Evaluating Barriers to Opioid Use Disorder Treatment From Patients’ Perspectives

Opioid use disorder (OUD) rates have increased over the past 2 decades, constituting a public health emergency affecting approximately 2 million people in the United States. ^1,2 Medication for opioid use disorder (MOUD) treatments, including methadone, buprenorphine, and naltrexone, have been shown to be safe and highly effective.² As of 2019, less than one-quarter of those with OUD received treatment with medications.³ The expansion of addiction treatment into primary care has previously been shown to be an effective solution to bridge this significant care gap and reduce overdose mortality.⁴ Our study took place in Milwaukee County, Wisconsin, which reported 20,000 overdoses between of January 2018 and February 2022.^5-7  In this study, we aimed to highlight various barriers that impact patients’ ability to obtain treatment for OUD and maintain their treatment progress.

This study took place at a family medicine residency program in Milwaukee, Wisconsin, which operates a dedicated “MOUD clinic” 1 day per week. We conducted semistructured, 10-minute interviews with patients receiving MOUD between July 2021 and May 2022. This qualitative research method allowed for open-ended data collection with insight into patient thoughts, motivations, sociocultural considerations, and overall experiences. This study was approved by the Ascension Health System Institutional Review Board prior to study activities, including an informed verbal consent process.

Inclusion criteria included individuals: (1) currently receiving OUD treatment, (2) aged 18 years or older, and (3) English-speaking. Convenience sampling was utilized by approaching patients during MOUD appointments. Most patients were recruited in-person while one interviewee participated virtually. The objective of the study was explained to patients by the physician or medical student working with the patient, and patients were verbally invited to participate in the study. Participation was nonincentivized. Participants were assured that their decision regarding participation would not affect their medical care. Patient identifiers were omitted from the data collection.

Interviews were audio recorded and transcribed verbatim by researchers. The established qualitative analysis of semistructured interviews, “Framework Method,” was utilized to code and sort transcripts.^8,9 To minimize the risk of group bias, each transcript was reviewed and coded independently by at least two researchers. Coded transcript data was then sorted into an excel matrix document. To minimize the risk of an individual bias on analysis, all research team members reviewed the matrix document and generated a consensus of data interpretation.

A sample of 30 patients participated in this study. We observed the following themes emerge within two domains: (1) decision-making leading to treatment utilization, and (2) influences on treatment progress and patient satisfaction (Table 1).

The patient decision-making process encompasses values, beliefs, influences, and choices leading to their choice to start or continue MOUD. Participants were asked about their primary motivations to seek treatment, decision to come to this clinic, and initial treatment concerns.

Motivations. Some patient motivations involved the desires to improve relationships with their children and loved ones, as well as setting a positive example for their children (Table 2). A larger majority emphasized being self-driven while seeking care. Participants noted seeking care to repair relationships but that this motivation was not enough to succeed and emphasized the importance of readiness to change for themselves (Table 2).

Connections to the Clinic. Many participants endorsed knowing a friend or family member who is currently receiving or had prior treatment at this same clinic. A smaller portion of participants mentioned a referral by another physician or community organization, while others found the clinic online.

COVID-19 Impacts. Six participants discussed the impact of COVID-19 on their treatment, focusing on social interactions. Two participants referenced the negative aspects of social isolation. Another referenced challenges with virtual therapy as a person with visual and hearing impairments. Two participants stated that the isolation was a positive as it prevented them from interacting with people supporting their drug use. The remaining participant discussed an increased urge to use during the pandemic as well as related cocaine use.

Participants were also asked about prior treatment experiences, specifically what has and has not worked for them in the past. Additionally, participants were asked about social stressors that challenged their treatment progress.

Previous Treatment Experience. Multiple patients spoke about prior treatment attempts. Interviewees highlighted varying methods of cessation including methadone clinics, inpatient treatment, and attempts at self-cessation. At least six participants endorsed ten or more treatment attempts, though this number is likely higher as some patients did not report previous number of attempts. Of note, several participants cited negative experiences with clinicians a contributing factor to unsuccessful treatment attempts.

Experience With Incarceration. Many interviewees discussed their history with incarceration, reporting avoiding future interactions with the carceral system as a driving factor for treatment, while others were mandated treatment as a part of probation (Table 3). One patient described their past incarceration as a barrier to care, sharing how the stigma of a criminal record interferes with their ability to find a job, afford necessities, and continue treatment. Participants also discussed incarceration as a time of forced sobriety and an experience that interfered with ongoing treatment.

Socioeconomic Influences. Many participants mentioned experience with housing insecurity. Of these individuals, most endorsed having unstable housing currently and with concurrent financial strain, job instability, or lack of insurance. Some attributed housing-related stress to living with people actively using. Patients also discussed transportation inadequacy as a challenge to receiving care or affecting treatment progress (Table 4).

Characteristics of a Family Medicine Residency MOUD Clinic. Of note, four participants spoke about characteristics of the clinic that have contributed to their positive experience. These perspectives can inform clinicians how the attitudes of providers and staff can create environments conducive to success in treatment (Table 5).

In our study, the primary drivers to seek treatment were the patients themselves and their loved ones rather than any external influences. Recommendations from family and friends often prompted patients to seek treatment at the clinic, suggesting the efficacy of word-of-mouth and patient handouts as community-based approaches to recruit patients and improve utilization.

Our study also highlighted the impacts housing instability, transportation availability, and incarceration can have on treatment progress. Felonies and incarceration for drug use make housing and employment difficult to secure.^11-13 Patients without employment or housing are often reliant on unreliable public transit or shared rides. The transportation burden is exacerbated as patients must travel long distances to find care. The barriers identified in this study resonate with previous work discussing the impact of stigma and barriers on accessing substance use disorder treatment. ^11-13 Increasing the number of clinicians that prescribe MOUD via education in residencies and medical schools has been shown to significantly improve availability of quality treatment.⁴ Working closely with clinical social workers to link patients to housing, legal aid, and employment services could improve treatment outcomes.^2,5

Limitations of this study include lack of a broad sampling pool, a single recruitment site, and the influence of mentioned barriers to care on study recruitment. Many potential participants missed appointments or chose not to participate because of needing to catch a bus or utilizing unreliable medical transport services. The barriers reported in this study are likely underreported as participants were actively engaged in care when discussing their barriers. Previous studies have indicated the role of identities such as gender, sexuality, and parenthood status in accessing MOUD; given our study highlighted loved ones as a major motivation in treatment, exploring social identity (eg, demographics of race, gender, zip code, or income level) and family structure could have further elucidated patient experiences in addiction treatment.¹⁴ Additionally, despite following a rigorous qualitative analysis process, it is still possible that bias influenced the coding and thematic analysis process.

This study highlights the necessity of incorporating the thoughts, beliefs, and experiences of people with OUD into primary care addiction medicine. In the face of a worsening opioid epidemic, primary care clinicians must overcome the entrenched stigma against treating addiction.¹⁵ We hope that health care professionals have gained insight and perspective from our patient’s stories and feel inspired to provide essential care for this vulnerable patient population.