ no financial stability. Intentional non-adherence relates to perceptions which shape an individual’s motivation to adhere. Motivation among this client group generally fluctuates, and other self-perceptions tend to exacerbate this issue. A lack of self-efficacy in one’s own ability to maintain abstinence, a lack of self-worth, and the self-disabling belief that one is undeserving of a better quality of life, are all potential perceptual barriers faced by this client group.

Considering the resources necessary to achieve and maintain recovery; many individuals released into the community have little ‘recovery capital’ to draw upon. They transition from behind bars, back into a life of chaos and instability. This is where adherence breaks down. It could be argued that the individuals’ ability, or inability, to adhere is the crux of the problem. Efforts to rehabilitate substance misusing offenders typically focus on perceptual factors including motivation, but seldom attempt to address the practical barriers that stand between individuals’ and adherence.

Implementing aspects of PAPA™ into interventions for this client group, to ensure a focus on motivation and ability, could lead to more sustainable outcomes. If instability breeds inability then, without tackling the perceptual and practical barriers among this client group, could any rehabilitative effort be truly successful?