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Gullahorn B, Kuo I, Robinson AM, Bailey J, Loken J, Taggart T. Identifying facilitators and barriers to the uptake of medication for opioid use disorder in Washington, DC: A community-engaged concept mapping approach. PLoS One 2024; 19:e0306931. [PMID: 39028730 PMCID: PMC11259286 DOI: 10.1371/journal.pone.0306931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 06/25/2024] [Indexed: 07/21/2024] Open
Abstract
INTRODUCTION Opioid overdose is a major public health challenge. We aimed to understand facilitators and barriers to engagement in medication for opioid use disorder (MOUD) among persons with OUD in Washington, DC. METHODS We used a cross-sectional mixed-methods concept mapping approach to explore MOUD engagement between 2021-2022. Community members at-large generated 70 unique statements in response to the focus prompt: "What makes medication for opioid use disorder like buprenorphine (also known as Suboxone or Subutex) difficult to start or keep using?" Persons with OUD (n = 23) and service providers (n = 34) sorted and rated these statements by theme and importance. Data were analyzed with multidimensional scaling and hierarchical cluster analysis, producing thematic cluster maps. Results were validated by our community advisory board. RESULTS Seven themes emerged in response to the focus prompt: availability and accessibility; hopelessness and fear; unmet basic needs; characteristics of treatment programs; understanding and awareness of treatment; personal motivations, attitudes, and beliefs; and easier to use drugs. "Availability and accessibility," "hopelessness and fear," and "basic needs not being met" were the top three identified barriers to MOUD among consumers and providers; however, the order of these priorities differed between consumers and providers. There was a notable lack of communication and programming to address misconceptions about MOUD's efficacy, side effects, and cost. Stigma underscored many of the statements, showcasing its continued presence in clinical and social spaces. CONCLUSIONS This study distinguishes itself from other research on MOUD delivery and barriers by centering on community members and their lived experiences. Findings emphasize the need to expand access to treatment, dismantle stigma associated with substance use and MOUD, and address underlying circumstances that contribute to the profound sense of hopelessness and fear among persons with OUD-all of which will require collective action from consumers, providers, and the public.
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Affiliation(s)
- Britta Gullahorn
- Department of Prevention and Community Health, George Washington University Milken Institute School of Public of Health, Washington, DC, United States of America
| | - Irene Kuo
- Department of Epidemiology, George Washington University Milken Institute School of Public of Health, Washington, DC, United States of America
| | - Artius M. Robinson
- Family and Medical Counseling Services, Inc., Washington, DC, United States of America
| | | | - Jennifer Loken
- Whitman-Walker Health, Washington, DC, United States of America
| | - Tamara Taggart
- Department of Prevention and Community Health, George Washington University Milken Institute School of Public of Health, Washington, DC, United States of America
- Whitman-Walker Health, Washington, DC, United States of America
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, United States of America
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Burke KN, Krawczyk N, Li Y, Byrne L, Desai IK, Bandara S, Feder KA. Barriers and facilitators to use of buprenorphine in state-licensed specialty substance use treatment programs: A survey of program leadership. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 162:209351. [PMID: 38499248 DOI: 10.1016/j.josat.2024.209351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 02/10/2024] [Accepted: 03/01/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION Medications for opioid use disorder (MOUD), including buprenorphine, reduce overdose risk and improve outcomes for individuals with opioid use disorder (OUD). However, historically, most non-opioid treatment program (non-OTP) specialty substance use treatment programs have not offered buprenorphine. Understanding barriers to offering buprenorphine in specialty substance use treatment settings is critical for expanding access to buprenorphine. This study aims to examine program-level attitudinal, financial, and regulatory factors that influence clients' access to buprenorphine in state-licensed non-OTP specialty substance use treatment programs. METHODS We surveyed leadership from state-licensed non-OTP specialty substance use treatment programs in New Jersey about organizational characteristics, including medications provided on- and off-site and percentage of OUD clients receiving any type of MOUD, and perceived attitudinal, financial, and regulatory barriers and facilitators to buprenorphine. The study estimated prevalence of barriers and compared high MOUD reach (n = 36, 35 %) and low MOUD reach (n = 66, 65 %) programs. RESULTS Most responding organizations offered at least one type of MOUD either on- or off-site (n = 80, 78 %). However, 71 % of organizations stated that fewer than a quarter of their clients with OUD use any type of MOUD. Endorsement of attitudinal, financial, and institutional barriers to buprenorphine were similar among high and low MOUD reach programs. The most frequently endorsed government actions suggested to increase use of buprenorphine were facilitating access to long-acting buprenorphine (n = 95, 96 %), education and stigma reduction for clients and families (n = 95, 95 %), and financial assistance to clients to pay for medications (n = 90, 90 %). CONCLUSIONS Although non-OTP specialty substance use programs often offer clients access to MOUD, including buprenorphine, most OUD clients do not actually receive MOUD. Buprenorphine uptake in these settings may require increased financial support for programs and clients, more robust education and training for providers, and efforts to reduce the stigma associated with medication among clients and their families.
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Affiliation(s)
- Kathryn N Burke
- Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States of America.
| | - Noa Krawczyk
- New York University Grossman School of Medicine, 550 1(st) Ave, New York, NY 10016, United States of America
| | - Yuzhong Li
- New York University School of Global Public Health, 708 Broadway, New York, NY 10003, United States of America
| | - Lauren Byrne
- Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States of America
| | - Isha K Desai
- George Washington University Milken Institute School of Public Health, 950 New Hampshire Ave NW #2, Washington, DC 20037, United States of America
| | - Sachini Bandara
- Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States of America
| | - Kenneth A Feder
- Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States of America
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Cardamone NC, Stewart RE, Kampman KM, Marcus SC. Perspectives of substance use disorder counselors on the benefits and drawbacks of medications for opioid use disorder. RESEARCH SQUARE 2024:rs.3.rs-4331201. [PMID: 38746408 PMCID: PMC11092808 DOI: 10.21203/rs.3.rs-4331201/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Background Medications for opioid use disorder (MOUD) are among the best tools we have to combat the opioid epidemic. Yet, use of MOUD among people with opioid use disorder (OUD) remains low. Interventions to increase MOUD access in the United States have largely focused on improving organizational capacity and addressing funding barriers, yet stigma toward MOUD may inhibit uptake even where MOUD is readily available. Substance use disorder (SUD) treatment counselors likely have considerable influence on a client's choice to initiate and adhere to MOUD, but beliefs that counselors convey about MOUD in interaction with clients are understudied. The current study explores what advantages and disadvantages that SUD treatment counselors communicate about buprenorphine, methadone, and naltrexone. Methods From June to December 2021, we surveyed counselors from publicly-funded SUD treatment agencies under a municipality-wide mandate to offer MOUD to all clients with OUD. Counselors were asked to describe, in a free-response format, the most important advantages and disadvantages to communicate to their clients about taking buprenorphine, methadone, and naltrexone. Counselor responses were coded for one or more advantage and disadvantage. Results A total of 271 SUD counselors from 29 agencies completed the survey, generating 1,995 advantages and disadvantages across three types of MOUD. The most frequently reported advantage across all three types of MOUD was their ability to reduce cravings and illicit drug use. The most frequently reported disadvantage related to the potential for some types of MOUD to develop long-term medication dependence. Conclusions As the availability and variety of MOUD treatment options continue to expand, it is important that SUD counselors are equipped with evidence-based recommendations for OUD care. We identified misalignments with the MOUD-prescribing evidence base and stigmatizing language toward MOUD within counselors' responses, highlighting the potential to refine training materials for MOUD and mitigate stigmatizing beliefs.
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Affiliation(s)
| | | | | | - Steven C Marcus
- University of Pennsylvania, School of Social Policy and Practice
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Martinez NG, Truong AQ, Nordeck CD, Agus D, Genberg BL, Buresh ME. "I want to stay here": Patient and staff perspectives on transitioning from a low-threshold buprenorphine program to clinic-based care. Drug Alcohol Depend 2024; 257:111130. [PMID: 38452408 DOI: 10.1016/j.drugalcdep.2024.111130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/09/2024] [Accepted: 02/11/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND The Project Connections At Re-Entry (PCARE) Van is a low-threshold buprenorphine program operating outside the Baltimore City Detention Center. Like other low-threshold programs, PCARE seeks to engage a vulnerable population in care, stabilize patients, then transition patients to longer-term care; however, <10% of patients transition to clinic-based buprenorphine treatment. Our goal was to better understand these low transition rates and center patient perspectives in discussion of broader low-threshold program design. METHODS From December 2022 to June 2023, semi-structured interviews were conducted with 20 former and current PCARE patients and 6 staff members. We used deductive and inductive coding followed by thematic content analysis to identify themes around treatment experiences and care preferences. RESULTS There were strong preferences among current and former patients for continuing buprenorphine treatment at the PCARE Van. Several themes emerged from the data that explained patient preferences, including both advantages to continuing care at the van (preference for continuity, feeling respected by the program's structure and philosophy) and disadvantages to transitioning to a clinic (perceived harms associated with rigid or punitive care models). Staff noted limited program capacity, and patients expressed that if needed, they would transition to a clinic for altruistic reasons. Staff expressed varied perspectives on low-threshold care, emphasizing both larger systems factors, as well as beliefs about individual patient responsibility. CONCLUSIONS While many low-threshold care settings are designed as transitional bridge models, this research highlights patient preference for long-term care at low-threshold programs and supports efforts to adapt low-threshold models to be sustainable as longitudinal care.
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Affiliation(s)
- Noelle G Martinez
- Division of Addiction Medicine, Johns Hopkins University School of Medicine, Mason F. Lord Building East Tower 2nd Floor, 5200 Eastern Avenue, Baltimore, MD 21224, USA.
| | - Ashley Q Truong
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Courtney D Nordeck
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD 21201, USA
| | - Deborah Agus
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA; Behavioral Health Leadership Institute, 2601N. Howard Street, Baltimore, MD 21218, USA
| | - Becky L Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Megan E Buresh
- Division of Addiction Medicine, Johns Hopkins University School of Medicine, Mason F. Lord Building East Tower 2nd Floor, 5200 Eastern Avenue, Baltimore, MD 21224, USA
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Lin CH, Siao SF, Lin PY, Shelley M, Chi YC, Lee YH. Understanding Healthcare Providers' Care for Patients with Medications Treating Opioid Use Disorder in the Emergency Department: A Scoping Review. Subst Use Misuse 2024; 59:622-637. [PMID: 38115559 DOI: 10.1080/10826084.2023.2294964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
BACKGROUND There is limited research exploring the changing clinical practices among healthcare providers (HPs) care for patients with Emergency Department (ED)-initiated Medication for Opioid Use Disorder (MOUD). METHODS This scoping review followed the methodological framework of Arksey and O'Malley to map relevant evidence and synthesize the findings. We searched PubMed, EMBASE, CINAHL, Web of Science, and Scopus for related studies from inception through October 12, 2022. Following the application of inclusion and exclusion criteria, 16 studies were included. Subsequently, they were charted and analyzed thematically based on ecological systems theory. RESULTS The main determinants in the four ecological systems were generated as follows: (1) microsystem: willingness and attitude, professional competence, readiness, and preference; (2) mesosystem: ED clinical practices, departmental factors; (3) exosystem: multidisciplinary approaches, discharge planning, and (4) macrosystem: stigma, health insurance, policy. The findings have implications for HPs and researchers, as insufficient adoption, implementation, and retention of MOUD in the ED affect clinical practices. CONCLUSIONS Across the four ecological systems, ED-initiated MOUD is shaped by multifaceted determinants. The microsystem underscores pivotal patient-HP trust dynamics, while the mesosystem emphasizes interdepartmental synergies. Exosystemically, resource allocation and standardized training remain paramount. The macrosystem reveals profound effects of stigma, insurance disparities, and evolving policies on treatment access and efficacy. Addressing these interconnected barriers is crucial for optimizing patient outcomes in the context of MOUD.
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Affiliation(s)
- Chia-Hung Lin
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shu-Fen Siao
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Pei-Ying Lin
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mack Shelley
- Department of Political Science, Department of Statistics, Iowa State University, Ames, IA, USA
| | - Yu-Chi Chi
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yen-Han Lee
- Department of Health Sciences, College of Health Professions and Sciences, University of Central Florida, Orlando, FL, USA
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Franz B, Dhanani LY, Hall OT, Brook DL, Simon JE, Miller WC. Differences in buprenorphine prescribing readiness among primary care professionals with and without X-waiver training in the US. Harm Reduct J 2023; 20:180. [PMID: 38129903 PMCID: PMC10740221 DOI: 10.1186/s12954-023-00918-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 12/16/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Medications for opioid use disorder (OUD) are effective at preventing overdose and infectious disease but are vastly under-prescribed in the US. For decades, prescribers faced additional training and regulation to prescribe buprenorphine which stigmatized the medication and lessened support for a harm reduction approach to treating opioid use disorder. The Drug Enforcement Administration removed the X-waiver requirement for prescribing buprenorphine in late 2022, which removed stigma and lessened important barriers to prescribing but also left training at the discretion of individual organizations. Our study aimed to assess differences in knowledge, confidence, and stigma regarding buprenorphine between those who went through the X-waiver training and those who did not, among practicing primary care providers (PCPs). METHODS We assessed buprenorphine prescribing readiness among primary care aligned outpatient providers in Ohio, USA. Using survey data, we conducted bivariate and regression analyses predicting primary prescribing outcomes. Primary outcomes measured knowledge of and confidence in buprenorphine, as well as perceived adequacy of one's training. Secondary outcomes were attitudes toward patients with OUD, including bias toward OUD patients, stress when working with them, and empathy toward them. Participants (n = 403) included physicians, nurse practitioners, and physician assistants practicing in primary care aligned disciplines. RESULTS Survey data showed that PCPs who received X-waiver training were more likely to understand and have confidence in the mechanism of buprenorphine, and consider their training on treating OUD to be adequate. PCPs with an X-waiver showed more empathy, less negative bias, and experienced less stress when working with patients with OUD. CONCLUSION Removing restrictive policies for prescribing buprenorphine is an important step to expanding access and reducing the stigma associated with opioid use disorder treatment. Yet, our findings suggest that the training received alongside regulation may be important for improving prescribing confidence and reducing stigma. Strategies to increase buprenorphine prescribing are unlikely to be effective without also expanding access to prescribing support for primary care providers across the career course.
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Affiliation(s)
- Berkeley Franz
- Ohio University Heritage College of Osteopathic Medicine, Appalachian Institute to Advance Health Equity Science, Athens, OH, USA.
| | - Lindsay Y Dhanani
- Rutgers University School of Management and Labor Relations, Piscataway, NJ, USA
| | - O Trent Hall
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Daniel L Brook
- Ohio State University College of Public Health, Columbus, OH, USA
| | - Janet E Simon
- Ohio University College of Health Sciences and Professions, Athens, OH, USA
| | - William C Miller
- Gillings School of Global Public Health, University of North Carolina Chapel Hill, Chapel Hill, NC, USA
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