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A multi-system evaluation of medication for opioid use disorder for people who use opioids
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A multi-system evaluation of medication for opioid use disorder for people who use opioids
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Content
A MULTI-SYSTEM EVALUATION OF MEDICATION FOR OPIOID USE DISORDER FOR
PEOPLE WHO USE OPIOIDS
By
Maria Bolshakova
A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(PREVENTIVE MEDICINE [HEALTH BEHAVIOR RESEARCH])
December 2022
Copyright 2022 Maria Bolshakova
ii
Acknowledgements
First and foremost, I would like to thank my dissertation committee for their endless
guidance and support throughout my time as a graduate student. Drs. Steve Sussman, Ricky
Bluthenthal, and Jennifer Unger provided invaluable research mentorship and opportunities that
helped make me the researcher I am today. Drs. Rebecca-Trotzky-Sirr and Todd Schneberk
offered not only research guidance, but also clinical perspectives that allowed this dissertation to
be multi-faceted and encompassing of many levels of healthcare.
I would also like to thank other faculty, colleagues, and peers for their involvement in my
education and growth as a scholar. Dr. Susanne Hempel and the entire USC Evidence Review
Center team, Dr. Jose Gonzalez, Dr. Siddarth Puri, and Dr. Spencer Liebman. I greatly value the
experiences I had conducting community-based research with people who use drugs with Dr.
Bluthenthal’s team, and I thank Karina Dominguez Gonzalez, Cheyenne Page, Kelsey Simpson,
Jesse Goldshear, Avaion Ruth, Nadia Alzuri, and Gilbert Orto Portillo for the important work
they do and for their contributions to my qualitative research. Also, a huge thank you to my
doctoral friends Cynthia Ramirez, Ingrid Zeledon, Raymond Hughley, and Donovan Ellis who
offered advice and above all friendship throughout my graduate journey.
I am grateful for the support of my family, Ilya Bolshakov, Svetlana Bolshakova, and
Katya Scagnelli throughout my life and especially to my parents for making the hard decision to
immigrate to America and always encouraging my academic pursuits. I wouldn’t have been able
to get through this program without the joys and experiences shared with friends both near and
far, especially my knitting club and Florida fam, my partner Brian Jephson, and the light of my
life – Nugget the Corgi.
iii
Table of Contents
Acknowledgements ......................................................................................................................... ii
List of Tables .................................................................................................................................. v
List of Figures ................................................................................................................................ vi
Abstract ......................................................................................................................................... vii
Introduction ..................................................................................................................................... 1
Opioid Use Disorder and Medication for Opioid Use Disorder ................................................. 1
Ecological Systems Theory......................................................................................................... 4
Macrosystem –Social Values and Public Policy ......................................................................... 5
Exosystem -Organizational and Community Structure .............................................................. 8
Microsystem and Mesosystem—PWOU-PWOU, Provider-Patient, and Provider-Provider
Interaction. ................................................................................................................................ 11
Patient/ Individual – Internal Attributes and Beliefs ................................................................ 14
Gaps in Knowledge on MOUD................................................................................................. 16
Chapter 1: “It helps and it doesn’t help”: A qualitative assessment of complex perspectives
on medication for opioid use disorder (MOUD) among people who use opioids ........................ 19
Introduction ............................................................................................................................... 21
Methods..................................................................................................................................... 25
Results ....................................................................................................................................... 27
Discussion ................................................................................................................................. 39
Limitations ................................................................................................................................ 42
Conclusion ................................................................................................................................ 43
Chapter 2: Patient-level and hospital-encounter characteristics as predictors of buprenorphine
prescription among patients with opioid use disorder (OUD) upon emergency room and.
inpatient discharge from a large, urban hospital ........................................................................... 44
Introduction ............................................................................................................................... 46
Methods..................................................................................................................................... 48
Results ....................................................................................................................................... 52
Discussion ................................................................................................................................. 58
Limitations ................................................................................................................................ 61
Conclusion ................................................................................................................................ 62
Chapter 4: A Qualitative Analysis of Internal Medicine Residents’ Experience with
Substance Use Disorder Education and Training ......................................................................... 64
Introduction ............................................................................................................................... 66
iv
Methods..................................................................................................................................... 68
Results ....................................................................................................................................... 70
Discussion ................................................................................................................................. 75
Chapter 4: Discussion ................................................................................................................... 79
Summary of Findings ................................................................................................................ 79
Policy Recommendations.......................................................................................................... 84
Macrosystem ............................................................................................................................. 85
Exosystem ................................................................................................................................. 87
Mesosystem and Microsystem .................................................................................................. 89
Individual .................................................................................................................................. 90
Future Research Directions ....................................................................................................... 91
Strengths and Limitations ......................................................................................................... 92
Conclusion ................................................................................................................................ 93
References ..................................................................................................................................... 95
v
List of Tables
Table 1: Participant Characteristics (N=22) ................................................................................. 27
Table 2: Demographic, previous healthcare, and drug use-related characteristics of patient
encounters (N=346) ...................................................................................................................... 52
Table 3: Hospital encounter-related features (N=346) ................................................................. 54
Table 4: Medication provision among patients with definitive opioid use-related sequala
(N=211) ......................................................................................................................................... 55
Table 5: Odds ratio (OR) associations between receipt of buprenorphine prescription and
demographic, drug use, and hospital-stay related features included at p <0.25 (N=343) ............ 56
Table 6: Final multivariable logistic regression models of buprenorphine prescription upon
discharge after hospital visit ......................................................................................................... 57
Table 7: Components of the Substance Use Disorder Initiative Provided to Internal Medicine
Residents ....................................................................................................................................... 69
Table 8: Descriptive Characteristics of Resident Physicians ........................................................ 71
Table 9: Summary of Key Findings of Studies at Ecological Systems Theory Levels ................ 82
Table 10: Proposed Solutions to Increasing MOUD Provision and Utilization ........................... 84
vi
List of Figures
Figure 1: Ecological Systems Theory Applied to Health Systems Research ................................. 4
Figure 2: Ecological Systems Theory Applied to the Multi-system Evaluation of Medication
for Opioid Use Disorder for People Who Use Opioids ................................................................ 16
Figure 3: Flow diagram of patient/encounter inclusion criteria.................................................... 49
vii
Abstract
Opioid use has been a steadily rising problem over the last two decades and is currently
considered a health crisis in the United States due to overdose deaths. Although medication for
opioid use disorder (MOUD) is the gold-standard for patients with opioid use disorder, it is
under-utilized by people who use opioids and under-prescribed. MOUD includes several
medications such as methadone, buprenorphine, or naltrexone in order to help opioid users
reduce their use of drugs or harm associated with their use. Barriers to uptake of MOUD exist on
individual, provider, care team, hospital, governmental, and societal levels. Previous studies
generally only investigate one level of under-utilization of MOUD, yet a framework of how the
interacting systems prevent appropriate linkage to MOUD has not yet been explored or
developed.
This dissertation follows a mixed-methods approach and contains three separate datasets
as well as integration of the results across studies, involving (1) qualitative PWOU interviews,
(2) quantitative patient medical records, and (3) qualitative resident physician interviews. Each
study considers patient, care team, and organizational factors that contribute to barriers and
facilitators of MOUD linkage. The aims of this project target the five levels of the Ecological
Systems Theory: individual, microsystem, mesosystem, exosystem, and macrosystem.
The overall goal of this dissertation was to identify areas of improvement in provision of
MOUD for people who use opioids using a mixed-methods research approach incorporating
multiple ecological systems. The dissertation addressed three main goals: 1.) identify attitudes,
beliefs, and preferences about MOUD among a sample of PWOU, 2.) assess predictors of
buprenorphine prescribing in a population of patients with OUD who had an ED or inpatient visit
at the Los Angeles County + USC Medical Center, and 3.) explore resident physicians’
viii
experiences with SUD education throughout medical school and residency, including a brief
SUD initiative. The findings from this dissertation highlight several key gaps in the clinical and
research domains that are crucial to improve upon in order to increase access to and uptake of
MOUD by PWUO. These findings give implication for recommendations for every system level,
including PWUO themselves, healthcare practitioners and their interactions amongst themselves,
organizations and hospital systems, and broad policy implications.
1
Introduction
Opioid Use Disorder and Medication for Opioid Use Disorder
Opioid use has been a steadily rising problem in the United States since the 1990’s. In
2020, an estimated 2.7 million people in the United States suffered from opioid use disorder
(OUD; including prescription opioids, heroin, and fentanyl misuse) (CBHSQ, 2021), although
that number may be underestimated. People who use opioids (PWUO) have high rates of
morbidity and mortality (Gomes et al., 2018; McCarthy et al., 2020) and other drug-related
harms such as incarceration, suicide attempts, unemployment, crime, homelessness, and social
isolation (European Monitoring Center for Drugs and Addiction, 2021; Gholami et al., 2022).
Opioid overdoses have increased over the last few years due to the COVID-19 crisis and
proliferation of fentanyl and fentanyl-analogues (Ahmad et al., 2022; Volkow, 2020), as have
rates of hospitalizations for infections among people who use drugs (McCarthy et al., 2020).
OUD is common in general medical settings, including inpatient, emergency room, and primary
care (Suen et al, 2021; Peterson et al., 2021; Wu et al., 2016) yet providers generally spend little
time assessing and treating substance use disorders (HHS, 2022).
Many PWOU experience barriers to treatment due to financial disparities, stigma,
inadequate local capacity for care, and other barriers (Mackey et al., 2020). A 2005 Cochrane
review reported that psychosocial treatment alone was not effective for the treatment of OUD
(Mayet et al., 2005). In particular, there is a paucity of access to and utilization of medications
for opioid use disorder (MOUD) such as buprenorphine and methadone. This treatment gap
persists despite a general consensus among addiction medicine researchers and clinicians that
MOUD is the gold-standard treatment for patients with OUD. A review of the literature strongly
supports the use of MOUD to reduce risk of overdose, use of illicit opioids, and serious opioid-
2
related acute care in addition to improving social functioning and relieving/preventing
withdrawal symptoms (Bart et al., 2012; Molero et al., 2018; Samples et al., 2020; Wakeman et
al., 2020) However, adjusted estimates suggest that approximately 87% of persons with OUD do
not receive MOUD treatment (Krawczyk et al., 2022).
Methadone is a full opioid agonist and is highly regulated in the U.S., dispensed almost
exclusively in specific methadone clinics when used to treat OUD (Des Jarlais et al., 1995).
Patients with OUD are either put on methadone maintenance treatment (MMT; long-term) or
methadone detoxification (short-term), both of which typically entail daily dosing at a specified
methadone clinic. Methadone has been described as “liquid handcuffs” for its inflexible and rigid
daily dosing and constant supervision of treatment (Allen et al., 2019; Muthulingham et al.,
2019). Daily appointments and strict treatment rules were perceived to be too harsh by many
MMT patients (Richert et al., 2015; Zelenev et al., 2018), who had issues with daily supervision,
treatment fatigue, not being able to travel, and conflicts with responsibilities that impacted
treatment entry and retention (Allen et al., 2019; Bojko et al., 2016; Muthulingham et al., 2019).
Methadone may also produce negative physical side effects (Bojko et al., 2015; Gryczynski et
al., 2019; Notley et al., 2013; Zelenev et al., 2018) that can lead to a sedating or zombie-like
effect as well as impairing cognitive functioning (Tofighi et al., 2019). Detoxification from
MMT is difficult and painful if initiated abruptly, such as experiencing forced detoxification due
to incarceration (Bojko et al., 2015) and otherwise involves a long tapering process that is
seldom successful (Nosyk et al., 2012).
Regulations developed by the Substance Abuse and Mental Health Administration
(SAMHSA) for opioid-treatment programs (OTPs) such as methadone clinics create barriers for
entry and retention, and contribute to stigmatizing treatment of PWUO (Aronowitz et al., 2022;
3
Frank et al., 2021; Simon et al., 2022). Furthermore, clinics have discretion to determine their
own rules, leading to considerable diversity in clinic rules and practices that many PWUO view
as controlling (Frank et al., 2021). Because of these issues, researchers and methadone patient
activists have endorsed the need for reform of strict methadone regulations and advocated for a
harm reduction-based approach (Frank et al., 2018; Simon et al., 2022), that respects the dignity
and behavioral/treatment goals of people who use drugs (Logan & Marlatt, 2010).
Buprenorphine is a partial opioid agonist that can reduce opioid use and cravings, reduce
risk of overdose, and helps alleviate withdrawal symptoms (Amato et al., 2011; Pozo et al., 2020;
Samples et al., 2020; Walsh et a., 1995). Buprenorphine is perceived by PWOU as being
efficacious, having fewer side effects than methadone, and being good for short term
detoxification (Schwartz et al., 2008). Buprenorphine is increasingly being considered an
appropriate medication for treating withdrawal symptoms in emergency departments and may
serve as a portal for the patients to go on to subsequent addiction treatment (D’onofrio et al.,
2015, Herrin et al., 2019). In contrast to MMT, buprenorphine can be prescribed as a standard
30-day supply which offers greater flexibility to PWUO (Checkley et al., 2022). However,
PWUO may be opposed to using buprenorphine as it often requires withdrawal symptoms to be
present before initiation because of its chemistry as an opioid partial agonist, and it may also be
less effective than methadone in patients with very high tolerance to opioids (Donaher & Welsh,
2006).
Buprenorphine is commonly prescribed by a physician or nurse practitioner that
possesses a special federal license (X-Waiver). As of 2021, the X-Waiver is relatively easy to
obtain by requesting the license, whereas in the past, physicians must have had 8 hours of
mandated training to receive it. However, relaxation of X-Waiver requirements has not
4
sufficiently expanded the number of clinicians able to prescribe buprenorphine (Samuels &
Martin, 2022; Spetz et al., 2022). Stigma, logistical issues, and lack of education/training in
using buprenorphine to treat OUD are also common barriers to prescribing buprenorphine among
clinicians (Mackey et al., 2020; Samuels & Martin, 2022).
Ecological Systems Theory
Ecological systems theory (EST) proposes that an individual is situated within a series of
systems and processes that are inter-related and shape the reality of the individual. Focusing on
only individual-level characteristics of the patient does not capture the complexity of the
elements that the individual does and does not have control over, and the interactive influence of
those elements. The theory (Bronfenbrenner, 1979; Bronfenbrenner, 1989) posits five levels: the
individual, microsystem, mesosystem, exosystem, and macrosystem. The patient is positioned in
the center of the model, with their own individual characteristics and beliefs. The microsystem
examines direct interactions between the individual and their providers, the mesosystem
examines interactions between providers, the exosystem examines organizational (hospital/health
system) procedures, and the macrosystem encompasses government policies and cultural views
that flow down and affect all other systems until it reaches the individual. Each level is
dependent on the surrounding systems, and attention must also be paid to how the systems
interact with each other. The theory has been applied to healthcare systems (Burholt et al., 2012)
in the past. Figure 1 displays how the Ecological Systems Theory has been applied to health
systems research. The review of the literature will be structured according to the Ecological
Systems Theory.
Figure 1: Ecological Systems Theory Applied to Health Systems Research
5
Two studies have incorporated Ecological Systems Theory as a framework for
conceptualizing barriers and facilitators to MOUD (Hewell et al., 2017, Monico, 2016). The
macrosystem, exosystem, and mesosystem were generally seen to be barriers to MOUD
treatment, while microsystem and individual levels acted as facilitators (Hewell et al., 2017).
Institutional and organizational policies of a buprenorphine clinic and Medicaid were found to be
exosystem barriers. A discrepancy between physicians prescribing buprenorphine yet pharmacies
being out of stock was endorsed as a mesosystem barrier. PWOU learned about and engaged in
treatment after hearing about positive experiences through word of mouth of other PWOU—a
microsystem facilitator (Monico, 2016). Individual willpower and motivation to change led to
PWOU seeking treatment and interacted with the external influences of the above mentioned
systems (Hewell et al., 2017).
Macrosystem –Social Values and Public Policy
2000 Drug Addiction and Treatment Act (X-Waiver)
6
Research has addressed various reasons for why practitioners under-utilize buprenorphine
for OUD. The 2000 Drug Addiction and Treatment Act (Bliley, 2000) stipulated that physicians
seeking to prescribe buprenorphine (i.e., obtain an X-Waiver) must undergo eight hours of
training modules, while advanced practitioners (physician assistants and nurse practitioners)
must undergo 24 hours of training. In April 2021, the training requirements were waived and all
physicians with a DEA registration are now eligible to apply for the waiver. As of 2020, only
about 7% of physicians possessed this license (SAMHSA, 2020) and though total treatment
capacity rose between 2018-2021, the rate of growth in number of licensed physicians declined
during the Covid-19 pandemic and continued to decline after the relaxed requirements (Spetz et
al., 2021; Samuels & Martin, 2022). The X-Waiver requirement was one of the biggest structural
barriers to MOUD access in the United States and contributed to exacerbated stigma towards
PWOU. The removal of the training requirement was a tremendous shift in MOUD treatment,
yet this alone is not sufficient to address the many barriers to prescribing buprenorphine.
Insurance
Providers endorse issues with insurance reimbursement (Andraka-Christou & Capone,
2018; Andrilla et al., 2020; Mackey et al., 2020; Molfenter et al., 2015) and oftentimes clinicians
may not receive a sufficient reimbursement rate (Barry et al., 2009; Huhn & Dunn, 2017) for
MOUD treatment. In fact, method of payment is associated with willingness to prescribe
buprenorphine (Knudsen et al., 2018), with cash payments preferred over private insurance and
Medicaid (Knudsen et al., 2018, Lagisetty et al., 2019), and lower retention rates of
buprenorphine treatment for PWOU on Medicaid or private insurance than those paying with
cash (Saloner et al., 2017). Medicaid covers a buprenorphine prescription in all states with most
states requiring no or low co-pays, however, states vary widely by requirements concerning prior
7
authorization paperwork and limits on service which is cited as a barrier by providers (Andrilla
et al., 2017; Kermack et al., 2017). For uninsured PWOU, buprenorphine costs can be
prohibitive, and as discussed further in this chapter, PWOU often seek out buprenorphine on the
streets, citing that it is oftentimes cheaper than a prescription (Cicero et al., 2018, Monico et al.,
2015).
Stigma
In numerous qualitative and quantitative patient studies, stigma emerged as a barrier to
MOUD entry. Generally, stigma can be classified into structural, public, and internalized stigma
(Allen et al., 2019). Social/public stigma derives from the perceived negative views of family
members and friends (Zelenev et al., 2018), and the general puritan societal disapproval of
“addicts”, viewing them as having ‘poor character’ (Hewell et al., 2017). A nationally
representative survey conducted in the U.S about people’s beliefs and attitudes towards people
with prescription OUD seems to support ongoing public stigma—a large majority of participants
endorsed high levels of stigma towards those with OUD, and believed they are to blame for the
problem and lacked self-discipline (Kennedy-Hendricks et al., 2017).
Structurally, stigma is prevalent in the healthcare system, as evidenced by patients
complaining of negative provider attitudes (Krull et al., 2011) and feeling mistreated by
providers and staff that appear to show disdain for their OUD patients (Bojko et al., 2016;
Tofighi et al., 2019). Physicians and providers have admitted to having stigma towards PWOU in
qualitative studies, citing negative attitudes towards patients with OUD and negative views of
OUD medications as a barrier to buprenorphine prescribing (Andraka-Christou & Capone, 2018;
Andrilla et al., 2017; Krull et al., 2011;; Mackey et al., 2020; Molfenter et al., 2015). Language
used by medical personnel may perpetuate stigmatizing beliefs; for instance, exposure to
8
stigmatizing language regarding a patient with sickle cell disease in a medical note was
associated with increased negative attitudes towards the patient (Goddu et al., 2018). Specific to
substance use disorder (SUD), clinicians randomized to reading a vignette containing the term
‘substance abuser’ were more likely to agree that the character in the vignette was personally
culpable and that penal measures should be taken compared to those exposed to the term ‘having
a substance use disorder’ (Kelly & Westerhoff, 2010). Stigma towards PWOU may also interact
with provider stereotyping and unconscious biases towards racial/ethnic minorities and low-
income patients (Im et al., 2020). For instance, one study found that program directors of
addiction treatment facilities had more negative attitudes towards the use of buprenorphine if
they served a higher percentage of patients experiencing homelessness and with co-morbid
mental health problems (Krull et al., 2011). Along with general stigma, physicians endorsed
‘difficult patients’ and mistrust of patients (Andraka-Christou & Capone, 2018; Andrilla et al.,
2017; Deflavio et al., 2015; Merill et al., 2002), with concerns about buprenorphine diversion or
misuse (Andrilla et al., 2017; Andrilla et al., 2020; Im et al., 2020; Merill et al., 2002; Webster et
al., 2020). emerging as significant barriers.
Exosystem -Organizational and Community Structure
PWOU Perspectives
The process of obtaining MOUD can be daunting and is especially affected by logistical
barriers such as long wait times for appointments, inconvenient locations and hours, and costs of
traveling to clinics and the medications themselves (Bojko et al., 2016; Cicero et al., 2018
McLean & Kavanaugh, 2019; Patrick et al., 2019; Richert & Johnson, 2015; Tofighi et al.,
2019). The demands that methadone clinics put on users of MMT are inconceivable for any other
long-term patient or condition, and are often seen as authoritative, controlling, and degrading
9
(Bojko et al., 2015; Bojko et al., 2016; Richert & Johnson, 2015). Finding a doctor who is
willing to prescribe buprenorphine can be difficult, and even when PWUO obtain a prescription
for buprenorphine, they may find that their pharmacy is out of stock (Dadiomov et al., 2022).
PWUO may obtain MOUD on the street to avoid organizational barriers for self-treatment of
OUD, including managing or preventing withdrawal symptoms, remaining abstinent off other
opioids, self-detox, and self-taper (Carroll et al., 2018; Cicero et al., 2014; Cicero et al., 2018;
McLean & Kavanaugh, 2019; Monico et al., 2015).
Provider Perspectives
Exosystem issues provided by physicians include liability fears, time constraints, lack of
office space, lack of trained staff, and a general lack of institutional support (Andraka-Christou
& Capone, 2018; Andrilla et al., 2017; Andrilla et al., 2020; DeFlavio et al., 2015; Huhn &
Dunn, 2017; Hutchinson et al., 2014; Jones & McCance-Katz, 2019; Kermack et al., 2017;
Mackey et al., 2020; Netherland et al., 2009). Lack of mental health and psychosocial support
services such as specialty backup and referral has also been widely cited as a major barrier
(Andrilla et al., 2017; Andrilla et al., 2020; Cunningham et al., 2006; Hawk et al., 2020;
Kermack et al., 2017; Mackey et al., 2020; Netherland et al., 2009). Providers endorse
facilitators to prescribing such as a standard approach to care for common clinical issues such as
opioid withdrawal, access to expert consultation, care coordination, support from leadership, and
buprenorphine clinical champions (Finlay et al., 2018; Green et al., 2014; Netherland et al.,
2009; Wiercigroch et al., 2019).
Patients who visit the emergency department for opioid use have as high as a 9.9%
mortality rate in the following year (Weiner et al., 2017). Experts in addiction medicine have
called for the expansion of buprenorphine provision in the ED, which is a critical point of access
10
for vulnerable populations who may have nowhere else to receive treatment (D’Onofrio et al.,
2018; Herring et al., 2019). Initiating patients on buprenorphine in the emergency department has
been found to be cost-effective (Busch et al., 2017), and more successful at retaining patients in
addiction treatment and decreasing illicit opioid use compared to referral and brief intervention
at two months post initiation (D’Onofio et al., 2017). ED clinicians endorsed system level
barriers to prescribing buprenorphine such as inability to ensure patient follow-up after the
patient leaves the ED, and an anticipated increase in volume of OUD patients and workload for
the providers (Im et al., 2020). Another ED-specific barrier was concern over competing patient
needs and resources in the ED, especially the time it takes to build a therapeutic relationship and
initiate buprenorphine while taking time away from other patients (Hawk et al., 2020; Im et al.,
2020; Webster et al., 2020). Generally, ED clinicians consulted social work and/or provided a list
of detoxification clinics to patients, and reported feeling frustration and helplessness with the
current practices (Im et al., 2020).
Lack of education, knowledge, and confidence in treating addiction and OUD (Andraka-
Christou & Capone, 2018; Barry et al., 2009; DeFlavio et al., 2015; Hawk et al., 2020; Finlay et
al., 2018; Huhn & Dunn, 2017; Mackey et al., 2020; Suzuki et al., 2014; Webster et al., 2020) is
a major exosystem barrier to adoption of buprenorphine prescribing. Some providers do not
believe in the efficacy of MOUD (Finlay et al., 2018; Huhn & Dunn, 2017), and others have a
lack of interest in prescribing (Barry et al., 2009). While nearly half (46%) of general internists
at an academic medical center stated they frequently cared for patients with a SUD, only 9% felt
prepared to discuss MOUD with a patient, and only 6% frequently prescribed MOUD. Almost a
third felt that substance use disorder (SUD) is a choice, and thus different from other chronic
diseases, and 14% believed that opioid agonists replaced one addiction for another (Wakeman et
11
al., 2016). Among a survey of family physicians, 80% regularly saw OUD patients, 70% felt a
responsibility for treating OUD, and yet only 10% were buprenorphine prescribers (DeFlavio et
al., 2015). With the recent removal of the X-Waiver requirement, this is the optimal time to
utilize health systems research to address other barriers which still exist among clinicians such as
institutional support and education regarding treatment of OUD (Samuels & Martin, 2022).
Microsystem and Mesosystem—PWOU-PWOU, Provider-Patient, and Provider-Provider
Interactions
PWOU Social Circles
Entering and remaining in recovery may necessitate changes in the individual’s micro
and mesosystem, especially if that individual’s primary microsystem was that of other persons
who use drugs. Exposure to peers using drugs and high availability of drugs in the social and
home environments have been found to decrease retention in MOUD and elevate risk of relapse
(Tofighi et al., 2019; Truong et al., 2019). It can be hard to establish a non-drug using social
circle, and to sever ties with friends that are still using. Accordingly, it can be hard to open up to
non-drug users about their past lives, and some endorse a feeling of being in limbo—cut off from
the drug world but not fully entered into the abstinent world (Notley et al., 2013).
Those who have faced incarceration might be exposed to adverse re-entry conditions and
stressful life events that contribute to relapse. They may also feel isolated and unprepared for
challenges facing re-entry, and might find themselves unable to break away from the constant
exposure to drug use (Fox et al., 2015). PWOU may see others in their community that are
‘models of failure’; that is, people who have tried to quit and failed, which can act as a
disincentive to those attempting recovery (Notley et al., 2013). On the other hand, hearing from
12
those that are in treatment and have been successful may give PWOU the motivation to enter
treatment, desiring what their in-recovery peers have achieved (Hewell et al., 2017).
PWOU Perspectives of Provider Practices
Dealing with emotions without using drugs and coping with other co-morbid mental
health conditions are more barriers to treatment entry and retention (Notley et al., 2013; Truong
et al., 2019). Many PWUO endorsed a desire for an individualized, patient-centered, and/or
compassionate approach to receiving medication for OUD (Bojko et al., 2016; Fox et al., 2016;
Tofighi et al., 2019) and thought collaborative models which included psychological support
such as peer groups, addiction counseling, and social work should be integrated into treatment
(Fox et al., 2016; Hewell et al., 2017; Marcus et al., 2018; Tofighi et al., 2019). Convenience of
clinics including administrative support to see if patients were eligible and flexible scheduling
(Muthulingham et al., 2019; Tofighi et al., 2019) were identified as facilitators to entry and
retention.
PWUO have expressed a mistrust of physicians; feeling stigmatized and mistreated when
seeking MOUD (Allen et al., 2019; Tofighi et al., 2019). Provider practices such as urine drug
screens, contracts, language used around OUD, and stringent attitudes towards
dosing/prescribing have led patients to feel stigmatized and reduced their interest in MOUD
(Allen et al., 2019; Feroni et al., 2005; Goddu et al., 2018). PWUO feel that it is the provider’s
responsibility to ensure that they have a clear picture of how MOUD works, and to discuss
treatment lengths and discharge planning so that the patient’s expectations for treatment structure
matches up with the providers’, and with where the patient is at in their recovery (Hewell et al.,
2017; Merill et al., 2008). Unfortunately, the patient-centered model is underutilized among
MOUD providers due to administrative and clinical barriers (Kermack et al., 2017), and many
13
physicians may not feel prepared to screen, refer to treatment, or discuss treatment options with
substance use disorder patients (Wakeman et al., 2016). As a previously mentioned exosystem
barrier, lack of education and support may be the reason that patients endorse mistreatment from
providers (Bojko et al., 2016; Hewell et al., 2017; Merill et al., 2002), and why clinicians
themselves endorse negative and stigmatizing attitudes towards drug users such as mistrust of
opioid users, viewing SUD as a crime or choice, and questioning patient’s need for MOUD to
treat pain and withdrawal (Duncan et al., 2015; Merill et al., 2002; Wakeman et al., 2016).
Providers’ Beliefs and Practices
The mean prescription length for buprenorphine among current prescribers, the majority
of whom worked in individual practice, was one week. Their willingness to prescribe
buprenorphine was increased when patients had no history of risky alcohol or benzodiazepine
use, used cash, and had an abstinent spouse (Knudsen et al., 2018). Being black, older age, and
having a co-occurring alcohol or other drug dependency have been found to be predictors of not
receiving a buprenorphine prescription (Lagisetty et al., 2019; Murphy et al., 2014). On the other
hand, living in a metropolitan area, having point of service insurance, chronic pain, or a co-
morbid drug induced mental disorder were determinants of receiving buprenorphine treatment
(Murphy et al., 2014). Among 30 buprenorphine providers in an outpatient setting, most
followed standard treatment guidelines but tended to prescribe lower maintenance dosages than
recommended by some studies (MacDonald et al., 2016).
A survey of ED clinicians across four geographically diverse areas revealed that only
21% of physicians, residents, and advanced practice clinicians felt ready to initiate
buprenorphine in the ED. Another survey demonstrated that 80% of ED clinicians agreed that
buprenorphine should be administered in the ED for opioid withdrawal, but only 44% felt
14
prepared to discuss it (Im et al., 2020). EMS personnel and ED clinicians both described trying
to influence subsequent behavior of overdose survivors, but also noted feelings of burnout, loss
of empathy, and frustration. While they wanted to or tried to educate overdose survivors
concerning harm reduction, many also felt that patients tended to be apathetic, not receptive, and
unreasonable (Elliot et al., 2019). Some believed it was not within their scope as an ED clinician
to prescribe medications for what would be considered a chronic illness (Im et al., 2020;
Wiercigroch, 2019), and cited the complexity of dealing with a patient with OUD as another
barrier (Hawk et al., 2020). Younger and less experienced physicians were more likely to
approve of ED initiated buprenorphine and to hold positive views about MOUD for OUD (Im et
al., 2020).
Patient/ Individual – Internal Attributes and Beliefs
Internal factors are important in how PWOU conceptualize themselves and find the
motivation to seek treatment. Many PWOU embraced the idea that a person has to have a
willingness or readiness for change (Andrews et al., 2012; Fox et al., 2015; Gryczynski et al.,
2013; Hewell et al., 2017; Marcus et al., 2018; Muthulingam et al., 2019; Teruya et al., 2014;
Zelenev et al., 2018) which includes a sense of willpower and taking responsibility for their
addiction (Fox et al., 2015). This personal readiness may be precipitated by a feeling of hitting
rock bottom (Andrews et al., 2020), legal consequences or the desire to stop engaging in crime
(Andrews et al., 2020; Muthulingam et al., 2019; Notley et al., 2013), and feelings of exhaustion
with the drug lifestyle (Andrews et al., 2020; Hewell et al., 2017). Females, but not males,
endorsed feelings of disgust about themselves and a loss of self-worth as a motivator for seeking
treatment, and were more likely to endorse fear of losing custody of their children as a motivator,
while males more frequently endorsed fear of jail time (Andrews et al., 2020). Some sought out
15
treatment after a medical emergency such as an overdose or mental illness treatment (Andrews et
al., 2020), and others were seeking a return to normalcy (Gryczynski et al., 2013; Muthulingam
et al., 2019) of a life that is not dominated by drugs (Notley et al., 2013).
Hitting a ‘critical point’ was mentioned by participants in two separate qualitative studies
(Hewell et al., 2017; Notley et al, 2013) in which dramatic moments or events prompted
individuals to change, and internal and external factors guided them towards recovery (Hewell et
al., 2017). However, it is important to note that individuals generally need to attend to their
physiological needs such as shelter and food (Maslow, 1943), before having the motivation to
focus on higher needs such as recovery (Notley et al., 2013). The internal models that PWOU
have of MOUD and their understanding of it operate as inherent frameworks which influence
treatment seeking (Hewell et al., 2017). One study found six key attributes in the decision to
initiate pharmacotherapy among patients with OUD. These include: perceived benefits, side
effects, medication delivery strategies, convenience, whether treatment expectations are met, and
medication representing trading one addiction for another (Muthulingam et al., 2019). Indeed,
many PWOU have expressed fear of MOUD replacing their addiction (Bojko et al., 2015;
Marcus et al., 2018; Makarenko et al., 2016; Muthulingam et al., 2019; Zelenev et al., 2018) and
of having to be on MOUD for a long time, possibly life (Bojko et al., 2015), which is in direct
contrast to the desire to be ‘totally clean’ (Fox et al., 2015). These views can be perpetuated by
recovery groups, friends/family, and society at large which leads to internalized stigma about the
use of MOUD (Allen et al., 2019).
Structural and societal stigma may lead to a loop effect within the PWOU, wherein they
internalize the stigma against the medication (Matthews et al., 2017). Many participants felt that
others believed that being on MOUD meant you’re not truly in recovery, which was perpetuated
16
by acquaintances, recovery groups, and the media (Hewell et al., 2017; Truong et al., 2019).
Finally, PWOU may experience multiple sources of stigma deriving from poverty, structural
racism, involvement with the criminal justice system, co-occurrence of mental disorders, being a
drug user, and being on MOUD, with an interaction of social class and status that can lead to
social marginalization (Allen et al., 2019; Fareed et al., 2012; Notley et al., 2013), and in some
instances, a feeling of being labeled as sub-human (Bojko et al., 2016).
Gaps in Knowledge on MOUD
Although MOUD is the gold-standard for patients with opioid use disorder, it is under-
utilized by people who use opioids and under-prescribed. Barriers to uptake of MOUD exist on
individual, provider, care team, hospital, governmental, and societal levels. Previous studies have
generally only investigated one level of under-utilization of MOUD, yet a framework of how the
interacting systems prevent appropriate linkage to MOUD has not yet been explored or
developed. This project will use Ecological Systems Theory as the overarching framework to
guide interpretation of results and integration among the three studies. The framework applied to
this project is displayed in Figure 2.
Figure 2: Ecological Systems Theory Applied to the Multi-system Evaluation of Medication for
Opioid Use Disorder for People Who Use Opioids
17
This project utilizes mixed-methods research by bringing together three separate datasets
with the goal of understanding what can be improved in the multiple systems a PWOU is
affected by. The results from the studies will be divided into three separate papers, presenting
qualitative perspectives regarding MOUD of people who use opioids; patient, provider, and
hospital predictors of buprenorphine prescribing; and efficacy of a resident physician-level
substance abuse education initiative. Furthermore, the results will be integrated in a mixed-
methods analysis using the Ecological Systems Theory to evaluate and conceptualize the multi-
system factors that contribute to under-utilization of MOUD for PWUO. This could in turn
inform development of evidence-based quality improvement interventions to increase MOUD
prescribing, which has been shown to reduce opioid use and overdose deaths. The overarching
goal of this dissertation is to begin a basic framework of how multiple levels within a public
health system can improve quality of care for PWUO and access to MOUD services. This will be
achieved through a broad understanding of how PWOU are affected through each Ecological
Individual
Microsystem
Provider (physician,
social worker, etc.)
interaction with patient
Mesosystem
Interaction between providers
Exosystem
Hospital procedures, medical school
and training hospital education on
substance use treatment
Macrosystem
Drug Addiction Treatment Act (DATA),
societal stigma and views on drug use
PWOU will have varying beliefs
about MAT and opinions regarding
barriers to MAT access
Providers may be affected by many
factors such as: not being able to
prescribe MAT, lack of knowledge of
appropriate OUD treatment, and
stigma towards drug users
Dynamics of interactions between
direct health providers and other
providers who may have more
experience with OUD and are able to
refer to appropriate treatment or
prescribe MAT
This encompasses the larger system
of healthcare such as insurance
policies and clinic/hospital network
procedures
The outermost level includes cultural
and societal views and stigma, and
government policies that affect each
subsequent system
18
Systems level, the interaction between levels, and what can be done to improve each system in
an evidence-based manner.
19
Chapter 1: “It helps and it doesn’t help”: A qualitative assessment of complex perspectives
on medication for opioid use disorder (MOUD) among people who use opioids
Abstract
Introduction
Medication for opioid use disorder (MOUD) such as buprenorphine and methadone are effective
in reducing overdoses, drug use, and drug-related harms. Despite their benefits, MOUD is under-
utilized among people who use opioids (PWUO). Current literature primarily investigates
MOUD as recovery-focused treatment but neglects to examine harm reduction benefits of
MOUD. This study qualitatively analyzes perceptions of MOUD among current opioid users to
explore use of MOUD in both treatment and harm-reduction approaches. We aim to achieve a
greater understanding of how harm reduction-based approaches to OUD treatment can be
improved.
Methods
Between May 2021-May 2022, in-depth qualitative interviews were conducted with PWUO in
Los Angeles, California (N=22) recruited from two community sites. Participants were at least
18 years old and self-reported opioid and injection drug use in the last 30 days. Participants
answered questions related to general experiences with MOUD. We conducted a thematic
analysis following a grounded theory approach in our data collection and analysis and identified
common themes that emerged from the qualitative data.
Results
The majority of participants were male (64%), Hispanic (64%), and had stable housing (64%).
Most (68%) were currently on a methadone maintenance program (MMT). Participants favored
methadone as a tool to reduce withdrawal, and buprenorphine for achieving abstinence from
20
other opioids. Prolonged MMT was viewed as controlling due to the need for daily dosing.
While some participants reported satisfaction with buprenorphine, others feared experiencing
precipitated withdrawal, especially in the context of fentanyl tolerance. Other prevalent themes
include first MOUD experiences and improvements that could be made to MOUD.
Conclusions
Our findings illustrate PWUOs’ complex relationships with MOUD, which can be used for
treatment or as a harm reduction tool independent of abstinence goals. Under the guise of
recovery-based models, MOUD has been heavily regulated to control lives of PWUO, without
much acknowledgement of its potential for use in reducing drug-use related harms outside of the
scope of abstinence-based treatment. Guidelines for MMT should be loosened towards a person-
centered approach, and buprenorphine dosing standards may need to be amended. This could
improve access to and quality of care for every PWUO, regardless of their readiness for
treatment.
21
Introduction
People who use opioids (PWUO) have high rates of morbidity and mortality in the United
States (Gomes et al., 2018; McCarthy et al., 2020), and are at risk of overdose deaths, in large
part due to fentanyl and fentanyl-analogues (Ahmad et al., 2022). Opioid use disorder (OUD)
can drastically impact an individual’s wellbeing; it is associated with drug-related harms such as
incarceration, suicide attempts, unemployment, crime, homelessness, and social isolation
(European Monitoring Center for Drugs and Addiction, 2021; Gholami et al., 2022). PWUO
often seek to stave off painful withdrawal symptoms which can result in a life of engaging in
dangerous or risky behaviors in order to acquire resources to purchase drugs that leads to further
medical, social, physical, emotional, and legal consequences (Bluthenthal et al., 2020; Coffin et
al., 2007; Scorsone et al., 2021). Medications for opioid use disorder (MOUD) such as
buprenorphine and methadone can reduce risk of overdose, use of illicit opioids, cravings for
opioids, serious opioid-related acute care, suicidal behaviors, and crime among PWUO (Bart,
2012; Molero et al., 2018; Wakeman et al., 2020). Treatment with MOUD can also improve
social functioning and relieve/prevent withdrawal symptoms (Bart, 2012; Samples et al., 2020).
Methadone is highly regulated in the U.S and is dispensed almost exclusively in specific
methadone clinics when used to treat OUD (Des Jarlais et al., 1995). A person with OUD can be
put on one of two methadone programs-- methadone maintenance treatment (MMT; long-term)
or methadone detoxification (short-term), both of which typically entail daily dosing at a
specified methadone clinic. Buprenorphine is commonly prescribed as a buprenorphine +
naloxone combination, known by its brand name Suboxone. Since buprenorphine is a partial
agonist (unlike methadone which is a full agonist), it can block the effects of other opioids when
administered. The combined formulation contains naloxone to deter misuse so that if it is
22
crushed up to be smoked, snorted, or injected, the user will generally immediately go into
withdrawal (Pergolizz et al., 2010). The buprenorphine + naloxone combination is the most
common formulation of buprenorphine, although buprenorphine without naloxone (brand name
Subutex) can also be prescribed for those with negative reactions to naloxone. A physician or
nurse practitioner must have a special federal license (X-waiver) to prescribe buprenorphine,
which is relatively easy to obtain as of 2021 when the 8-hour mandated training to receive the
license was waived. Still, relaxation of X-waiver requirements has not sufficiently expanded the
number of clinicians able to prescribe buprenorphine (Samuels & Martin, 2022; Spetz et al.,,
2022). Stigma, logistical issues, and lack of education/training in using buprenorphine to treat
OUD are also common barriers to prescribing buprenorphine among clinicians (Mackey, 2020;
Samuels & Martin, 2022).
For those participating in MMT, daily appointments and strict treatment rules were
perceived to be too harsh by many patients (Simon et al., 2022; Zelenev et al., 2018) who had
issues with daily supervision, treatment fatigue, not being able to travel, and conflicts with
responsibilities that impacted treatment entry and retention (Allen et al., 2019; Bojko et al., 2016;
Muthulingam et al., 2019). Methadone has been described as “liquid handcuffs” for its inflexible
and rigid daily dosing and constant supervision of treatment (Frank et al., 2021). Patients on
MMT stated that methadone is harmful and has adverse physical side effects (Notley et al., 2013)
that can lead to a sedating or zombie-like effect (Muthulingam et al., 2019), as well as impairing
cognitive functioning (Tofighi et al., 2019). Fear of dependence on and withdrawal from
methadone is prevalent, with specific fears of ‘slipping into’ long-term maintenance on
methadone (Bojko et al., 2016; Notley et al., 2013; Marteau, 2015).
23
The demands that methadone clinics put on users of MMT are inconceivable for any
other long-term patient or condition, impact daily lives and responsibilities of PWUO, create
barriers for entry and retention, and contribute to the cruel and stigmatizing treatment of people
who use drugs (Aronowitz et al., 2022; Frank et al., 2021; Simon et al., 2022). Researchers and
methadone patient activists have endorsed the need for a re-conceptualization of MMT away
from being viewed solely as treatment in a recovery-based framework (Frank, 2018; Simon et
al., 2022). Acknowledging that MOUD doesn’t have to be based in the desire for treatment may
reduce barriers for PWUO who would benefit from MOUD but do not want to pursue
abstinence-focused recovery (Frank, 2018; Simon et al., 2022). Opponents of relaxing
methadone treatment guidelines claim to worry about diversion and adverse effects of non-
supervised consumption of methadone such as overdose, yet no evidence of a difference in
adverse effects, abstinence, or diversion between supervised and unsupervised provision of
methadone has been found (Amram et al., 2021; Saulle et al., 2017).
Buprenorphine has a better safety profile than methadone, has no ceiling effect for pain
relief (Pergolizzi et al., 2010), and produces fewer/milder side effects (Schwartz et al., 2008). It
offers greater flexibility than methadone because it can be prescribed monthly and some PWUO
perceive it to have greater effectiveness in reducing cravings for opioids (Checkley et al., 2022).
However, a transition to buprenorphine can be difficult as buprenorphine binds to opiate
receptors in the brain, preventing other opioids from being able to attach. Buprenorphine often
requires withdrawal symptoms to be present before initiation because of its chemistry as an
opioid partial agonist and it may also be less effective than methadone in patients with very high
tolerance to opioids (Donaher & Welsh, 2006). With the domination of fentanyl and fentanyl
analogues in the illicit drug market, PWUO have been increasingly anxious about experiencing
24
precipitated withdrawal after buprenorphine induction due to the much higher tolerance that
fentanyl use induces (Shearer et al., 2022; Silverstein et al., 2019; Spadaro et al., 2022;
Varshneya et al., 2021). Clinicians have developed alternate buprenorphine dosing strategies
including high-dose initiation and micro-induction of small, multiple doses with success in
combating precipitated withdrawal (Herring et al., 2021; Antoine et al., 2021). However, current
guidelines on buprenorphine dosing (SAMHSA, 2020) do not reflect recent research
developments which may result in adherence to older models of initiation and lack of innovation
in treating patients at risk of precipitated withdrawal.
Much of the literature surrounding MOUD is focused on abstinence outcomes, and so
neglects to consider MOUD benefits such as reducing opioid use, preventing opioid withdrawal,
and other harms associated with obtaining illicit drugs (Bart, 2012; Molero et al., 2018). In
contrast to the abstinence-based approach, a harm reduction approach supports any changes in
individual behavior that reduces problems related to drug use. Overall, it respects the dignity and
behavioral/treatment goals of people who use drugs (Logan & Marlatt, 2010). PWUO vary in
their stages of readiness to change but may still use MOUD through a harm reduction lens to cut
down on or supplement their supply and avoid harms related to the criminalization of drug use
(Frank 2018; Sud et al., 2022). Additionally, framing MOUD as beneficial regardless of
treatment goals can give clinicians the opportunity to build trust and rapport with PWUO who
are not quite ready for treatment (Logan & Marlatt, 2010). The objective of this study was to
qualitatively explore PWOU’ perceptions of MOUD to obtain a better understanding of how
harm reduction-based approaches to OUD treatment can be improved. We aimed to qualitatively
analyze the attitudes, beliefs, and preferences about MOUD among a sample of PWOU,
25
including: how PWOU make the choice to seek treatment; what are pathways to treatment; and
the impact that MOUD has had on their opioid use and general well-being.
Methods
Participants
Our study team conducted structured quantitative interviews with PWUO in two
locations in Los Angeles: Hollywood and Northeast LA as part of a larger study examining the
effects of cannabis use on opioid use (NIDA grant #RO1DA046049). We recruited participants
through street outreach using a targeted sampling method. This method is a systematic approach
to sampling hard-to-reach populations when true random sampling is not feasible and has been
widely used in epidemiological studies of people who use drugs (Bluthenthal & Watters, 1995;
Kral et al., 2010). The Northeast LA participants were primarily recruited from a nearby
methadone clinic utilizing the University of Southern California’s Street Medicine outreach
team, while the Hollywood recruitment location was located next to a syringe service program
(SSP) and recruited visitors of the program.
Between May 2021-May 2022, participants returning for a follow-up interview or check-
in visit were told about an additional interview and offered the opportunity to participate in a
qualitative interview concerning experiences with MOUD and withdrawal. Twenty dollars were
offered to the participants for completing the baseline parent-study interview, and an additional
$40 was offered to complete the qualitative MOUD interview. Inclusion criteria for the parent
study was self-reported opioid use (including heroin and/or fentanyl) in the last 30 days,
injection drug use in the last 30 days, and at least 18 years of age. Qualitative interviews were
conducted between 6 weeks and 6 months after the baseline interview. We did not reassess
opioid use or injection drug use within the last 30 days prior to beginning the qualitative
26
interview, so it is possible that some of our participants were no longer actively using/injecting
opioids or other drugs.
Procedure
The interview guide was based on a review of the literature of previously identified
barriers/facilitators to MOUD (Mackey et al., 2020; Muthulingham et al., 2019; Simon et al.,
2022; Tofighi et al., 2019; Uebelacker et al., 2016; Yarborough et al., 2016) as well as novel
questions developed by the research team. The semi-structured qualitative interview featured
questions broadly related to the following: current and past drug and MOUD use, initial
experiences with MOUD, comparisons of methadone and buprenorphine, general feelings about
MOUD and its impacts, hospital and methadone clinic experiences, and withdrawal experiences..
Interviews ranged from approximately 30 minutes to 75 minutes. Audio recordings of the
interviews were collected without any identifying information on the digital recording. All
qualitative interviews were conducted by graduate researchers (MB and KS). Audio recordings
of interviews were later transcribed by undergraduate and graduate researchers on our team with
the assistance of the transcription service Otter.ai. All study procedures were approved by the
University of Southern California Institutional Review Board (IRB).
Analysis
To describe the sample, we examined baseline parent-study data using SPSS 22. We
followed an iterative, inductive, grounded theory approach in our data collection and analysis
(Birks, 2015). Two graduate researchers (MB and KS) used an open coding process to develop a
codebook based on initial readings of the first set of transcripts and memos, which included
preliminary codes, definitions, and examples. Transcripts were then thematically analyzed using
Nvivo 12 software. All transcriptions were coded by the two researchers to ensure all relevant
27
themes were identified, and discrepancies were discussed and resolved. The researchers met
periodically to discuss and improve the interview guide, adding new material and removing
redundancies according to the grounded theory approach, as well as to discuss coding and update
the codebook to what would be its final edition. The final set of transcripts were independently
coded by the two graduate researchers in sets of 3-5 until adequate consensus was reached
(Kappa > 0.70). A constant comparative approach was implemented to identify significant
themes that emerged from the Nvivo codes that were relevant to the objectives of this study. The
interviews occurred until theoretical saturation was reached, and no new data provided additional
information to the existing categories (Birks, 2015; Thomson, 2011).
Results
We interviewed 22 participants in East LA (77%) and Hollywood (23%) regarding their
experiences with MOUD (See Table 1 for participant characteristics). The median age of
participants was 46.5 and they were predominantly male (64%), Hispanic/Latino (64%), and had
stable housing (64%). All but one participant (96%) had tried MOUD in some form at any point
in their life, and half had tried methadone only. None of the participants had tried buprenorphine
only. The majority of our sample were current dual users of MOUD and other opioids (all were
on MMT; 68%), and all but one had used methadone at some point in the past or currently
(96%). No one we interviewed was currently using buprenorphine.
Table 1: Participant Characteristics (N=22)
Characteristic Median (range) or N
(%)
Age 46.5 (27-70)
Male 14 (63.6%)
28
Race
White
Black
Native American or Alaskan Native
Mixed race
Other
7 (31.8%)
1 (4.5%)
2 (9.1%)
4 (14.2%)
8 (36.4%)
Hispanic or Latino ethnicity 14 (63.6%)
Homeless or unstably housed 8 (36.4%)
Income less than $1,400/month 16 (72.3%)
Location
East LA
Hollywood
17 (77.3%)
5 (22.7%)
Relationship status
Single, no main partner
In a relationship but not living as married
Married or living as married
13 (59.1%)
5 (22.7%)
4 (18.2%)
High school education or greater 13 (59.1%)
Ever used MOUD
None
Methadone only
Buprenorphine only
Both
1 (4.5%)
11 (50%)
0 (0%)
10 (45.5%)
Current MOUD Use
None
Methadone only
7 (31.8%)
15 (68.2%)
Participants shared their experiences of using MOUD both as treatment and as a harm
reduction tool to reduce occurrence of withdrawal. Several themes emerged that demonstrated
the perceived differences between methadone and buprenorphine: perspectives prior to use, first
initiation experiences, concurrent use with other opioids, and impact of prolonged use. We have
organized the responses based on these themes.
Perspectives prior to initiation of MOUD
All the participants had heard of MOUD in one way or another through other users,
family, friends, and healthcare workers. In the case of methadone, the daily, long-term aspect of
MMT frightened some prior to initiation, especially when it seemed like it was just another drug
29
to get ‘hooked’ on. A few participants endorsed having an aversion to methadone due to negative
and stigmatic views of others, and the fear of exposure attending a methadone clinic daily.
“I just think it’s kind of backward to get hooked on something else. I understand it makes you
more functional. It’s not as damaging to you. But uh, you’re still like a slave to something. You
know, you still have to have it.”
“Once you go to a methadone clinic, now everybody knows you go there. They know what you’re
doing.”
“Over time, it does damage. People there at the methadone clinic, they’re there for too much of
their life. I don’t want to do that”
Less than half of our participants had ever tried buprenorphine, nevertheless,
misconceptions about buprenorphine were prevalent among most of our participants.
Participants’ experiences with and perceptions of differences between methadone and
buprenorphine are explored in more detail further in this paper. Generally, however, multiple
participants who had never tried buprenorphine believed that it (particularly in the combined
formulation) was incongruous with heroin use and could only be used if the person quit opioid
use altogether because it blocks the effects of other opiates. The fear of precipitated withdrawal
after initiation of buprenorphine was quite strong, and led to most participants having negative
views of buprenorphine.
“Well cause if you use it, you can’t use, cause you use and it blocks off the receptors. So you
can’t get high and so if you do, you just get sick. You have to stop being on drugs.”
“Suboxone? It’s like a methadone. They use it for a deterrent. From what I understand, if you
went and you were high, and you took the Suboxone, you get viciously sick. So yeah, that was
one thing I never wanted to even get near.”
Reasons for initiation
It took several years to decades for many of our participants to initiate MOUD for the
first time, and several have had on/off relationships with MOUD since. Two main motivations
30
for starting MOUD were identified; a desire to ‘get their lives together’, as well as a desire to
stop experiencing withdrawal symptoms. Of course, these motivations often overlap. Those who
endorsed initiation of MOUD for reasons of wanting to get their lives together spoke about
wanting to feel normal and be better for themselves and their families. Opioid withdrawal played
a big role in the initiation of methadone – many participants emphasized not wanting to be ‘dope
sick’ (i.e., experiencing withdrawal) anymore, which intersected with being tired of hustling for
money in order to obtain more heroin. As demonstrated further in this paper, access to daily
methadone dosing eliminated or greatly reduced the experience of opioid withdrawal which led
to some participants reducing risky behaviors related to illicit drug procurement.
“I got tired of waking up dope sick. And having to chase it every morning. And it will be times
when I’m broke and I’m like, ‘fuck’ so now I knew what I had to do to go get a fix.”
“I wanted to get my life back together. I used to dress, wouldn’t comb my hair, wouldn’t brush
my teeth. I had holes in my blouses, everything. My shoes torn up by my dog. Oh, I looked like
the walking dead….So it was like I need to get back my life.”
First MOUD experiences
There were three settings that participants identified as their initial introduction to
MOUD: methadone clinics, rehabilitation facilities, and hospitals. While use of ‘street’ MOUD
was occasionally mentioned in the interviews, none of the participants cited using a non-
regulated source of MOUD their first time trying it. There were few if any barriers experienced
by participants who sought out either buprenorphine or methadone to obtain a prescription or
enroll in a program.
Methadone clinic
31
Initiation of methadone maintenance held the least number of barriers for our
participants, as everyone who had been on MMT endorsed the ease of starting the program,
which is fully covered by insurance for low-income individuals in California (Medi-Cal).
Interviewer: So when you first tried to go to the methadone clinic was it hard for you to get in, to
enroll?
Participant: It was no problem.
Interviewer: So you didn’t have to wait?
Participant: No, a couple hours to take my information. But wait a few days or something, no.
They got me. And I’m glad they did.
Rehabilitation facility
First initiation of buprenorphine sometimes occurred at a rehabilitation facility that
offered MOUD treatment as part of the inpatient rehabilitation program. One participant stated
that it helped with detoxification from opioids and made him feel normal.
“The first rehab that I went to, what they were giving me was Suboxone to detox. And it helped.
It was a real short period of time, even though I was doing a lot of heroin for a period of time,
but they had it set up and weaned me off, you know, nicely. Instead of making it a maintenance
thing. And after that, when I left, I was prescribed it and I felt normal. So every month, I’d come
and get my bottle from [doctor] and I felt like I was you know- like I was before I started using.”
Hospital
Finally, we asked participants if they had ever had an emergency room or hospital
(inpatient) visit that was related to their drug use, such as an overdose or abscess. Specifically,
we probed to determine if hospital staff addressed their opioid use during the visit by offering to
start them on MOUD if they were not already on it. Two participants in our study had good
experiences of being initiated on buprenorphine while in withdrawal during a hospital encounter.
“I detoxed in a hospital and they gave me Suboxone there, which I will admit I didn’t have any
withdrawal symptoms at all in the hospital….So I went into the emergency room and I didn’t
want to use anymore. And so they went and aided me and they gave me a doctor that did nothing
but that.”
32
However, the majority of hospital encounters that our participants experienced were not
as sympathetic. Participants endorsed being stigmatized, poorly treated, lectured, and
embarrassed. Often, clinicians did not address their drug use at all during their encounter. One
participant who had quit heroin and methadone after previously being on it had a hospital
experience in which he had a staph infection and was put back on methadone rather than his
preference of Vicodin after being stereotyped as a heroin user. This led him to be back on
methadone and eventually return to using heroin.
Interviewer: “If you’ve ever been in an emergency room, do they offer you any types of treatment
for opioids?”
Participant: “No. Now that I think of it, they don’t want to give you that stuff .You know, in the
ER, or even in the hospital, that’s something that, the minute you mention heroin, it’s like,
‘Eww’. That’s how they act a lot of times and it’s not something I’m proud to just blurt out....It’s
embarrassing for me….No, they don’t like to, in the hospitals, to offer you anything like that. It’s
weird. It’s weird. “
“See that’s how I got back into [using heroin], because of the doctors assuming that I’m still a
drug addict. They stereotype me kind of like to say, okay, he’s an opiate user, we can’t give him
Vicodin no more, so we’ll put him back on methadone. So when you’re around, you know, a
barber shop, what happens? You get a haircut. So well, that’s what happened. I went back into
drug use again.”
“They kind of lectured me on [drug use]. But they didn’t do anything else. Actually, they didn’t
refer me or anything like that... You’d think they would, coming in for an overdose. That should
be a sign like ’This guy’s got a problem!’…..Drug abuse becomes pretty serious when the guy
overdoses.”
Comparing MOUD
Participants who had personal experience with both methadone and buprenorphine
(N=10, 45%) tended to view the two medications as distinct entities, yet both aligned with harm
reduction and treatment properties. Buprenorphine was perceived as a better way to fully detox
from heroin, to subdue cravings, as well as to stay off heroin if the person was fully committed to
not using other opioids anymore. Buprenorphine was not mentioned by any participants as a
means to manage withdrawal symptoms for current opioid use. In contrast, methadone helped to
33
avoid withdrawal symptoms, and allowed for a sense of a high, or to feel “loaded” when using
heroin concurrently, however, it did not reduce cravings for heroin.
Participant: Methadone, I still had the craving. I still wanted to get high. I just like didn’t with
Suboxone. I didn’t really think about it.
Interviewer: And were you not using at all on top of it?
Participant: On Suboxone? I wasn’t using at all. Then with methadone, I wasn’t using but I
wanted to. I thought about it.
Interviewer: So Suboxone really helped you not have cravings as much?
Participant: Yeah. It was actually like, I don’t want to call it a wonder drug. But it was really
like, it made me, ’me’ again.
“I think the Suboxone made me feel regular period, and the methadone…sometimes makes you
feel like loaded.”
Among those who tried buprenorphine, there was a difference in preference among two
formulations, Suboxone (buprenorphine-naloxone formulation) and Subutex (buprenorphine only
formulation). Subutex was regarded as a better MOUD due to it not having a ‘blocker’ effect like
Suboxone does, although this seems to stem from a misconception about the formulation of the
drugs. Suboxone was perceived to instill precipitated withdrawal because of the ‘blocker’ (i.e
naloxone) in it, while Subutex was deemed safer and able to still get the user high, unlike
Suboxone. Participants also noted that it was much harder to get a prescription of Subutex vs
Suboxone, and that Subutex was extremely expensive and not covered by insurance in
California.
“Suboxone—you feel normal. Like that normal you want to feel when you use all the time and
pretty soon you have to use to feel normal. That’s what the Suboxone did. Because it didn’t give
you any kind of high. Subutex did. You could get high. It didn’t necessarily get you high so much,
but you can get high. Suboxone didn’t.
We asked participants who had only ever tried methadone and not buprenorphine, or had
success with buprenorphine but were now using methadone, why they did not want to switch
back to buprenorphine. Most were content with their situation and had not given it much thought.
34
Yet, a few participants mentioned the difficulty of switching from methadone to buprenorphine
due to the logistics of tapering methadone and fear of subsequent withdrawal symptoms.
“It’s not an easy switch. If I was able to do it within the week, it would have been done. I have to
wean myself off, and it’s not always the fastest thing as you would like.”
Use of MOUD in combination with other opioids
Use of MOUD had completely stopped other opioid use, reduced use, or kept it exactly
the same depending on the participant, and also varied over their lives. For participants on MMT
who continued to use heroin, methadone was essential in the avoidance of withdrawal symptoms,
which often meant less ‘hustling’ for money and drugs.
“It helps. It helps not being dope sick. You get up in the morning. You're not dope sick, going out
and getting that bag and trying to fix and being sick….It helps out, it helps out. Heroin you close
your eyes and you go to sleep…as soon as you open your eyes, you're dope sick. You've got to
have that fix. So you've either got to make your money the night before or ahead of time and get
the dope ahead of time. Because if you open up your eyes and you got to go get that dope you
can't think straight, you can't concentrate. You're no good to yourself. You're no good to no one.
And with methadone it takes all that away.”
Participant: [Methadone] helped me use less heroin. And at the same time, I ain't got to be out
there hustling for the dope and get the dope money. And it's a lot of changes to take care of a
habit…
Interviewer: So you feel like being on the methadone has really helped your life?
Participant: Yeah it's helped out my life a lot. Because I'm not out there hustling. Sometimes you
get yourself in situations where you're trying to get dope money and the situation don't end up
right. And you end up in jail. I'm not trying to end up in jail. I'm too old to be doing time.
Conversely, none of the participants had used buprenorphine intermittently with other opioids as
a harm reduction tool to avoid withdrawal, although one mentioned keeping some buprenorphine
with him as a “security blanket”.
“[Suboxone] is like a comfort, like I said, a security blanket, same thing…Like I don’t have to go
out and get [heroin], I have suboxone in my pocket.”
35
The majority of our sample who were currently on MMT were still using heroin; some
who used every day and others only when they were not able to access the methadone clinic.
Despite frequency of heroin use, those endorsing use of heroin and MMT together frequently
stated that they were not able to feel high on heroin any longer, due to the tolerance gained by
using methadone. A few participants acknowledged that it was a waste of money to keep using
heroin, but kept using it anyway on top of methadone in the hopes that the next time it would
achieve the rush they were hoping for. One participant explained the concurrent use of heroin
while being on methadone with the Spanish word ‘ansias’ – a want or yearning for something.
Interviewer: Do you use heroin the same days you go to the methadone clinic?
Participant: Sometimes, not all the time, though. Like, I might go and I might use heroin, but it’s
just pointless. So I start feeling like "What the fuck did I do?" like "Why did I do that?" Because
I’m hoping that maybe next time I use something that it’ll hit me, and I’ll be in a relaxation
mode, and it doesn’t hit me, it doesn’t relax. This doesn’t relax me at all no more….Yeah, just
pointless…It’s not fun. It’s not nothing. So it’s like "Why the fuck am I doing it?" You know?
Interviewer: So now that you're on the methadone, when do you use heroin?
Participant: In Spanish, it's called ansias; that means want. And to me, that's some
motherfucking shit. Cause I start looking at my friends, and the homie come…And I want some
too, know what I mean.
A couple of participants had success with prolonged buprenorphine use, in which they
reported an elimination of opioid cravings and subsequent heroin use. Nevertheless, even those
who had prolonged abstinence of opioid use with buprenorphine eventually went back to using
opioids and were no longer currently using buprenorphine. Just as some users of methadone still
wanted to use heroin, so did users of buprenorphine, but found that it was difficult or dangerous
to get high. A participant who had previously used buprenorphine with some success recounted
her experience of precipitated withdrawal after using street-purchased buprenorphine days after
using fentanyl.
“I took suboxone too early. Cause I was gonna try it again out here... And I waited till I was
dope sick. But like, apparently I didn't wait long enough. I waited 36 hours. But apparently you
36
have to wait 72 hours. So yeah, that's apparently how long it takes for fentanyl to get entirely out
of your body. And it was the worst sick I've ever been…I wouldn't wish that on my worst enemy.”
General experiences of prolonged use of MOUD
Use of long-term MOUD resulted in a range of positive and negative consequences for
participants. One chief positive was the stability of MOUD even though programs were often
controlling. Still, participants complained about feeling too dependent on MOUD after prolonged
use.
“I'm in full support of the Suboxone and methadone … because I've seen how it helped my
friends. I just wish that they had something that was not as long term … I just think it's kind of
backwards to get hooked on something else. I understand it makes you more functional. It's not
as damaging to you. But uh, you're still like a slave to something. You know, you still have to
have it.”
“I will give it to Suboxone. It did help me but I just didn't like the whole fucking you know –
mental-- I mean, the whole physical fucking dependency upon it. Because that's what happens.
You can't just stop taking it, your body will go through withdrawals.”
“Well, I would like to quit altogether because I don’t like the needing it. That’s the part I hate. I
don’t like having to need it. Like I said I sleep in this neighborhood just to get my little
methadone. But I don’t want to be around here every day really. I’m homeless. I should be able
to move around and go all these different places you know, but I’m stuck here because of
methadone.”
“Because when you use the methadone, it’s like a more of a stable crutch, instead of one that
you’re out there hunting for it.”
Quality of life generally improved for most participants who were on MOUD for a
prolonged period of time.
Interviewer: And do you feel like your quality of life is better using the methadone compared to if
you didn’t?
Participant: It helps. It helps. And it doesn’t help. But in general, it really is a lifesaver.
Suggested improvements to MOUD
Finally, we asked participants how provision of MOUD could be improved for them and
others. For buprenorphine, the only way participants thought to improve it would be to ‘take the
37
blocker out’ of the buprenorphine + naloxone combination (Suboxone), essentially providing
buprenorphine only (e.g., Subutex) and making that formulation free and easy to obtain via
prescription. Perhaps PWUO are misinformed about this distinction, and thus misinterpret the
difference between the two formulations.
Interviewer: If there was anything you could change about Suboxone now, what would you do?
Participant: Take the blocker out. Have you heard of Subutex? Yeah. It’s the blocker out.
Interviewer: Is that accessible to you?
Participant: No. Because of the price, you can’t get it….Nobody will prescribe it.
There was far more discussion of improvements that could be made to methadone
programs. Participants shared their desire for more autonomy regarding their treatment which
included decisions of program and dosing, longer clinic hours, and expanded access to take-
home doses. Many participants noted that they had been started at very high doses and/or had
their dose increase steadily, even though ideally, they wanted to taper down to a lower dose or to
have started with methadone detoxification (short-term) over maintenance (long-term). One
participant observed that this might be a result of methadone clinics receiving more funding the
higher they dose and keep patients in treatment.
Participant: “I don’t know, I guess I should have got on detox. But they want you to get on
maintenance. You need to get on detox or maintenance…But they encourage you to be on the
maintenance and give you a high dose. And you can’t get off it because it takes like a year. So I
guess I should have just done that, the detox. “
Interviewer: “But did you have the option to do detox if you wanted to?”
Participant: “Yeah, but they’re like, strongly suggesting I shouldn’t.”
“One last thing, I tell all the new people that I meet at the clinic is that no matter what, don’t let
them talk you into getting your dose up over 100 milligrams, you don’t need it. And I’ve noticed
that these places, they try to get your dosing up, and I think it correlates with their funding, like
the more they can put you on, the more money they get for you, and I think that’s wrong.”
Another participant described the importance of the harm reduction principle of meeting people
where they’re at in retaining beginners.
38
“For the beginners, I think, leave them alone. That's why a lot of people leave. Because people
bother them. ‘You want to see a counselor, you want to see a counselor?’ Yeah don't bother
them. Let them get used to it. Then talk to them but don't jump on them. Then all you're doing is
throwing them out on the street.”
About halfway through data collection for this study, the clinic started to be open 24/7, as
opposed to until 1pm, which was a big help according to some. A few participants were able to
receive take-homes of methadone, which is only allowed after testing clean for a certain number
of weeks/months. Participants were divided in their views of take-homes. A few participants
found comfort in the routine of visiting the methadone clinic every day, and some believed that
take-homes should only be offered for those who are genuinely trying not to use other drugs.
Yet, the majority thought that take-homes should be available to everyone and would make their
lives much easier.
Interviewer: And do you wish you could get take homes for methadone?
Participant: I like the way of, the routine of going to the clinic. It helps me out.
Interviewer: Do you wish that they just didn’t have the drug testing requirements for take-
homes?
Participant: No, it’s okay. That way they know the people who are trying and who are not.
One participant recounted a grim story of a friend who was a caretaker of his elderly
parents. The friend was in a daily MMT program but was unable to receive take-homes of
methadone, and thus one day when driving to the clinic, was not present to aide or call for help
when his father suffered a fatal heart attack.
“I think that changing the situation will help out a lot of people there. I know this one guy he's
taking care of his mom and his dad. And the take homes would have helped him out a lot…It just
happened to be that he was driving and there was an accident in front of him and he got stuck on
the freeway where he couldn't get off…He was stuck there for two and a half hours and in those
two and a half hours his dad had a heart attack and passed. Yeah, so the guy I know, it messed
him up. He blames himself but it's just things happen. And I kept telling him you don't want to
39
hear it but it would've help out if he had take-homes. If he had the take homes in the house he
would have never been on the freeway. He would have been there when something happened
with his dad. His dad was hollering, his mom was bedridden so she couldn't get up to see what
dad was hollering about.”
Discussion
This study adds to the literature by offering perspectives on MOUD within the context of
current users of opioids who may use MOUD for reasons outside of the accepted treatment-based
goals. Participants showed a clear preference for methadone treatment over buprenorphine, yet
this sample is highly biased due to most participants having used methadone rather than
buprenorphine. Participants favored methadone as a harm reduction tool to reduce occurrence of
withdrawal, and buprenorphine for treatment with the goal of abstinence from other opioids.
However, prolonged MMT produced negative side effects and held control over participants due
to the need for daily dosing. While some participants reported satisfaction with buprenorphine,
others feared experiencing precipitated withdrawal, especially in the context of fentanyl
tolerance. Our findings illustrate that while many PWUO use MOUD for treatment successfully,
it is also an essential tool for reducing harms related to opioid use and can be used independent
of treatment/abstinence goals. The perspectives on MOUD that we identified through a
qualitative approach contribute to the growing literature that seeks to reform strict MOUD
regulations, as well as to incorporate harm reduction principles and needs of PWUO into
provision of MOUD (Frank, 2018; Frank et al., 2021; Simon et al., 2022; Sud et al., 2022).
Methadone “helps, and it doesn’t”. MMT changed the lives of some participants, yet it
came with a cost. It allows PWUO to reduce the ‘hustle’ for money and drugs, and initiation of
methadone within a clinic was easy and straightforward for our participants, which is not the
case for many others in the U.S (Mackey et al., 2020). Nevertheless, users of MMT forewarned
the negative physical consequences of prolonged methadone use, as well as the control that
40
methadone can have on one’s life. The experiences of our participants support findings from
other qualitative studies which conclude that daily dosing of methadone in the clinic negatively
impacts lives, and that take-home doses would be preferable (Bojko et al., 2016; Frank et al.,
2021; Simon et al., 2022). PWUO would benefit from The Substance Abuse and Mental Health
Services Administration (SAMHSA) loosening opioid treatment program (OTP) regulations on
take home doses and reducing punitive and controlling guidelines that set the rules for
methadone patients (Amram et al., 2021; Frank et al., 2021). Moreover, perhaps regulatory
forces should increase scrutiny over methadone clinic practices that prioritize profits over patient
well-being (Bachhuber et al., 2015).
Several participants on MMT were frustrated with their concurrent heroin use,
commenting that they were no longer able to feel the same effects of heroin, yet continued to use
despite knowing it would be a “waste of money”. In our examination of the literature, we have
not been able to find studies that investigate this phenomenon or the reasons behind why PWUO
continue to use heroin when it has stopped giving them its intended effect due to methadone
tolerance. However, one of our participants gave a simple yet poignant explanation for this
seemingly contradictory behavior – he had ‘ansias’, meaning ‘want’ or ‘craving’ to use,
especially in the context of hanging out with his social group of other people who use drugs
(PWUD). Indeed, having friends who use drugs is associated with increased concurrent heroin
use (Li et al., 2012). While some PWUD may be able to restructure their social circles away
from temptation of drug use, the reality is, for some, MOUD will never replace the euphoric,
self-medicating, and familiar effects of their drug of choice, but it may be able to moderate its
related harms.
41
Use of buprenorphine made some participants feel ‘normal’ again, while others perceived
it to be a generally negative and problematic medication. The harms of buprenorphine identified
by our participants echoed concerns of other PWUO with respect to precipitated withdrawal,
such as one participant who had previous good experiences with buprenorphine, but found
herself ‘the worst sick I’ve ever been’ after initiation of buprenorphine too soon after fentanyl
use. PWUO may be at an increased risk of experiencing precipitated withdrawal if they initiate
themselves based on a casual understanding of time and withdrawal symptoms since last use or
are not dosed adequately in a healthcare setting (Shearer et al., 2022). For buprenorphine
initiation in hospital-based care, the evidence indicates that there is no longer a one-size-fits-all
approach. Current treatment guidelines of buprenorphine induction (SAMHSA, 2020) may lead
to incorrect dosing, and thus should be modified accordingly and tailored to patient history and
experiences (Hartley et al., 2022; Shearer et al., 2022). Emergent alternate dosing strategies have
gained popularity among hospital clinicians and PWUO choosing to self-induct for being safe,
resistant to precipitated withdrawal, and may even bypass prerequisite withdrawal symptoms
(Adams et al., 2021; Antoine et al., 202; Herring et al., 2021; Moe et al., 2021; Spadaro et al.,
2022). However, buprenorphine initiation-related issues first have to reckon with foundational
problems that PWUO experience while accessing healthcare that include stigma, judgement, and
lack of attention paid to treating substance use (Allen et al., 2019; HHS, 2016).
As evidenced in our study and others, preconceived notions about MOUD, unfavorable
initiation experiences, and regulatory barriers can impact entry and retention into MOUD (Simon
et al., 2022; Uebelacker et al., 2016; Yarborough et al., 2016). It would be advantageous to
disseminate new and developing MOUD-related information to PWUO on a community level
through outreach work. For example, to educate on differences in buprenorphine formulations
42
and alternate dosing strategies which may impact misconceptions about its effects. Additionally,
users of drugs and researchers are calling for low-threshold approaches to MOUD treatment
which includes: same day entry to treatment, harm reduction, flexibility in monitoring (i.e.,
provision of take homes and optional, rather than mandatory counseling), and wide availability
of service including emergency departments and syringe services (Aronowitz et al., 2022;
Jakubowski & Fox, 2020; Simon et al., 2022). Low-threshold clinics have been shown to
increase retention and quality of life, while decreasing drug use and injection-related behaviors
(Millson et al., 2007; Scheibe et al., 2020). Ultimately, there are no easy solutions to increase
access to and uptake of MOUD for PWUO. Policy, hospital/clinic, and provider-level changes
need to be developed and implemented according to the newest research in order to improve
MOUD-based care for PWUO.
Limitations
The qualitative design of this study limits our abilities to make any statistical conclusions
regarding perceptions of MOUD among PWUO. Nevertheless, the richness of the qualitative
data offers insights into experiences of PWUO regarding MOUD that supports prior literature
and informs developing issues. This study was limited by a small sample size of a specific
population– current users of opioids in Los Angeles, CA. About a third of our sample was
unhoused, compared to about 80% of participants in our parent-study, which may impact
generalizability to PWUO who experience homelessness. The population extracted from the
parent study was that of current PWUO, which by its nature means that there were few
participants who have had current/recent prolonged abstinence from opioids using MOUD.
However, participants were still able to provide valuable information regarding harm reduction
using MOUD, which can lessen the negative consequences of opioid use. Finally, the data was
43
collected amidst the Covid-19 pandemic, which may have impacted recruitment and results as
SAMHSA loosened some restrictions on MOUD provision during the pandemic.
Conclusion
In a time of ever-rising rates of overdose deaths, primarily involving synthetic opioids
such as fentanyl (Ahmad et al., 2022), new strategies must be developed to reduce overdoses and
other drug-related harms. Access to the two most popular forms of MOUD (methadone and
buprenorphine) should be expanded, and regulations that aim to control and discipline PWUO
should be loosened in the aim of a more progressive approach to drug use ‘treatment’ in light of
an ever-worsening overdose crisis (Aronowitz et al., 2022; Bennett, 2011; Bonn et al., 2020;
Frank, 2018; Simon et al., 2022). For decades, MOUD has been researched as treatment for
opioid use disorder, with ‘successful’ outcomes of reduced illicit opioid use, abstinence, and
treatment retention (Dugosh et al., 2016; Mattick et al., 2014). Under the guise of medication for
the recovery of drug addiction, MOUD has been heavily regulated and oftentimes inaccessible in
the U.S. without much acknowledgement or acceptability of its potential for use outside of the
scope of OUD treatment. This paper offers researchers, clinicians, and policymakers nuanced
perspectives of MOUD use through lived experiences of current PWUO, with differing
perspectives of reasons for and effects of methadone and buprenorphine use. It is time to
improve access to and quality of MOUD for every person who uses opioids, whether they are
seeking complete abstinence, moderation of use, or simply a means to lessen the hustle.
44
Chapter 2: Patient-level and hospital-encounter characteristics as predictors of
buprenorphine prescription among patients with opioid use disorder (OUD) upon
emergency room and inpatient discharge from a large, urban hospital
Abstract
Introduction
A growing literature supports the effectiveness of buprenorphine as a medication for opioid use
disorder (OUD) during patient discharge from a hospital encounter. This study analyzed patient-
level and hospital encounter characteristics that were associated with a buprenorphine
prescription upon discharge from the emergency department (ED) or inpatient hospitalization in
a large, safety net, urban hospital.
Methods
A nested case-control study was performed within a cohort of OUD patients, among whom a
total of 173 patients received a prescription of buprenorphine upon discharge and for which an
equal number of controls were randomly selected from the source cohort of OUD patients.
Multivariable logistic regression was performed to determine predictors of receiving a
buprenorphine prescription.
Results
Most patients were male (79%), unstably housed (53%), had evidence of injection drug use
(60%) with a mean age (SD) of 42.0 (14.0). Encounters were divided between emergency
department (ED) and inpatient hospitalizations equally, and inpatient admission did not predict
buprenorphine prescription. Hospital encounters that received addiction medicine consult
services (AMCS) were significantly more likely to receive a buprenorphine prescription (aOR
125.65, 95% CI, 28.34-557.01, p<0.001). After controlling for AMCS, patient experience of
45
opioid withdrawal symptoms predicted receipt of buprenorphine prescription (aOR 3.87, 95%
CI, 2.09-7.19). Prior satisfactory experience with MOUD and patient amenability to substance
use treatment was also associated with increased odds of buprenorphine prescription, regardless
of AMCS. Being placed on a temporary psychiatric hold (aOR=0.11, 95% CI: 0.02, 0.56) and
increased number of concurrent physical problems (aOR=0.80, 95% CI: 0.68, 0.93) were
associated with lower likelihood of buprenorphine prescription.
Discussion
We found that AMCS was the strongest predictor of a buprenorphine prescription. Findings
suggest that that physicians are more likely to prescribe MOUD when they have evidence that
the patient will succeed in treatment, or when patients have fewer medical or psychiatric
comorbidities. This paper highlights the need to integrate AMCS into hospital systems and to
train hospital clinicians to identify and treat OUD in an evidence-based manner.
46
Introduction
Prescription of buprenorphine is an effective treatment for opioid use disorder (OUD) and
may lessen negative impacts of opioid use such as overdose, withdrawal, and serious opioid-
related acute care events (Wakeman et al., 2020). Despite these benefits, many barriers prevent
it, and other medications for OUD such as methadone and naltrexone, from being used to treat
patients with OUD (Mackey et al., 2020). Adjusted estimates of OUD prevalence and MOUD
provision suggest that approximately 87% of persons with OUD do not receive MOUD treatment
(Krawczyk et al., 2022).
OUD, opioid overdoses, and opioid-related morbidity is common among emergency
department (ED) visits and hospitalizations (Suen et al., 2021; Weiss et al., 2017). Accordingly,
hospitalization may be an optimal time for patients with substance use disorder (SUD) to receive
treatment due to increased motivation and a disruption in regular substance use (Velez et al.,
2017). Initiation of buprenorphine and further linkage to a buprenorphine prescription during a
hospital encounter is effective in engaging patients and reducing illicit opioid use, even among
patients who are not seeking addiction treatment (Liebschutz et al., 2014). Experts in addiction
medicine have called for the expansion of buprenorphine provision in the ED, which is a critical
point of access for vulnerable populations who may have nowhere else to receive treatment
(D’Onofrio et al., 2018; Herring et al., 2019).
Most patients do not receive evidence-based treatment of OUD with buprenorphine
during ED visits or hospitalizations (Chua et al., 2021; Kilaru et al., 2020). Among ED visits for
a non-fatal opioid overdose, buprenorphine was prescribed only 8.3% of the time and naloxone
(an opioid overdose reversal agent) was prescribed only 7.4% upon discharge across 5,800
hospitals in the US (Chua et al., 2021). Healthcare claims data has shown that patient
47
characteristics such as being Black, older age, and having a co-occurring alcohol or other drug
dependency were associated with not receiving a buprenorphine prescription (Lagisetty et al.,
2019; Murphy et al., 2014;). On the other hand, living in a metropolitan area, having point of
service insurance, chronic pain, or a co-morbid drug induced mental disorder were predictors of
receiving buprenorphine treatment (Murphy et al., 2014). To our knowledge, there are no
retrospective cohort or case-control studies that evaluate factors associated with buprenorphine
prescription among patients discharged from an urban hospital.
Naloxone is recommended by the FDA for any patient at risk of opioid overdose, has
fewer barriers to prescribing than buprenorphine, and is commonly prescribed alongside
buprenorphine for OUD patients (Chua et al., 2021). Two retrospective cohort studies assessed
naloxone prescription receipt upon ED discharge, and found that prior opioid overdose, history
of mental illness, and polysubstance use were predictors of not receiving a naloxone prescription
(O’Brien et al., 2019; Lebin et al., 2021). Hospital-encounter related factors such as inpatient
admission and patient leaving before completing treatment were also associated with not
receiving a naloxone prescription after discharge from the ED, while receiving a social work
consult and length of ED stay did not influence naloxone prescribing (O’Brien et al., 2019; Lebin
et al., 2021).
To bridge SUD treatment gaps, some hospitals have begun to integrate addiction
medicine consult services (AMCS) within their health systems. These services have shown
promise in reducing 30-day hospital readmission and increasing patient engagement in substance
use treatment services (Englander et al., 2019; Wakeman et al., 2020). However, an assessment
of the impact of AMCS on buprenorphine prescribing has not yet been reported. This study
assessed patient characteristics and situational hospital-encounter characteristics related to
48
receipt of a buprenorphine prescription upon hospital discharge among patients with OUD. We
included relevant variables from prior literature as well as variables derived from addiction
medicine clinician consensus as predictors. Identifying patient characteristics and hospital
encounter-related factors that result in a buprenorphine prescription may help make
recommendations for quality improvement initiatives in hospital systems.
Methods
Participants
We performed a single site, nested case-control study within a cohort of OUD patients
presenting to the emergency department or admitted as an inpatient at an urban, safety-net
hospital in Los Angeles, California. We used a pre-established administrative healthcare report
used by public hospitals within the Los Angeles Department of Health Services to identify cases
of patients who had a primary or secondary diagnosis of OUD or opioid overdose poisoning
based on ICD-10 coding (eligible codes: F11; T40.1; T40.2; T40.3; T40.4; T40.6) and had been
prescribed buprenorphine upon discharge. Patients must have had a hospital encounter between
May 2019-May 2021 and have been 18 years or older upon admission date. Controls were
selected from the same source cohort of OUD/opioid poisoning patients, and were matched 1:1.
Study approval was obtained from the University of Southern California Institutional Review
Board prior to study initiation.
Over the two-year time span, buprenorphine was prescribed upon discharge for 696
hospital encounters including the emergency department and inpatient hospitalization.
Encounters that occurred at the Urgent Care Clinic (UCC- part of our Emergency Department)
were excluded due to ongoing grants and initiatives occurring in partnership with the CA Bridge
Program to increase buprenorphine prescribing, including linkage to the UCC after an initial
49
hospital visit (Snyder et al., 2021). Consequently, it is possible that patients who did not receive
a prescription during their initial encounter were able to obtain a buprenorphine prescription
upon a follow-up visit to the UCC. We excluded 407 cases (58%) that were UCC encounters
(including UCC Telehealth). The remaining patient encounters were sorted by medical record
number (MRN) and duplicates of patients were deleted so that each patient only had one
encounter date which was the latest hospital encounter to minimize bias due to high-healthcare
utilization patients. This resulted in a total of 249 eligible cases (Figure 3).
Figure 3: Flow diagram of patient/encounter inclusion criteria
50
Procedures
The remaining 249 cases were subject to manual chart review by the lead author (MB).
Further exclusion criteria were applied during manual chart review to ensure that patients had
current OUD as documented by a clinician during the selected encounter. Exclusion criteria and
number of patients excluded is presented in a flow diagram (Figure 3).
The final case sample included 173 unique patients with OUD that received an initial
prescription of buprenorphine upon discharge from the ED or inpatient hospitalization, not
including UCC. An equal number of controls were randomly selected from the source cohort of
OUD patients and included if they met all the above criteria upon manual chart review and were
not currently on a methadone maintenance program (another form of MOUD). A final sample of
346 unique patient encounters (173 cases and 173 controls) were abstracted and included for
analysis.
Once an encounter was deemed eligible for inclusion in the study, clinical information
was abstracted into a secure external server database (REDCap). Data were not labeled with any
personal identifying information. The lead author (MB) abstracted all clinical data and utilized a
second coder (BH) to abstract 10% of charts to ensure inter-rater reliability, tested by measuring
the intra-class correlation (ICC = 0.78).
The primary outcome was the prescription of buprenorphine upon discharge after hospital
encounter. We used prior research findings and clinician/researcher input to develop the
electronic medical record (EMR) codebook. Demographics, drug use, prior SUD treatment, and
healthcare utilization were selected as patient characteristics. Hospital-encounter situational
variables included inpatient admission, length of stay, psychiatric condition, distrust of the
healthcare system (evidenced by leaving prior to treatment completion and/or hostile behavior),
51
experience of opioid withdrawal or overdose, social work consult, amenability to SUD treatment,
physical problems, and addiction medicine consult. Most variables were binary and coded as
‘yes’ if there was evidence in the patient chart of the variable being present. If there was no
evidence, the variable was coded as ‘no’. Provision of naloxone and buprenorphine variables
were obtained from the original administrative data report rather than the patient chart,
eliminating ambiguity.
Statistical analysis
Data cleaning, management, and analysis were conducted in SPSS 22. Descriptive
statistics were reported, and t-tests and chi-squares were used to identify statistical differences
between cases and controls. Bivariate analysis was employed to test whether dependent variables
predicted discharge with a prescription for buprenorphine. To construct the final models, we
used a purposeful selection method (Zhang, 2016) in which variables with a bivariate p-value of
<0.25 were included for further multivariable analysis. Likelihood ratio tests and p-values were
used to assess deletion of variables and model fit. The final multivariable models were checked
for goodness of fit and explained variance.
The AMCS variable was detected as a confounder of many other independent variables.
Encounters that included an addiction medicine consult note generally had more specific details
regarding drug use and prior treatment and were by nature more likely to be made by physicians
that were more knowledgeable about ACMS within the hospital. This also made it more likely
that evidence of certain variables were present compared to encounters with less detailed
documentation. The final multivariable logistic regression of all encounters (N=346) controlled
for the AMCS variable. Furthermore, the same analytical process was repeated for a sub-group
52
of encounters that did not receive the addiction consult, which consisted of 81 cases and 171
controls (N=252).
Results
After chart review, 346 patients with OUD were included in the analysis, with an equal
sample of patients that received an initial buprenorphine prescription and those that had no
prescription upon discharge (cases and controls; N=173 each). Demographic, previous
healthcare, and drug use characteristics of patients are summarized in Table 2. Patients’ ages at
time of encounter ranged from 18-76 and the total sample had a mean age of 42.0 (SD=14.0).
Most patients were male (78.6%), homeless or unstably housed (52.6%), and had evidence of
injection drug use (59.5%) and polysubstance use (54.9%) in their charts. More control patients
were identified as Non-Hispanic White in the medical record than case patients (31.2% vs
19.7%), although nearly a quarter (23.4%) of patients did not have race/ethnicity information
documented.
Table 2: Demographic, previous healthcare, and drug use-related characteristics of patient
encounters (N=346)
Number (%) of with feature, or mean (SD) value of
feature
p-value
(χ² or
t-test)
1
All Received
buprenorphine
prescription
Did not received
buprenorphine
prescription
N=346 N=173 N=173
Age (years)
Range: 18-76
42.0 (14.0)
41.2 (13.7) 42.8 (14.2) 0.28
Patient-reported male gender 272 (78.6%) 136 (78.6%) 136 (78.6%) 1.00
Homeless or unstably housed 182 (52.6%) 85 (49.1%) 97 (56.1%) 0.196
English as primary/preferred language 327 (94.5%) 162 (93.6%) 165 (95.4%) 0.479
Insurance
Medi-Cal
Self-pay
Medicare
Private insurance
261 (75.4%)
45 (13.0%)
22 (6.4%)
18 (5.2%)
127 (73.4%)
21 (12.1%)
13 (7.5%)
12 (6.9%)
134 (77.5%)
24 (13.9%)
9 (5.2%)
6 (3.5%)
0.374
0.265
0.244
0.378
0.146
Navigation of the healthcare system
None
Has insurance only
32 (9.2%)
254 (73.4%)
15 (8.7%)
135 (78.0%)
17 (9.8%)
135 (78.0%)
0.075
0.947
1.00
53
Has insurance and is empaneled
Insurance, empaneled, and PCP visit within past
year
56 (16.2%)
4 (1.2%)
19 (11.0%)
2 (1.2%)
19 (11.0%)
2 (1.2%)
1.00
1.00
High utilization of healthcare (>3 ED and/or >1
inpatient visit in the past year)
57 (16.5%) 32 (18.5%) 25 (14.5%) 0.310
Past year ED encounters
Range: 0-32
Past year inpatient encounters
Range: 0-11
1.3 (3.0)
0.5 (1.2)
1.3 (3.3)
0.5 (1.3)
1.3 (2.7)
0.4 (1.1)
0.886
0.179
Race/Ethnicity
Mexican/Hispanic/Latin American
Non-Hispanic white
African-American/Black
Asian
Mixed race
American Indian
Other/unknown
120 (34.7%)
88 (25.4%)
49 (14.2%)
3 (0.9%)
3 (0.9%)
2 (0.6%)
81 (23.4%)
64 (37.0%)
34 (19.7%)
21 (12.1%)
2 (1.2%)
2 (1.2%)
0 (0%)
50 (28.9%)
56 (32.4%)
54 (31.2%)
28 (16.2%)
1 (0.6%)
1 (0.6%)
2 (1.2%)
31 (17.9%)
0.040
0.366
0.014
0.280
0.562
0.562
0.156
0.016
Injection drug use 206 (59.5%) 102 (59.0%) 104 (60.1%) 0.827
Polysubstance use
Alcohol use disorder
Methamphetamine/amphetamine
Cocaine/crack
Sedatives (benzodiazepines, hypnotics)
190 (54.9%)
42 (12.2%)
145 (41.9%)
36 (10.4%)
34 (9.8%)
96 (55.5%)
15 (8.7%)
71 (41.0%)
18 (10.4%)
20 (11.6%)
94 (54.3%)
27 (15.6%)
74 (42.8%)
18 (10.4%)
14 (8.1%)
0.829
0.048
0.744
1.00
0.279
Prior opioid overdose (past year) 20 (5.8%) 14 (8.1%) 6 (3.5%) 0.065
Previous satisfactory experience with MOUD
(treatment, street MOUD)
54 (15.6%) 39 (22.5%) 15 (8.7%) <0.001
Previous non-MOUD substance use treatment
(rehab, outpatient, NA, etc)
63 (18.2%) 28 (16.2%) 35 (20.2%) 0.329
1
Bolded p-values are significant at p<0.05
Characteristics of hospital encounters are presented in Table 3. Half of the patients (50%)
were only seen in the emergency department while the other half were admitted to the hospital.
Encounters were just as likely to result in a buprenorphine prescription upon discharge from the
ED or inpatient hospital (Chi sq=0.104, p=0.747). However, in unadjusted bivariate analysis, for
every one-day increase in length of hospital stay, there was an approximate 8.5% increase in
odds of receiving a buprenorphine prescription (OR=1.08, 95% CI: 1.02, 1.15). A current
psychiatric condition was present in a third (32.1%) of all patients, and 10% of patients were
placed on a temporary psychiatric hold during the encounter. Control patients were more likely
to have experienced distrust of the healthcare system (evidenced by hostile/aggressive behavior
54
or leaving against medical advice, p=0.019). Naloxone was prescribed for 141 (40.8%) of all
OUD patients and was commonly prescribed alongside buprenorphine (72.3% of cases).
Table 3: Hospital encounter-related features (N=346)
Number (%) of with feature, or mean (SD) value of
feature
p-value
(χ² or
t-test)
1
All Received
buprenorphine
prescription
Did not received
buprenorphine
prescription
N=346 N=173 N=173
General
Admitted as an inpatient 173 (50.0%) 88 (50.9%) 85 (49.1%) 0.747
Length of stay
Range: 1-45
3.18 (5.1) 4.0 (6.4) 2.4 (3.1) 0.003
Number of other physical diagnoses/problems
during encounter (including injection related)
Range: 0-15
2.5 (2.5) 2.6 (2.7) 2.5 (2.3) 0.783
Partner, family member, or friend present 23 (6.6%) 8 (4.6%) 15 (8.7%) 0.131
Psychiatric condition (temporary or diagnosed)
Placed on a temporary psychiatric hold
Depressive disorders
Suicidal ideation
Bipolar and related
Schizophrenia, schizoaffective, and related
Altered mental status (AMS)
Anxiety disorders
Unspecified psychosis
Post-traumatic stress disorder (PTSD)
111 (32.1%)
36 (10.4%)
36 (10.4%)
29 (8.4%)
27 (7.8%)
26 (7.5%)
22 (6.4%)
21 (6.1%)
14 (4.0%)
8 (2.3%)
45 (26.0%)
8 (4.6%)
15 (8.7%)
6 (3.5%)
15 (8.7%)
12 (6.9%)
10 (5.8%)
7 (4.0%)
3 (1.7%)
2 (1.2%)
66 (38.2%)
28 (16.2%)
21 (12.1%)
23 (13.3%)
12 (6.9%)
14 (8.1%)
12 (6.9%)
14 (8.1%)
11 (6.4%)
6 (3.5%)
0.016
<0.001
0.291
<0.001
0.548
0.683
0.659
0.115
0.029
0.152
Distrust of the healthcare system during the
encounter (left AMA, left before treatment
completion, and/or aggressive/hostile behavior)
76 (22.0%) 29 (16.8%) 47 (27.2%) 0.019
Drug-use related
Brought in for overdose 64 (18.5%) 30 (17.3%) 34 (19.7%) 0.580
Experiencing opioid-related withdrawal symptoms 160 (46.2%) 116 (67.1%) 44 (25.4%) <0.001
Co-morbid potential injection drug use related
sequela
Hepatitis B or C
Abscesses or cutaneous infection
Cellulitis
Bacteremia
HIV
Endocarditis
137 (39.6%)
76 (22.0%)
66 (19.1%)
13 (3.8%)
11 (3.2%)
10 (2.9%)
7 (2.0%)
72 (41.6%)
40 (23.1%)
39 (22.5%)
7 (4.0%)
8 (4.6%)
3 (1.7%)
6 (3.5%)
65 (37.6%)
36 (20.8%)
27 (15.6%)
6 (3.5%)
3 (1.7%)
7 (4.0%)
1 (0.6%)
0.442
0.603
0.101
0.777
0.125
0.199
0.056
Spoke with social worker/mental health
professional/ substance use navigator
179 (51.7%) 85 (49.1%) 94 (54.3%) 0.333
Amenable to MOUD/ SUD treatment 183 (52.9%) 117 (67.6%) 66 (38.2%) <0.001
Patient chart reviewed by addiction medicine
consult team
94 (27.2%) 92 (53.2%) 2 (1.2%) <0.001
Medication provision
Administered naloxone during encounter
Administered buprenorphine during encounter
12 (3.5%)
150 (43.4%)
10 (5.8%)
125 (72.3%)
2 (1.2%)
16 (9.2%)
0.019
<0.001
55
Prescribed naloxone 141 (40.8%) 125 (72.3%) 25 (14.5%) <0.001
Reason for admission varied widely among patient encounters so that OUD was not
always the primary concern for the encounter. Nevertheless, 211 (61.5%) of patient encounters
had unambiguous documentation of opioid overdose or opioid withdrawal symptoms (Table 4).
Sixty-four patient encounters (18.5%) were identified as presenting with an opioid overdose. Of
these, 40 (62.5%) were prescribed naloxone and 30 (46.9%) were prescribed buprenorphine. A
total of 160 participants (46.2%) had documented evidence of experiencing opioid-withdrawal
symptoms during the hospital encounter, although this was much more common among cases
(67% vs 25%). Out of these, 131 were initiated on buprenorphine (81.9%) during their stay, 116
(72.5%) received a buprenorphine prescription upon discharge, and 83 (51.9%) were prescribed
naloxone. Buprenorphine was initiated in 19 additional encounters that did not have
documentation of opioid withdrawal symptoms for a total of 150 encounters (43.4%) in which
buprenorphine was administered. Of those 150 encounters, 72.3% also received a buprenorphine
prescription.
Table 4: Medication provision among patients with definitive opioid use-related sequala (N=211)
Brought in for opioid overdose (N=64)
Prescribed naloxone 40 (62.5%)
Administered buprenorphine during encounter 16 (25.0%)
Prescribed buprenorphine upon discharge 30 (46.9%)
Amenable to MOUD/SUD treatment 32 (50.0%)
Addiction medicine consult 17 (26.6%)
Experiencing opioid-related withdrawal symptoms (N=160)
Prescribed naloxone 83 (51.9%)
Administered buprenorphine during encounter 131 (81.9%)
Prescribed buprenorphine upon discharge 116 (72.5%)
Amenable to MOUD/SUD treatment 141 (71.3%)
Addiction medicine consult 65 (40.6%)
56
Variables that were considered for inclusion in the final model of buprenorphine
prescription are presented in Table 5. The final multivariable logistic regression model (Table 6)
was statistically significant, χ
2
(5) = 263.57, p <0.001). The model explained 61.9%
(Nagelkerke R
2
) of the variance in buprenorphine prescription and identified 82.4% of the cases
correctly. Hospital encounters in which the addiction medicine team reviewed the patient chart
and gave consult were significantly more likely (aOR=125.65, 95% CI 28.34, 557.01) to receive
a buprenorphine prescription upon discharge. After controlling for AMCS, patient experiencing
withdrawal symptoms (aOR=3.87, 95% CI: 2.09, 7.19), evidence of previous satisfactory
experience with MOUD (aOR =3.11, 95% CI: 1.39, 6.94), and patient being amenable to
substance use treatment (aOR =2.99, 95% CI: 1.58, 5.68) were associated with an increased
likelihood of receiving a buprenorphine prescription. Being placed on a temporary psychiatric
hold during the encounter was associated with an 89% reduction in the likelihood of a receiving
a buprenorphine prescription (aOR=0.11, 95% CI: 0.02, 0.56).
Table 5: Odds ratio (OR) associations between receipt of buprenorphine prescription and
demographic, drug use, and hospital-stay related features included at p <0.25 (N=343)
Unadjusted OR
(95% CI)
1
Adjusted OR
(95% CI)
2
Unstably housed/homeless 0.76 (0.50, 1.16) 0.70 (0.42, 1.18)
Non-Hispanic White race/ethnicity 0.54 (0.33, 0.88) 0.74 (0.41, 1.33)
Other/unknown race/ethnicity 1.86 (1.12, 3.10) 1.46 (0.78, 2.74)
Alcohol use disorder 0.51 (0.26, 1.00) 0.33 (0.12, 0.87)
Previous satisfactory experience with MOUD
(treatment, street MOUD)
3.07 (1.62, 5.81) 4.43 (2.18, 9.00)
Length of hospital stay (days) 1.08 (1.02, 1.15) 0.96 (0.89, 1.04)
Past year inpatient hospitalizations (occurrences) 1.14 (0.94, 1.37) 0.98 (0.77, 1.25)
Psychiatric condition (temporary or diagnosed) 0.57 (0.36, 0.90) 0.53 (0.30, 0.94)
Placed on a temporary psychiatric hold 0.25 (0.11, 0.57) 0.12 (0.03, 0.46)
Suicidal ideation 0.23 (0.09, 0.59) 0.07 (0.01, 0.42)
Unspecified psychosis 0.26 (0.07, 0.95) 0.22 (0.04, 1.32)
Co-morbid abscesses or cutaneous infection 1.57 (0.91, 2.71) 0.84 (0.40, 1.76)
Co-morbid endocarditis 6.18 (0.74, 51.88) 4.44 (0.41, 48.51)
Partner, family, or friend present 0.51 (0.21, 1.24) 0.44 (0.13, 1.44)
Distrust of the healthcare system during the
encounter
0.54 (0.32, 0.91) 0.34 (0.16, 0.71)
Experiencing opioid-related withdrawal symptoms 5.97 (3.74, 9.51) 5.17 (2.96, 9.04)
Prior opioid overdose (past year) 2.45 (0.92, 6.54) 2.65 (0.87, 8.09)
57
Amenable to MOUD/ SUD treatment 3.39 (2.18, 5.27) 4.47 (2.53, 7.93)
Patient chart reviewed by addiction medicine
consult team
97.11 (23.34,
404.02)
NA
1
Bolded odds ratio associations are significant at p<0.05
2
Adjusted for addiction medicine consult team chart review
Table 6: Final multivariable logistic regression models of buprenorphine prescription upon
discharge after hospital visit
Variable Parameter Estimate ( 𝛽 )(95%
CI)
Sample of all patient encounters (N=346)
Intercept 0.13 (0.02, 0.56)
Addiction medicine team consult 125.65 (28.34, 557.01)
Experiencing opioid withdrawal symptoms 3.87 (2.09, 7.19)
Previous satisfactory experience with MOUD 3.11 (1.39, 6.94)
Patient is amenable to SUD/MOUD treatment 2.99 (1.58, 5.68)
Placed on a temporary psychiatric hold 0.11 (0.02, 0.56)
Sample of patient encounters that did not receive an addiction medicine consult
(N=252)
Intercept 0.19 (0.07, 0.68)
Experiencing opioid withdrawal symptoms 3.87 (2.03, 7.38)
Previous satisfactory experience with MOUD 3.08 (1.34, 7.05)
Patient is amenable to SUD/MOUD treatment 3.38 (1.73, 6.59)
Placed on a temporary psychiatric hold 0.17 (0.04, 0.76)
Number of other physical diagnoses/problems
during encounter (including injection related)
0.80 (0.68, 0.93)
The LAC+USC addiction medicine team consulted 94 (27.2%) of all patient encounters,
with all but two of the consulted encounters resulting in a buprenorphine prescription upon
discharge (97.9%). We conducted a sub-group analysis of encounters that did not have an
addiction medicine consult, which included 81 patients who received buprenorphine and 171
who did not. We repeated the same model building procedures for this sub-group analysis. The
final model of the sub-group analysis explained 38.6% of the variance, predicted 79.4% of cases,
was statistically significant, and showed adequate goodness of fit (p<0.001). For the sub-group
of encounters that did not receive AMCS, the same variables predicted buprenorphine
prescription with similar effect sizes (Table 6). Number of other physical problems was uniquely
significant in this sub-group analysis after controlling for all other variables, with each additional
58
physical problem decreasing odds of buprenorphine prescription by 20% (aOR=0.80, 95% CI:
0.68, 0.93).
Discussion
Prescribing buprenorphine to patients with OUD upon discharge from inpatient
admission and the ED is crucial to address OUD treatment gaps (Kim & Samuels, 2020;
D’Onofrio et al., 2018). Our study found that overwhelmingly, the strongest predictor of receipt
of a buprenorphine prescription was the hospital-level factor of an addiction medicine consult.
After controlling for AMCS, encounters were more likely to result in a buprenorphine
prescription when there was evidence that the patient will likely have a successful experience
with buprenorphine. In contrast, patients who had medical or psychiatric complications during
the encounter had reduced odds of receiving buprenorphine. Our findings highlight two primary
areas for quality improvement within healthcare systems: 1.) increased training of clinicians to
identify and treat OUD in an evidence-based manner, and 2.) the need to integrate AMCS into
hospital systems to supplement the inadequate addiction medicine practice capacity.
Multiple studies have shown that patients, clinicians, and other hospital staff such as
pharmacists and social workers report that AMCS helps to improve hospital experiences and
contributes to improved patient outcomes (Callister et al., 2021; Englander et al., 2019; Hyshka
et al., 2019; Wakeman et al., 2021; Wilson et al., 2022). AMCS can be executed electronically
through consult notes in the patient chart, making for a feasible and straightforward
organizational intervention, given adequate funding and resources. Implementation of AMCS
typically includes general responsibilities of education and culture change, delivery of
psychosocial and medical services, and development of hospital guidance documents (Priest, &
McCarty, 2019). Nonetheless, many AMCS, including ours, have limitations of staffing
59
resources and 9-5 weekday-day only hours (Priest & McCarty, 2019). In addition, clinicians may
lack the time, interest, or awareness to conduct substance use screenings and to document OUD
in the patient record, leading to patients that are ’missed’ by the consult team. Other problems
with AMCS have included conflicts between hospital staff regarding harm reduction vs
abstinence-only approaches to treatment and concerns about acquiring finances to fund the
consult team (Hyshka et al., 2019; Priest & McCarty, 2019). Addressing discrimination and
hospital limitations, as well as utilizing clinical champions can support AMCS development and
increase delivery of MOUD (Priest et al., 2020).
Variables included in the final models as associated with increased likelihood of
buprenorphine prescription shared a common theme—they were all indicators that might signal
to clinicians that the patient would have success with buprenorphine. Treatment of opioid
withdrawal with buprenorphine is effective and widely recommended (Gowing et al., 2017;
Hawk et al., 2021; Kim & Samuels, 2020), and after AMCS, experience of withdrawal
symptoms was the largest predictor of buprenorphine prescription. It is likely that buprenorphine
initiation during the encounter acts as a mediator; most patients who experienced opioid
withdrawal symptoms were initiated on buprenorphine and prescribed buprenorphine. This
indicates that positive buprenorphine induction may prime physicians to provide buprenorphine
upon discharge. Likewise, prior satisfactory experience with MOUD and patient amenability to
SUD/MOUD treatment increased likelihood of buprenorphine prescription upon discharge.
These predictors suggest that physicians take patients’ experiences into account and are more
likely to prescribe buprenorphine when they have direct evidence from the patient that the
medication has worked before, or that they are in a stage of readiness to change. This highlights
areas of improvement for clinicians to employ motivational interviewing to help patients find the
60
motivation to make a behavior change, and to educate patients on the benefits of using MOUD
both in harm-reduction and recovery-based contexts. For example, addressing fears or prior
negative experiences regarding MOUD such as concerns over precipitated withdrawal using an
empathetic approach is recommended for easing apprehension toward MOUD initiation (Hartley
et al., 2022).
Physical and psychological co-morbidities add to patient complexity, potentially leaving
substance use-related problems to be overlooked (Ziedonis, 2004). Our study found that 10% of
OUD patients were placed on a temporary psychiatric hold during their hospital encounter,
which is similar to other studies of the same population of people who use opioids (Simpson, et
al., 2021). In both final models, being placed on a temporary psychiatric hold drastically reduced
odds of buprenorphine prescription even after controlling for other variables. Additional physical
diagnoses/problems during the encounter also decreased likelihood of receipt of a buprenorphine
prescription in the sub-group analysis, indicating that as the mental and physical complexity of a
patient increases, less attention is focused on treating substance use related issues. Decreasing
physicians’ cognitive load with automatic protocols, clinical decision support, and consulting
AMCS to address competing patient needs can be effective in addressing OUD among complex
patients (Kim & Samuels, 2020).
There is ample evidence that shows barriers to buprenorphine initiation and prescription
among ED physicians, most notably inadequate training on substance use treatment and MOUD,
lack of time, competing priorities, and physician stigma (Hawk et al., 2020; Kestler et al., 2021;
Kim & Samuels et al., 2020; Webster et al., 2020). Patients discharged from the ED received a
buprenorphine prescription at the same rate as those admitted to the hospital, although we found
in un-adjusted analyses that longer length of stay (LOS) predicted buprenorphine prescription.
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Longer LOS may increase likelihood of an AMCS referral especially when considering AMCS
availability and allows for a more thorough discharge plan to be established which may be more
likely to include a buprenorphine prescription. Our results demonstrate that encounters in which
physicians consult AMCS, and/or are given time to identify OUD and gather evidence of future
success with buprenorphine are more likely to result in evidence-based OUD treatment. Training
clinicians on identification of SUD and motivational interviewing, implementing protocols for
buprenorphine initiation, bridge programs, and AMCS can help reduce the patient care gap
(Hawk, 2021 et al.; Kim & Samuels, 2020).
Limitations
Recommended strategies for ensuring reliable and valid data collection via chart review
were followed which included a priori research questions, detailed inclusion/exclusion criteria,
definition of variables, abstraction forms, training, monitoring, testing inter-rater agreement, and
team meetings (Panacek, 2007). Nevertheless, data obtained from medical records via
retrospective review has limitations of incomplete or missing data, difficulty interpreting
documentation pertaining to select variables, variability in the quality of documentation, and
selection bias. Our cohort database of patients likely did not represent all patients with OUD seen
at LAC+USC, a common problem with using ICD-10 codes to identify OUD patients (Lagisetty
et al., 2021; Ranapurwala et al., 2021). Our hospital does not itemize physician billing unlike
many other healthcare systems, so diagnosis codes and complexity are not captured as
completely as other sites that have more stringent billing requirements, contributing to sampling
bias. Patients with ICD codes of OUD often lack documentation of meeting OUD criteria
(Lagisetty et al., 2021), which is why we performed thorough, manual chart review and
abstraction to verify that patients were identified by a clinician as having current OUD during the
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selected encounter. Despite these limitations, the sample represented a wide variety of OUD
patients who were admitted for overdose, withdrawal, injection-related health sequalae, and non-
opioid-related medical problems.
Patients who were not prescribed buprenorphine upon hospital discharge may have
received it after bridge services to the urgent care clinic, although this was not considered in this
evaluation. Our AMCS is similar to others presented in the literature (Priest & McCarty, 2019) in
overall team composition and limitations of staff and time. However, there are biases concerning
referral to AMCS, in that clinicians who are more knowledgeable about SUD treatment and
MOUD may be more likely to consult the AMCS. Likewise, those clinicians may be more likely
to have more thorough documentation of OUD and other variables of interest in our study, which
may introduce collinearity. However, we performed a sub-group analysis which excluded
encounters that received an AMCS referral to combat this issue, which resulted in a final model
that was nearly identical to the original except for the addition of one variable.
Conclusion
AMCS was the strongest predictor of a buprenorphine prescription upon discharge from
inpatient hospitalization or the ED among a cohort of patients with OUD. Addressing physician
concerns and lack of comfort prescribing buprenorphine by implementing increased training,
structural support, and addiction consult services is essential to improving provision of
buprenorphine in hospital settings. Evidence of possible success with buprenorphine may
encourage physicians to prescribe buprenorphine. Clinicians who assess patient readiness to
change through motivational interviewing and educate them on treatment and harm-reduction
benefits of MOUD may be able to help narrow the treatment gap. Nonetheless, physicians face
institutional barriers to treating psychologically and/or physically complex patients that can be
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difficult to overcome without increased resources. As the evidence for efficacy of buprenorphine
treatment during hospital encounters continues to grow, decision-makers in hospitals should
integrate evidence-based quality improvement and policy initiatives to increase initiation and
prescribing of buprenorphine. While it may take time to change norms and expectations around
buprenorphine treatment within a hospital, initiatives such as the development of an addiction
medicine consult team, clinical decision pathways, buprenorphine initiation protocols, and
training clinicians in treatment of SUD can improve delivery of care to patients with OUD.
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Chapter 4: A Qualitative Analysis of Internal Medicine Residents’ Experience with
Substance Use Disorder Education and Training
Abstract
Introduction
Lack of education and training on caring for patients with substance use disorder (SUD) is
common among healthcare providers, often resulting in clinicians feeling unprepared to treat
patients with SUD. This study explored resident physicians’ experiences with SUD education
throughout medical school and residency and qualitatively evaluated whether a SUD initiative
improved residents’ knowledge and efficacy of treating various SUDs.
Methods
We implemented a brief (7 hours total) educational initiative focused on treating SUDs virtually
over the course of an academic year for residents enrolled in the University of Southern
California Internal Medicine Residency program. Semi-structured interviews were conducted
with residents after completion of the initiative. A thematic analysis was conducted to identify
common themes that emerged from the qualitative data.
Results
Every resident noted receiving insufficient training for the treatment of SUDs prior to the
initiative. The initiative was viewed favorably, and participants particularly appreciated having
an introduction to prescribing medication for the treatment of SUD such as buprenorphine.
Despite the perceived success of the initiative in increasing awareness of treatment modalities for
SUD, residents expressed a lack of comfort in handling SUD cases and desired additional
practical lectures and application of knowledge through increased experiential training.
Discussion
65
SUD education and training appears to be a useful constituent of resident training and should be
included in the standard curriculum and rotations. Residency programs should consider including
formal education, hands-on practice, and providing adequate resources for residents to develop
their capabilities to care for patients with SUD.
66
Introduction
Substance use disorders among patients are common in general medical settings,
including inpatient, emergency room, and primary care (Peterson et al., 2021; Suen et al., Wu et
al., 2017). The total annual cost attributable to substance use disorder (SUD) in hospitals was
estimated at $13.2 billion in 2017 (Peterson et al., 2021). In 2018, alcohol use disorder (AUD) or
SUD was present in approximately 10.4% of emergency room visits and 14.4% of inpatient
hospitalizations (Suen et al., 2021).
People who use drugs (PWUD), particularly those who used
heroin and/or opioid analgesics, were significantly more likely to have been hospitalized within
the last 12 months compared to non-users (Gryczynski et al., 2016). Patients who use opioids are
particularly at risk for developing infections such as HIV, HCV, and other infectious diseases,
with increasing rates of hospitalizations for infections among PWUD (McCarthy et al., 2017).
The rate of drug overdose deaths has also steadily grown since 2012, with a sharp spike
following the beginning of the Covid-19 pandemic, resulting in an estimated 100,000 deaths in
2021 (CDC, 2021; NIDA, 2021). Despite the significant prevalence of substance use among
healthcare recipients, providers spend little time assessing and treating SUDs (HHS, 2022).
Residency program directors in internal medicine, family medicine, and psychiatry
reported that residents frequently treat PWUD; however, only 1/4 of programs dedicated 12 or
more hours to addiction medicine (Tesema et al., 2018). Residency training involves the practical
application of knowledge acquired in medical school, yet instruction on SUDs in medical school
is lacking (Bäck et al., 2018; Ram & Chisolm, 2016). A lack of training may be responsible for
resident physicians being underprepared to manage co-morbid SUD among their patients. In a
survey of internal medicine residents, 25% felt unprepared to diagnose and 62% felt unprepared
to treat substance use disorder; meanwhile, over half (55%) of residents rated overall instruction
67
in SUD as poor or fair (Wakeman et al., 2013). Lack of organizational support, insufficient
number of faculty with expertise in addiction, competing curricular priorities, and lack of
psychosocial support were commonly cited barriers to implementing substance use training in
residency (Tesema et al., 2018; Wakeman et al, 2013).
Physicians are especially unprepared to discuss and prescribe medications such as
buprenorphine, naltrexone, and naloxone that may help treat SUD and/or reduce associated
harms of alcohol and drug use, including overdose deaths and all-cause mortality (Ma et al.,
2019; Wakeman et al., 2016; Wilson et al., 2016). Residents and Attendings have noted a lack of
education and self-efficacy as the biggest barriers to treating SUDs, particularly in the case of
utilizing medications such as buprenorphine (Cunningham et al., 2006; Mackey et al., 2020;
Wilson et al., 2016). With the recent removal of the certification requirements (8 hours of
training) needed to obtain an X-Waiver to prescribe buprenorphine, all physicians with a DEA
registration are eligible to apply for the waiver, making for an opportune time to institute
integrated buprenorphine training in residency programs.
Several institutions have implemented education and training on SUD into their
curriculum, with promising results. An intensive substance use training for chief residents
reported significant increases in substance use knowledge, as well as confidence and
preparedness to diagnose and treat SUD compared to a control group (Alford et al., 2009). A
review of the literature on substance use education for physicians recommended integrating the
following components into any training program: 1) brief, skills-based curricula, 2) combined
interactive, experiential, and didactic curricula, 3) expert faculty in addiction to serve as role
models, 4) feedback to trainees, and 5) reinforcement of training (Polydorou et al., 2009). We
developed an education initiative on SUD approximately 7 hours in length that incorporated
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most of the aforementioned components and delivered it to resident physicians over the course of
an academic year. There are few qualitative evaluations of healthcare providers’ experiences
with SUD education and training, although a better understanding of areas of deficits and
efficacious training programs is needed. This study explored the following through thematic
qualitative analysis: 1.) resident assessment of SUD education in medical school and prior
residency years, 2.) preparedness to treat patients with SUD, and 3.) assessment of a SUD
education initiative during residency. This study is particularly novel because 100% of the
instruction was remote, making for easier dissemination of the initiative across medical school
curriculums and residency programs.
Methods
Participants
The USC Internal Medicine Residency Program is housed in Los Angeles, California at
the University of Southern California Health Sciences Campus. Residents gain experience
primarily in the LAC + USC Medical Center – one of the largest public acute care hospitals in
the U.S. As a public safety-net hospital, LAC + USC Medical Center providers healthcare for the
medically underserved, with 150,000 ED visits, 1 million ambulatory care visits, and 39,000
inpatient discharges every year. Each residency class consists of 55 students, for a total of 165
residents from postgraduate years 1-3 (PGY1-PGY3) who received the initiative.
Initiative
Residents participated in an educational initiative consisting of three didactic lectures and
an interactive patient performance series aimed at expanding SUD treatment services between
July 2020-June 2021 (Table 7). Residents were given protected time for each of the lectures,
which had an average attendance rate of 84%; attendance was not recorded for the patient case
69
series. This study evaluated residents’ overall perceived self-efficacy and preparedness to treat
SUD longitudinally as a result of this educational initiative. Originally, this training was
designed to be delivered to residents in person; however, due to the Covid-19 pandemic, these
components were adapted to an online format. The University of Southern California
Institutional Review Board (IRB) approved this study and informed consent was obtained from
all participants.
Table 7: Components of the Substance Use Disorder Initiative Provided to Internal Medicine
Residents
Initiative Component Activities Duration Learning Outcomes
Resident Lecture Series
(Delivered via Zoom)
Alcohol use and tobacco
use/nicotine dependence
lecture
1 hour ● Increase knowledge about the
identification, diagnosis and treatment of
alcohol and tobacco use disorder (AUD
and TUD).
● Familiarize students with medications
available for treatment of AUD and TUD,
including those used for management of
withdrawal symptoms in the hospital.
Motivational interviewing
lecture
1 hour ● Introduce a counseling approach that can
be used for addressing ambivalence to
change in treatment of various SUDs.
Opioid use disorder lecture
and X-Waiver training
4 hours ● Increase knowledge about the
identification, diagnosis, and treatment of
opioid use disorder (OUD).
● Familiarize students with medications
available for treatment of OUD including
inpatient use of buprenorphine for the
symptom-targeted treatment of acute
withdrawal.
● Provide students with four of the eight
hours of training required to obtain an X-
Waiver to prescribe buprenorphine.
*
Patient Performance
Series (Delivered via
Zoom)
Performance series consisting
of five scenarios in which
patient actors and residents
acted out a clinical encounter
related to addiction
1 hour ● Practice interviewing, diagnosing, and
treating patients with SUD and decrease
stigma towards people who use drugs.
*
At the time of this initiative, 8 hours of training in prescribing buprenorphine was required to
obtain the X-Waiver. This requirement has been waived as of April 2021. Physicians still need to
apply for the X-Waiver, but no longer need mandated training hours to receive it.
Data Collection
Upon completion of the initiative, residents were asked to participate in a remote
qualitative interview regarding the initiative and their overall experiences with SUD education.
70
Residents received $75 for participation. All participating residents were interviewed by a
graduate researcher (M.B.) between July 2021- December 2021. The interview questions were
developed based on existing literature and using input from clinicians and researchers. The semi-
structured interview asked participant’s questions regarding: their experiences with SUD
education throughout their medical career, desired improvements in SUD education/training,
their experiences with the initiative, and attitudes towards initiating and prescribing medication
for the treatment of SUDs. Interviews were audio-recorded over Zoom, transcribed, and de-
identified.
Qualitative Analysis
The research team utilized an iterative, multi-step process to analyze the qualitative data.
First, two coders (M.B and T.T) individually read through the transcripts to identify preliminary
codes and thematic elements found in the interviews. The two coders then met and discussed
their notes to develop an initial codebook and corresponding definitions. The coders applied
initial codes to a first set of four transcripts using Nvivo 12, and the codebook was refined after
discussion to resolve discrepancies. Two additional meetings were held to check coding and
resolve inconsistencies until adequate consensus was reached (Kappa =0.95, ranging from 0.86-
0.98). The final thematic analysis included reviewing and discussing queries of codes to
construct and interpret common themes that emerged from the data until theoretical saturation
was reached. The team then identified quotes from the coded passages that encompassed the
central ideas of the identified themes.
Results
Participant Characteristics
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Of the 14 residents who participated in the qualitative interview, ages ranged from 26-34;
the majority were female, Asian American, and in their 2
nd
or 3
rd
year of residency during the
SUD initiative. All the interviewees suspected they would encounter many people who use drugs
in their future clinical practice. Many residents (36%) had plans to work as hospitalists after their
residency training (Table 8).
Table 8: Descriptive Characteristics of Resident Physicians
Characteristic Median (range) or N
(%)
Age 29 (26-34)
Gender
Female
9 (64.3%)
Residency year during initiative
1
2
3
5 (33.3%)
6 (42.9%)
3 (21.4%)
Race
Asian
White
Mixed race
10 (71.4%)
2 (14.3%)
2 (14.3%)
Plans for after residency
Hospitalist
Gastroenterology
Pulmonary critical care
Hematology oncology
Endocrinology
Rheumatology
Undecided
5 (35.7%)
2 (14.3%)
2 (14..3%)
2 (14.3%)
1 (7.1%)
1 (7.1%)
1 (7.1%)
Thematic Analysis
The main themes identified relating to education and training on SUD included:
reflections on the initiative, inadequate preparation to treat PWUD in medical school and
residency prior to the initiative, a lack of comfort handling SUD cases, and a desire for additional
hands-on training and physical resources.
Initiative Experience
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The initiative was viewed favorably, and participants particularly appreciated a lecture
that included a step-by-step process of how to identify OUD and initiate buprenorphine for
someone experiencing opioid withdrawal symptoms in the hospital. The lectures helped to
establish an adequate knowledge base and brought awareness to the topic of treating PWUD.
Residents indicated feeling more prepared to screen, refer, and treat PWUD after the initiative.
Multiple participants suggested offering various times for the lectures for those with conflicting
schedules, making the trainings mandatory, and holding refresher courses.
“ I really enjoyed the fact that [addiction medicine lecturer] was very thorough in going through
the process of what we should do when treating substance use. And then he went through the
management step by step.”
“And I think until we really had those talks with [addiction medicine lecturer], we were more or
less following blindly on other people’s recommendations, whether that be our mentors or
Attendings. And moving forward, I think having that kind of knowledge base that we learned just
on the side effects, when you would use it, dosing, how to recognize, how to screen people, it was
very helpful, and something that I would take away for the rest of my career.”
“I feel like it actually changed the culture a lot . . . In addition to specifics of what do you do,
XYZ, but also just awareness of…this is the issue, it’s really prominent in our patients, how do
you address it? So I thought it was really good.”
“Maybe if it was a little bit more frequent, or maybe in the beginning of the year, because I only
remember having that patient simulation only once. I feel like a little bit more frequently would
just get me a little bit more used to it, like how the more frequently you do procedures the more
quickly it’ll come back to you when you do it again.”
Prior Education and Training
For many residents, the initiative was their first formalized introduction to SUD
treatment. We identified a prevalent theme of dissatisfaction with the inadequate amount of SUD
training provided in medical school and residency prior to the initiative. Most residents recalled
having only 1-2 lectures, if any, on treating substance use in medical school, with a focus on
theoretical components of addiction and basic pharmacology. Not one of the participants felt that
73
their prior education had adequately prepared them to treat PWUD. Residents frequently
emphasized the need for integration of substance use curriculum in medical school and
recommended introducing SUD education early in the internship year, for example as part of an
intern bootcamp that occurs at the start of the first year of residency.
“I think before these lectures by [addiction medicine lecturer] I only had a very brief one-time
session in medical school talking about primarily opioid use. And so coming into a new area
with new population needs, the kind of lack of training so to speak was pretty tough in the first
couple weeks when I started.”
“I think, just having it early on, even as part of intern boot camp, fully realizing that half of that
info will probably not be remembered, because you’re overwhelmed by so much stuff going on.
But just exposure to it very early on, like -- there’s addiction medicine, this is …who you reach
out to, this is how you prescribe. These are the medications you prescribe. I think the earlier the
better.”
Provider Comfort and Confidence
A theme commonly cited in the qualitative data was a lack of comfort and confidence in
handling SUD cases. Residents often felt uncomfortable bringing up drug use when speaking
with their patients and were not sure how to build a relationship with the patients and
comfortably talk to them about SUD treatment regimens. About half of the participants stated
they would feel comfortable initiating and/or prescribing buprenorphine after the initiative, while
the other half felt that they did not know enough about dosing and titration to start a patient on
the medication safely.
“My initial instinct is to feel a little bit uncomfortable or awkward in terms of how to address it
when I’m addressing their other medical issues. I just don’t know how to approach it and I don’t
want to offend the patient by saying they have an addiction problem. I guess it’s just not enough
experience with it.”
“Just lack of maybe, just not feeling comfortable with it, when you haven’t done it before and
you don’t really see people around you doing it and you also don’t tend to do it, you don’t want
to be the first, I guess… but maybe knowledge plays a big role as well.”
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Many participants endorsed utilizing the hospital’s addiction medicine electronic consult
service (a team of addiction medicine clinicians review patient charts and write
recommendations for treatment) when they were unsure of how to treat a patient. Those who
worked alongside Attendings who were knowledgeable about addiction and medications for
SUD reported having increased feelings of confidence in treating PWUD.
“I’ve done a couple of wards blocks now, and I’ve had to consult addiction medicine every time.
Just because not just me, but our whole team isn’t really comfortable with dealing with this stuff.
We’ve had patients who… used heroin prior to coming in and they’re obviously actively
withdrawing. And other than consulting addiction medicine we don’t really know what to do. We
can start Suboxone but we don’t know how the dosing works. So we just placed a formal
consult.”
“Because once I had that picture of -- and once [addiction medicine Attending] explained the
dosing to us, then I was like oh yeah I should definitely be using this all the time and it’s fine to
use for all these different patients, and I should try to use it instead of opioids even for like
treating pain.”
“It’s not something that I really felt comfortable with until I really worked with [addiction
medicine Attending], he does addiction medicine, and he was my Attending. And I just started to
feel really comfortable with it, because he would also just be like, oh, we’re gonna start them on
buprenorphine eight (mg), you know, and then you would send messages like, Hey, this guy looks
like he might be withdrawing…So it’s really nice to have him as my Attending, that really
solidified this further.”
Additional Training, Practice, and Resources
Despite the success of the initiative in increasing awareness of treatment modalities for
SUD, residents desired additional training in caring for PWUD. In almost every interview,
residents mentioned a desire for more practice and hands-on learning with real patients. The two
most endorsed solutions for providing further education and training were adding addiction
medicine rotations and distributing physical resources such as QuickStart guides (educational
materials containing instructions on assessing the patient for induction and/or prescribing of
75
medication, along with dosing information and other considerations) in the form of handouts,
posters, and electronic materials.
“I think just with anything with residency, like kind of doing things multiple times where I feel
comfortable. So now that I’ve had one patient with it, I think it’s in the span of the rest of my
year, during the ward setting, if I continue to do that, I think by the end of my training, I’ll feel
comfortable just having more. I think just clinical training and clinical experience would be the
most helpful. And then I guess also if we had a chance to rotate to addiction medicine or having
time in that setting, I think that would be helpful as well.”
“I think it would be helpful to maybe, I don’t know if addiction medicine has outpatient clinics,
or if they have like a consult service that we can maybe do a brief rotation on. I think that would
be, you know, an interesting kind of addition to our program.”
“If we could have just like an info sheet with everything narrowed down to, you know, these are
the starting doses. This is the Quickstart. And then this is the addiction medicine info. I know that
very often in our group chat, somebody will be like, Oh, how do we reach the addiction team or
what’s the best way to reach out and somebody always has like a little, you know, text saved
somewhere, and we’ll share it. But I think having just like a, you know, a snapshot of a card of
here’s all the information for the providers, for the prescribers and then the starting steps, I
think could be really useful.”
Discussion
The education initiative was implemented as a one-time trial made possible by external
grant funding, yet this type of training should be given a more permanent and integrated home in
the curriculum of residency programs by enacting deliberate changes. Despite the rise in
overdose deaths and the prevalence of SUD in communities, medical school and residency
programs give less weight to the treatment of SUD than other diseases and do not treat SUD as a
core topic (Bäck et al., 2018; HHS, 2022; Ram & Chisolm, 2016). Our brief initiative yielded
promising results; however, residents continued to express the need for more practical training.
Particularly, residents requested additional training in the form of 1. structured
knowledge/guides, 2. interviewing patients, and 3. practical knowledge (via rotations and hands-
on training).
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Analysis of the qualitative responses revealed that small educational initiatives in the
form of brief lectures may go a long way in providing residents with desired knowledge and
practice on caring for patients with SUD. Interventions as simple as providing a Quickstart guide
which can be found on the SAMHSA website (SAMHSA, 2022). may help residents feel
comfortable prescribing buprenorphine for a patient in active withdrawal. Interviewed residents
frequently mentioned appreciating the structured lectures that provided step-by-step instructions
for the initiation of medication for SUD over more theoretical education. This type of education
can be implemented in 1-2 hour lectures, was requested at the beginning of residency training,
with supplemental reinforcing material throughout the residency. Despite the inclusion of a
motivational interviewing (MI) component in the training, our participants still felt uneasy
interviewing patients and talking to them about their substance use. Providing an extended and
comprehensive MI training to all residents may lessen the uncomfortable gap and help future
physicians in all aspects of their career.
Our study aimed to identify the most useful components of the initiative, but perhaps the
most important finding from this analysis is what residents believe is left to be desired—more
practical experience. We identified that having a dedicated addiction medicine consult team
helped residents’ refer patients to get the treatment they needed if they were unprepared to treat
the patient themselves. Additionally, residents who worked alongside knowledgeable addiction
medicine physicians felt that the practical and hands-on training improved their comfort level in
prescribing medications for OUD. Many of our participants desired addiction medicine rotations
and increased experiential training to apply the knowledge gained from lectures, which we
recommend integrating into future initiatives. Hospitals should consider hiring more physicians
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with addiction medicine experience, as well as forming addiction medicine consult teams and
providing residents with hands-on training with those knowledgeable clinicians.
Our study had a number of limitations, particularly involving lack of in-person didactic
training and length of the overall initiative. Because of Covid-19, all of the lectures and patient
case series had to be delivered online, which may have reduced engagement. Yet, this provided
us with a novel way of implementing the educational initiative, which can be disseminated
across other programs with relative ease. Attendance of all of the components was
communicated to be mandatory; however, there were no measurable consequences for skipping
the lectures, although the attendance rate for the lectures was still high (84%). We originally had
two quantitative measures (pre-post overall intervention, and pre-post patient case series) to
assess changes in overall knowledge, attitudes, and stigma, but we were unable to analyze the
quantitative data due to a low participation rate in the pre-post surveys as they were not
mandatory. We recommend taking attendance and making participation mandatory for any
education initiatives developed in the future, as well as including additional ‘make-up sessions’
for residents who have a conflict due to their rotation schedule. Fourteen of 165 (8.5%) eligible
residents participated in the qualitative interview, and our sample disproportionately consisted of
more female and Asian participants than the average distribution of internal medicine residents
in the U.S
(AAMC, 2022) which may impact generalizability of the findings. Lastly, the three
didactic lectures and patient cases series were spread out over the course of a year and provided
to residents at different dates depending on residency year. Because of this, there may have been
discrepancies in evaluation of the overall initiative due to participant recall bias.
The brief SUD education initiative delivered to Internal Medicine residents was well-
received and perceived by the residents to be effective in establishing a knowledge base on how
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to treat SUD, particularly using medications such as buprenorphine for OUD withdrawal. Still,
our ad-hoc training was only made possible by outside funding, and is just the beginning of the
substantial amount of work that needs to be done towards a more integrated and comprehensive
training model in addiction treatment. The qualitative analysis revealed that beyond formal
education which increased awareness of identifying SUD and subsequent treatment options,
residents felt that more practice caring for PWUD was necessary, much like treating any medical
condition. Clinicians in training need to be provided with structured, practical education, hands-
on experiences, and adequate resources to develop their capabilities to care for patients with
SUD. It is time for medical school and residency programs to incorporate SUD education and
training into their standard curriculum and rotations that match the magnitude of the problem.
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Chapter 4: Discussion
Summary of Findings
The overall goal of this dissertation was to identify areas of improvement in provision of
MOUD for people who use opioids using a mixed-methods research approach incorporating
multiple ecological systems. The dissertation addressed three main goals: 1.) identify attitudes,
beliefs, and preferences about MOUD among a sample of PWOU, 2.) assess predictors of
buprenorphine prescribing in a population of patients with OUD who had an ED or inpatient visit
at the Los Angeles County + USC Medical Center, and 3.) explore resident physicians’
experiences with SUD education throughout medical school and residency, including a brief
SUD initiative. The findings from this dissertation highlight several key gaps in the clinical and
research domains that are crucial to improve upon in order to increase access to and uptake of
MOUD by PWUO. These findings give implication for recommendations for every system level,
including PWUO themselves, healthcare practitioners and their interactions amongst themselves,
organizations and hospital systems, and broad policy implications.
The purpose of Study 1 was to qualitatively explore use of MOUD by current users of
other opioids such as heroin and fentanyl. Because most of the literature focuses on using
MOUD for recovery-based treatment, there are gaps in understanding how PWUO engage with
MOUD for harm reduction purposes such as relieving withdrawal symptoms, reducing use of
other illicit drugs, and reducing other drug-related harms. Thus, this study analyzed attitudes,
beliefs, and preferences about MOUD including: how PWOU make the choice to seek treatment;
pathways to treatment; and the impact that MOUD has had on their opioid use and general well-
being. The study found that participants favored methadone as a tool to reduce withdrawal, and
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buprenorphine for achieving abstinence from other opioids. The study also explored perspectives
on MOUD prior to first initiation, reasons for initiation, and improvements that could be made
from the PWUO perspective. Overall, prolonged MMT was viewed as controlling due to the
need for daily dosing, and PWUO feared experiencing precipitated withdrawal on
buprenorphine, especially in the context of fentanyl tolerance. Participants favored methadone as
a harm reduction tool to reduce occurrence of withdrawal, and buprenorphine for treatment with
the goal of abstinence from other opioids. The findings of Study 1 contribute to the literature by
adding unique perspective of PWUO on their use of MOUD for both treatment and/or for harm
reduction purposes.
Study 2 investigated predictors of patients with OUD receiving a buprenorphine
prescription upon discharge from ED or inpatient admission at Los Angeles County Hospital.
The goal of Study 2 was to identify elements of a hospital encounter that predicted
buprenorphine prescribing, which could help inform domains for quality improvement initiatives
in hospital systems. This study selected potentially relevant patient-level and hospital encounter-
level variables to abstract in a review of patient’s electronic medical records. Using a nested
case-control design within a cohort of patients diagnosed with OUD, this study found that
hospital encounters that received an addiction medicine consult were significantly more likely to
receive a buprenorphine prescription. Buprenorphine was also more likely to be prescribed
during encounters that had less physical and/or psychiatric co-morbidities, indicating that
complexity of patients may decrease the likelihood of buprenorphine prescription. Patients who
had documented symptoms of opioid withdrawal were frequently initiated on buprenorphine
during the hospital encounter, which is a likely mediator of buprenorphine prescription. Finally,
encounters that had documented evidence of the patient having a prior satisfactory experience
81
with MOUD, and/or being amenable to treatment were more likely to receive a prescription,
suggesting that physicians feel more comfortable prescribing buprenorphine when they have
positive feedback from the patient.
The final study of the dissertation qualitatively assessed internal medicine resident
physicians’ prior experiences with SUD education throughout medical school and residency;
their experiences with a brief SUD initiative which focused on MOUD; and their
recommendations for improvements in medical education regarding treatment of SUD. Thematic
analysis of semi-structured interviews revealed that residents were generally unsatisfied with the
training they received on SUD treatment prior to the year of the initiative, regardless of their year
of residency. The initiative was viewed favorably and was seen as a meaningful way to establish
an adequate knowledge base around treating SUD and using MOUD. Residents found the
practical, step-by-step lectures of how to initiate buprenorphine for patients with OUD
particularly beneficial, and overall were more prepared to screen, refer, and treat patients with
SUD after the initiative. However, most participants expressed some levels of discomfort and
lack of confidence treating SUD patients even after the initiative. Finally, the residents’
discussed their desire for more education and training in treating SUD with MOUD, particularly
applying knowledge through hands-on experiences and practice, addiction medicine rotations,
and practical lectures.
While this dissertation features three stand-alone, distinct studies utilizing multiple study
populations, data sources, and statistical methods, it is brought together under the Ecological
Systems Framework to conceptualize the multi-system factors that contribute to the provision of
MOUD for PWUO. The key findings from each study are presented in Table 9 stratified by the
82
five system levels. It is also important to keep in mind that the systems interact, so findings from
these studies may overlap and influence each other.
Table 9: Summary of Key Findings of Studies at Ecological Systems Theory Levels
Individual Microsystem Mesosystem Exosystem Macrosystem
Study
1
- Two main
motivations for
starting MOUD
were to ‘get their
life together’, and to
reduce or eliminate
experience of
withdrawal.
- MOUD helped
reduce other opioid
use, experience of
withdrawal, and
risky behaviors
associated with drug
use or procurement
of money for drugs.
-Behavioral goals
drove use of MOUD
– buprenorphine
was perceived to be
better for full
abstinence, while
methadone was
more commonly
used for harm
reduction goals such
as alleviating
withdrawal.
-Participants feared
and experienced
physical dependency
on both
buprenorphine and
methadone. MMT
was reportedly
much harder to fully
quit. On the other
hand, PWUO feared
initiating
buprenorphine
because they might
experience
precipitated
withdrawal.
-PWUO learned
about MOUD
through other users,
friends, family, and
healthcare workers,
which influenced
their decision to
start MOUD.
-Other people’s
experiences with
and view of
buprenorphine may
have created
misconceptions
about how the drug
works in the body.
-Being around other
users including
friends that use can
encourage use of
other opioids while
on MOUD.
-PWUO had
generally negative
experiences when
visiting a hospital
for drug-use related
problems such as
overdose and
abscesses. PWUO
often felt
stigmatized by
providers.
Participants reported
being lectured to
about their drug use,
but were not offered
adequate treatment,
including MOUD.
-Methadone clinic
providers
encouraged MMT
over detoxification
and encouraged
-Going to the
methadone clinic
can be very
exposing, and may
lead PWUO to not
start MMT fearing
that everyone they
know will know
their business.
-Participants visiting
the hospital for a
drug-related issue
expressed that
providers did not
refer them to any
kind of SUD
treatment.
-None of our
participants
experienced
barriers to starting
methadone or
buprenorphine
when they sought
it out themselves.
-MOUD and
overall SUD
treatment was
generally not
provided during
hospital
encounters for
drug related
problems.
-Many PWUO
viewed the
methadone clinic
policies as
controlling.
Having to dose
daily restricted
PWUO lives in
many ways, and
missing a dose
often meant
supplementing
with illicit
opioids. Most
participants were
in favor of
relaxing the rules
for take home
dosing.
-PWUO
embraced ideas
from others that
MMT did
physical damage
to the body and
being on MMT
treatment meant
a life-time
commitment.
Many were not
interested in
buprenorphine
due to an
apparent fear
among PWUO of
experiencing
precipitated
withdrawal.
-PWUO may not
disclose their
drug use to
healthcare
providers due to
their own or
others past
experiences of
provider stigma.
83
-PWUO on MMT
were still able to get
high on other
opioids and felt that
methadone made
them feel ‘loaded’.
Contrastingly,
buprenorphine made
some PWUO feel
‘normal’, and none
of the interviewee
PWUO reported
getting high while
being on
buprenorphine.
-Quality of life
generally improved
for PWUO who
were on MOUD for
a prolonged period
of time.
patients to start at
high doses, which
may not have been
the best for the
patients.
-Participants felt
that providers at the
methadone clinic
should try to meet
them where they’re
at in regards to their
goals, rather than
pushing for
counseling and
treatment.
Study
2
-Presentation of
patient condition
influenced
buprenorphine
prescribing. Being
placed on a
temporary
psychiatric hold and
increased number of
other physical
problems was
associated with
decreased likelihood
of patients receiving
a buprenorphine
prescription upon
discharge. Patients
who experienced
opioid withdrawal
were more likely to
receive a
prescription.
-Hospital encounters
in which patients
were documented to
be amenable to
treatment and/or had
previous satisfactory
experience with
MOUD were more
likely to result in a
buprenorphine
prescription.
-Most encounters in
which patients were
experiencing opioid
withdrawal led to
buprenorphine
initiation during the
encounter, as well as
a buprenorphine
prescription,
indicating that
opioid withdrawal
acts as a mediator
for buprenorphine
prescribing for
providers.
-A buprenorphine
prescription was
substantially more
like in encounters
that provided a
consult from the
addiction medicine
to other providers
involved in that
patient’s care.
-A hospital-
implemented
addiction
medicine consult
service (AMCS)
resulted in
increased
likelihood of
buprenorphine
prescribing for
patients with
OUD.
N/A
84
Study
3
N/A -Residents generally
felt uncomfortable
addressing
substance use with
patients and lacked
confidence initiating
patients on MOUD.
-A dedicated
addiction medicine
consult team helped
residents obtain a
consultation to get
patients the
treatment they
needed if they were
unprepared to treat
the patient
themselves.
-Residents who
worked alongside
knowledgeable
addiction medicine
physicians felt that
the practical and
hands-on training
improved their
comfort level in
prescribing MOUD.
-The SUD
initiative
established a
knowledge base
around SUD
treatment for
residents and
increased
awareness of
using MOUD to
treat SUD.
Residents
generally felt
more prepared to
screen, refer, and
treat patients with
SUD after the
initiative.
-Residents had
favorable
opinions of the
SUD initiative,
yet desired
additional
training.
-Practical lectures
on MOUD
initiation and
application of
knowledge
through
experiential
training were the
most commonly
suggested
improvements for
SUD education of
clinicians.
-All the
interviewed
residents
reported
insufficient
education and
training on SUD
treatment
throughout their
medical career.
-Residents
suggested
implementing
addiction
medicine
rotations,
fellowships, and
improved
education in
medical school
as suggestions
for increasing
knowledge and
comfort with
treating SUD.
Policy Recommendations
This dissertation followed a mixed-methods approach to identify key components of each
Ecological Systems Theory level that may benefit from evidence-based improvements. A general
overview of broad implications and policy recommendations of this dissertation and potential
solutions at each level are presented in Table 10.
Table 10: Proposed Solutions to Increasing MOUD Provision and Utilization
85
Ecological
System Level
Proposed Solutions
Macrosystem
Laws and
policies, societal
stigma and views
on drug use
• Drug legalization and regulation on a federal level
• Safe supply
• De-stigmatization of drug use and focus on harm reduction over abstinence-based
recovery
• Reformation of SAMHSA policies for opioid treatment programs (OTPs)
• Regulation of methadone clinic funding
Exosystem
Hospital
procedures and
organizational
procedures
• Integrating SUD treatment components into medical school curricula
• Implementing addiction medicine rotations into residency programs
• Increasing structural support for clinicians
• Developing addiction medicine consult teams within hospitals
• Integrate prompts into hospital EHR systems to trigger AMCS or buprenorphine
prescribing for patients diagnosed with OUD
Mesosystem
Interaction
between
providers
• Clinicians and staff that regularly interacts with SUD patients should know how to
contact the AMCS and request a consult
• Clinicians that are knowledgeable about addiction medicine can educate others on
MOUD treatment and dosing strategies
Microsystem
Provider
(physician,
social worker,
etc.) interaction
with patient
• Providers should strive for an empathetic approach to treatment that integrates harm
reduction principles such as meeting the patient where they are at and be prepared to
discuss the benefits and drawbacks of MOUD
• Clinicians should be up to date on alternate buprenorphine dosing strategies and
tailor their approach to the patients’ needs and prior experiences
• Clinicians who administer buprenorphine and/or interact with patients who are
interested in MOUD should prescribe buprenorphine or consult AMCS if they do
not feel prepared to do so themselves
Individual • PWUO should evaluate their overall goals to determine if MOUD is right for them,
and if so, ask experienced clinicians or trusted peers which one would be right for
them
Macrosystem
At the macrosystem level, there are many issues that impede MOUD provision that exist
in policy and overall cultural views on drug use. While a full discussion of drug
decriminalization, legalization and regulation is not within the scope of this dissertation, it is
important to note that any discussion of MOUD cannot be fully understood without
acknowledging the detrimental effects of the War on Drugs to PWUD (Frank, 2018). Briefly,
drug decriminalization and/or full legalization remains controversial in the U.S. but is supported
by prominent human rights groups such as the ACLU and the Drug Policy Alliance, as well as
numerous researchers (cites). Current drug policies in the United States criminalize individuals
who use drugs, punish small segments of the population, disproportionately disadvantage the
86
poor and racial minorities, and force persons to engage in illegal and oftentimes dangerous
activities to procure and consume drugs (Bonn et al., 2020; Boyd, 2021). Portugal’s
decriminalization of possession and use of all drugs has increased the number of individuals
entering treatment, and Switzerland’s approach of harm reduction, prevention, treatment, and
law enforcement (including medical prescriptions of heroin) has reduced overdose deaths by
50% (Greenwald, 2009). Decriminalization could also reduce stigma surrounding drug use and
allow PWOU to access treatment sooner (Csete & Wolfe, 2017) and has been argued as essential
to prevent substance use disorder (Hoss, 2019).
Researchers, health professionals, and drug advocates have proposed providing safe
supplies of opioids, defined as legal and regulated supplies of drugs that traditionally only have
been accessible through illicit markets to PWOU to respond to the overdose crisis (Bonn et al.,
2020; McNeil et al., 2022; Tyndall, 2020). Providing safe supply extends the benefits of MOUD
to outside of treatment contexts, possibly eliminating the many barriers that exist within
treatment contexts (McNeil et al., 2022). Pilot testing of a safe supply initiative in British
Columbia has shown feasibility as well as reductions in illicit drug use and positive effects on
quality of life (Ivsins et al., 2020, Ivsins et al., 2021).
Overall, a shift to a harm reduction-based approach to substance use treatment is critical
(Simon et al., 2022; Vearrier, 2019). Harm reduction approaches to drug use vary, but very
broadly, harm reduction treats PWUD with dignity and respect, is non-judgmental, and
encourages agency in the decision-making process of a person who uses drugs (Logan & Marlatt,
2010). Researchers and drug user activists have endorsed the need for a re-conceptualization of
MOUD away from being viewed solely as treatment in a recovery-based framework (Frank,
2018; Simon et al., 2022). Acknowledging that MOUD doesn’t have to be based in the desire for
87
treatment may reduce barriers for PWUO who would benefit from MOUD but do not want to
pursue recovery (Frank, 2018; Simon et al., 2022). As a society, viewing drug use within a
framework which incorporates multiple sources of social marginalization including income
inequality, race, and criminal justice involvement could help to humanize PWOU (Allen et al.,
2019; Fareed et al., 2012). Reducing drug use stigma can include changing the way we speak
about drug use (replacing ‘abuse’ for ‘use’; ‘addict’ for ‘person who uses drugs’), interacting
with PWUD and hearing their experiences, as well as contact-based training and stigma-reducing
based interventions to target healthcare professionals (Livingston et al., 2012).
Policies set forth by SAMHSA concerning methadone clinic regulations should continue
the successful relaxation of take-home protocols brought on by the Covid-19 pandemic (Amram,
et al., 2021), yet much more progress is needed in the eyes of drug user activists and researchers
(Simon et al., 2022). Reformation of SAMHSA policies could lead to clinics adopting a ‘low-
threshold’ approach, which has been shown to increase quality of life and treatment retention
while decreasing drug use (Millson et al., 2007; Scheibe et al., 2020). Low-threshold clinics
typically include elements of: same day entry to treatment, harm reduction, flexibility in
monitoring (i.e., provision of take homes and optional, rather than mandatory counseling).
Finally, perhaps more scrutiny should be placed on methadone clinics and their care of patients,
including potential predatory behavior of unnecessarily high dosing and how it relates to their
funding and profits (Bachhuber et al., 2014).
Exosystem
At the exosystem level, hospitals and organizations have many options for reform and
quality improvement to increase provision of MOUD. Across the three studies, this dissertation
found that hospital experiences for PWUO did not always result in evidence-based treatment or
88
even discussion of their substance use. Comprehensive education has been proposed as one way
to address physician stigma and lack of knowledge concerning patients with OUD (Allen et al.,
2019). Counseling techniques such as motivational interviewing could be incorporated into SUD
education so that physicians remain compassionate and maintain non-judgmental attitudes (Fox
et al., 2016). Education on SUD and particularly OUD training has been successful for select
medical school programs in increasing knowledge about SUDs and reducing stigma towards
PWUD (Livingston et al., 2012; McCance-Katz et al., 2017; Neufeld et al., 2012). Our SUD
initiative for internal medicine resident physicians was perceived to increase knowledge and
comfort of treating patients with SUD, which corroborates findings of other SUD treatment
residency initiatives (Alford et al., 2009; Suzuki et al., 2014). However, our results showed that
the brief initiative was not sufficient for residents to gain full confidence in using MOUD.
Residency program directors should consider integrating addition medicine rotations, hands-on
training with addiction medicine clinicians, and practical lectures on SUD treatment to improve
education of future physicians and increase provision of MOUD.
Physicians have limited time to treat patients in the hospital and may struggle to treat
SUD in part due to competing resources (Kim & Samuels, 2020). In Study 2, we found that
patient complexity including additional physical problems and active psychiatric crises may
impact buprenorphine prescribing. Increasing structural support for physicians such as dosing
guides, automated protocols, buy-in from clinical staff, clinical champions, and changing the
culture around MOUD prescribing may be effective (Kim & Samuels, 2020). Studies 2 and 3
demonstrated the utility of AMCS within a hospital system. The findings in Study 2 show that
the strongest predictor of receipt of a buprenorphine prescription upon patient discharge was an
addiction medicine consult. AMCS can be executed electronically through consult notes in the
89
patient chart, making for a feasible and straightforward organizational intervention. AMCS is
additionally beneficial in the context of Covid-19, and can be successfully adapted to include
telehealth appointments with vulnerable patients (Harris et al., 2021). Furthermore, health
systems may want to consider integrating EHR prompts to facilitate SUD treatment and MOUD
prescribing. One study found that a prompt based on the presence of specific terms in the patient
record which triggered the discharging physician to consider providing a naloxone prescription
increased take home naloxone distribution to patients seen for opioid overdose (Marino et al.,
2019). Similar prompts can be applied to trigger an addiction medicine consultation, and to
prescribe naloxone and buprenorphine.
Mesosystem and Microsystem
The benefits of AMCS have already been discussed in the context of the exosystem,
which interacts with the mesosystem as a provider-provider action. Study 2 showed that not
every patient diagnosed with OUD received an AMCS, and many who did not receive the
consult also did not receive a buprenorphine prescription. This could be due to the structure of
AMCS, which commonly operates on weekday-only hours and may be understaffed (Priest &
McCarty, 2019). Providers may also lack the time, interest, or awareness to properly document
OUD in the patient chart. Additionally, providers may experience conflicts between hospital staff
regarding harm reduction vs abstinence-only approaches to treatment (Hyshka et al., 2019). If an
AMCS is implemented within a hospital system, efforts should also be made by relevant
stakeholders to ensure acceptability among staff and feasibility of requesting the consults (Priest
et al., 2020). Addiction medicine experts and other clinicians who are knowledgeable about
utilizing MOUD treatment can also help train those that are less experienced, as evidenced in
Study 3. Resident physicians who worked alongside an addiction medicine clinician felt more
90
comfortable prescribing MOUD after witnessing their process and having a better understanding
of dosing strategies.
The microsystem implications strongly interact with the rest of the levels, demonstrating
the influence of wider system policies. As mentioned in the exosystem portion of this discussion,
embracing harm reduction principles can be an effective way for providers to build trust and
rapport with PWUO who are not quite ready for treatment (Logan & Marlatt, 2010). PWUO in
Study 1 emphasized negative hospital experiences in which they felt judged by clinicians and not
offered SUD treatment. Providers in methadone clinics may also want to consider meeting
patients where they are, for instance, not mandating counseling or not requiring negative drug
tests to receive take home doses (Simon et al., 2022). Additionally, clinicians should consider
patients’ previous experiences and history of drug use (especially fentanyl) when preparing to
administer buprenorphine to avoid precipitated withdrawal and stay up to date on alternate
dosing strategies including micro and high dose induction (Adams et al., 2021; Hartley et al.,
2022; Herring et al., 2021). If clinicians do not feel prepared to treat a patient with OUD or feel
that the patient is too complex for them to consider MOUD, an AMCS should be initiated if
those services exist within the hospital system.
Individual
This dissertation demonstrates how PWUO’ relationship to MOUD is shaped by
complex, interacting systems within the Ecological Systems framework. PWOU had varying
beliefs about MOUD, preferences for MOUD, and experiences with MOUD. To increase
utilization of MOUD by PWUO, changes must be made within and across the system levels.
Study 1 found that PWUO were generally motivated to start MOUD either to relieve withdrawal
symptoms and/or to improve their life and ‘get it together’. Overall, MOUD improved lives of
91
PWUO, although there were negative effects of both forms. Buprenorphine was preferred for
abstinence of using other opioids, while methadone was often endorsed for its ability to reduce or
eliminate withdrawal symptoms, which sometimes led to reduction of other dangerous behaviors
that were associated with drug procurement. PWUO who are interested in MOUD should
evaluate their overall goals to determine if MOUD is right for them, and if so, ask experienced
clinicians or trusted peers which one would be right for them.
Future Research Directions
Study 1 identified potential misconceptions that PWUO held about the differences in
drug formulations of buprenorphine. Multiple participants in the study stated their preference for
the buprenorphine only formulation over the buprenorphine-naloxone formulation, reasoning that
the naloxone combination has a blocker that initiates precipitated withdrawal. Naloxone is only
activated in the formulation if it is crushed up, but removing the naloxone has been proposed as a
way to eliminate barriers to MOUD for patients who otherwise refuse to attempt buprenorphine
in that form (Blazes & Morrow, 2020). Future research should quantitatively evaluate if PWUO
would truly be more open to buprenorphine if it did not contain naloxone. Likewise, PWUO
were concerned about precipitated withdrawal occurring after buprenorphine initiation. Hospital-
based education initiatives can be implemented to teach clinicians about alternate dosing
strategies, which could be evaluated empirically to assess if the initiative led to a decrease in
patients experiencing precipitated withdrawal. More empirical data is also needed on predictors
of buprenorphine initiation and prescribing; while Study 2 used a nested case-control design, a
retrospective cohort design among a greater sample of OUD patients would add beneficial
knowledge.
92
Strengths and Limitations
Mixed methods research integrates quantitative and qualitative data on a subject and
permits more complete and synergistic utilization of data than conducting only one type of
analysis (Wisdom & Creswell, 2013). Advantages to using this design are: 1.) ability to compare
contradictions between quantitative and qualitative findings, 2.) giving a voice to participants’
experiences, 3.) encouraging scholarly multi-disciplinary interaction, 4.) adaptability and
flexibility in study design, and 5.) an end result of rich and comprehensive data. However,
because of the complexity of this approach and amount of time necessary to complete 3 separate
studies, the collected data may have smaller sample sizes than similar other works. Using the
Ecological Systems Theory framework allowed for a holistic approach to a broad problem, but
testing findings empirically in the context of the framework is difficult.
Two studies used qualitative data, which limits the ability to make any statistical
conclusions regarding the resident SUD initiative or perceptions of MOUD among PWUO.
Nevertheless, the richness of the interviews offers insights into both PWUO and resident
physicians’ experience with MOUD and SUD treatment. Study 2 faces limitations of data
obtained from medical records such as of incomplete or missing data, difficulty interpreting
documentation pertaining to select variables, variability in the quality of documentation, and
selection bias. Additionally, our cohort database of patients likely did not represent all patients
with OUD seen at the county hospital due to inaccuracy of billing and diagnoses codes
(Lagisetty et al., 2021; Ranapurwala et al., 2021). Finally, the Covid-19 pandemic not only
affected data collection, but resulted in a number of changes that affected PWUO including
increased opioid overdoses and relaxation of MOUD regulations. Thus, the three studies and
93
overall dissertation must be understood within the context of a unique time period of a global
epidemic.
Conclusion
Provision of MOUD for PWUO is a key component of reducing opioid use-related harms
such as overdose deaths, drug-related morbidity, and negative societal consequences of opioid
use. This dissertation triangulates three studies worth of findings to identify potential changes in
policy and practice at multiple levels of the surrounding environment that affect PWUO. Federal
regulations concerning MOUD and overall drug policy trickle down to effect lower-level
systems, leading to punitive and controlling methadone clinic policies and an underdeveloped
capacity of clinicians that are comfortable prescribing buprenorphine. Physicians lack adequate
training in treating SUD and more so are not comfortable using buprenorphine for treatment of
OUD. Healthcare organizations and hospital systems (including residency training programs) can
effect substantial change by integrating SUD education and training into their organizations.
Hospital systems would also benefit from developing addiction medicine consult services to
supplement gaps in SUD treatment-related care. These interventions have the potential to affect
change throughout system levels by normalizing MOUD and allowing for a reconceptualization
of MOUD as person-centered care. Systemic changes of loosened MOUD regulations, decreased
stigmatization of drug use, and providers competent in treating OUD would benefit PWUO and
potentially increase utilization of MOUD.
94
95
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Abstract (if available)
Abstract
Opioid use has been a steadily rising problem over the last two decades and is currently considered a health crisis in the United States due to overdose deaths. Although medication for opioid use disorder (MOUD) is the gold-standard for patients with opioid use disorder, it is under-utilized by people who use opioids and under-prescribed. MOUD includes several medications such as methadone, buprenorphine, or naltrexone in order to help opioid users reduce their use of drugs or harm associated with their use. Barriers to uptake of MOUD exist on individual, provider, care team, hospital, governmental, and societal levels. Previous studies generally only investigate one level of under-utilization of MOUD, yet a framework of how the interacting systems prevent appropriate linkage to MOUD has not yet been explored or developed.
This dissertation follows a mixed-methods approach and contains three separate datasets as well as integration of the results across studies, involving (1) qualitative PWOU interviews, (2) quantitative patient medical records, and (3) qualitative resident physician interviews. Each study considers patient, care team, and organizational factors that contribute to barriers and facilitators of MOUD linkage. The aims of this project target the five levels of the Ecological Systems Theory: individual, microsystem, mesosystem, exosystem, and macrosystem.
The overall goal of this dissertation was to identify areas of improvement in provision of MOUD for people who use opioids using a mixed-methods research approach incorporating multiple ecological systems. The dissertation addressed three main goals: 1.) identify attitudes, beliefs, and preferences about MOUD among a sample of PWOU, 2.) assess predictors of buprenorphine prescribing in a population of patients with OUD who had an ED or inpatient visit at the Los Angeles County + USC Medical Center, and 3.) explore resident physicians’ experiences with SUD education throughout medical school and residency, including a brief SUD initiative. The findings from this dissertation highlight several key gaps in the clinical and research domains that are crucial to improve upon in order to increase access to and uptake of MOUD by PWUO. These findings give implication for recommendations for every system level, including PWUO themselves, healthcare practitioners and their interactions amongst themselves, organizations and hospital systems, and broad policy implications.
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Bolshakova, Maria
(author)
Core Title
A multi-system evaluation of medication for opioid use disorder for people who use opioids
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Keck School of Medicine
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Doctor of Philosophy
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Preventive Medicine (Health Behavior)
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2022-12
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11/10/2022
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buprenorphine,case control,ecological systems theory,EHR,est,harm reduction,Health services,Medical education,medication for opioid use disorder,medication-assisted treatment,methadone,moud,nested case-control,OAI-PMH Harvest,opioids,people who use drugs,people who use opiods,pwou,pwud,qualitative,qualitative interviews,substance use,substance use disorder
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cisadmin@lib.usc.edu
Tags
buprenorphine
case control
ecological systems theory
EHR
est
harm reduction
medication for opioid use disorder
medication-assisted treatment
methadone
moud
nested case-control
opioids
people who use drugs
people who use opiods
pwou
pwud
qualitative
qualitative interviews
substance use
substance use disorder