A National Survey of Barriers and Facilitators to Medications for Opioid use Disorder among Legal-Involved Veterans in the Veterans Health Administration

Abstract

Background: Medications for opioid use disorder (MOUD) are clinically effective at treating OUD among legal-involved populations. However, research shows that legal-involved veterans who receive care through the VHA have lower rates of MOUD use compared to non-legal-involved veterans. Education may be a key factor in intervention strategies to improve MOUD access. This study was a national survey of VHA staff to identify barriers to and facilitators of MOUD, as well as MOUD-related education needs for VHA staff, community partners, criminal justice partners, and legal-involved veterans. Method: A 98-item online survey was conducted to examine VHA staff perspectives (N = 218) around needed education, barriers to, and facilitators of MOUD for legal-involved veterans. Descriptive statistics were conducted and linear regression analyses were used to evaluate differences in perceptions by respondents’ current position at the VHA and their VHA facility's rate of provision of MOUD among legal-involved veterans. Results: Respondents endorsed a need for education in all areas of MOUD (e.g., existing medications for the treatment of OUD) for VHA staff and providers, community partners, criminal justice partners, and legal-involved veterans. VHA staff perceived barriers to MOUD for legal-involved veterans to include stigma and complicated guidelines around MOUD and OUD treatment. Facilities with low rates of MOUD use highlighted barriers including MOUD conflicting with the philosophy of the local VHA facility and provider stigma toward patients with OUD. Perceptions of efficacy of MOUD differed by respondents’ current position at the VHA such that substance use disorder treatment providers perceived buprenorphine and methadone as more effective compared to Veterans Justice Specialists. Conclusion: The results of this study suggest a need for an educational intervention emphasizing the evidence supporting use of MOUD as a lack of knowledge about these medications was considered a barrier to access, whereas gaining education about MOUD was a facilitator to access. Education strategies specifically tailored to address VHA facility-level differences may help address barriers to MOUD experienced by legal-involved veterans.

Keywords

Opioid addiction medication assisted treatment of opioid veterans criminal justice

Get full access to this article

View all access options for this article.

References

Binswanger

, Blatchford

, Mueller

, Stern

MF.

Mortality after prison release: opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009. Ann Intern Med. 2013;159(9):592–600.

Green

, Clarke

, Brinkley-Rubinstein

Postincarceration fatal overdoses after implementing medications for addiction treatment in a statewide correctional system. JAMA Psychiatry. 2018;75(4):405–407.

Wortzel

, Blatchford

, Conner

, Adler

, Binswanger

IA.

Risk of death for veterans on release from prison. J Am Acad Psychiatry Law. 2012;40(3):348–354.

Baser

, Chalk

, Fiellin

, Gastfriend DR.

Cost and utilization outcomes of opioid-dependence treatments. Am J Manag Care. 2011; 17(Suppl 8):S235–S248.

Coviello

, Cornish

, Lynch

A multisite pilot study of extended-release injectable naltrexone treatment for previously opioid-dependent parolees and probationers. Subst Abus. 2012;33(1):48–59.

Gisev

, Shanahan

, Weatherburn

A cost-effectiveness analysis of opioid substitution therapy upon prison release in reducing mortality among people with a history of opioid dependence. Addiction. 2015;110(12):1975–1984.

Murphy

, Polsky

Economic evaluations of opioid use disorder interventions. Pharmacoeconomics. 2016;34(9):863–887.

Wyse

, Gordon

, Dobscha

Medications for opioid use disorder in the Department of Veterans Affairs (VA) health care system: historical perspective, lessons learned, and next steps. Subst Abus. 2018;39(2):139–144.

U.S. Department of Veterans Affairs and Department of Defense. VA/DoD Clinical Practice Guidelines for the Management If Substance Use Disorders. Washington, DC: U.S. Department of Veterans Affairs; 2015.

10.

Finlay

, Harris

AHS

, Timko

Disparities in access to medications for opioid use disorder in the Veterans Health Administration. J Addict Med. 2021;15(2):143–149.

11.

Peterson

, Schwartz

, Mitchell

Why don't out-of-treatment individuals enter methadone treatment programmes?

Int J Drug Policy. 2010;21(1):36–42.

12.

Tofighi

, Williams

, Chemi

, Suhail-Sindhu

, Dickson

, Lee

JD.

Patient barriers and facilitators to medications for opioid use disorder in primary care. Subst Use Misuse. 2019;54(14):2409–2419.

13.

Gordon

, Kavanagh

, Krumm

Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration. Psychol Addict Behav. 2011;25(2):215–224.

14.

Mackey

, Veazie

, Anderson

, Bourne

, Peterson

Evidence Brief: Barriers and Facilitators to Use of Medications for Opioid Use Disorder. Washington, DC: Department of Veterans Affairs (US); 2019. http://www.ncbi.nlm.nih.gov/books/NBK549203/. Accessed May 30, 2020.

15.

Csete

Criminal justice barriers to treatment of opioid use disorders in the United States: the need for public health advocacy. Am J Public Health. 2019;109(3):419–422.

16.

Reichert

, Gleicher

. Probation clients’ barriers to access and use of opioid use disorder medications. Health Justice. 2019;7(1):10

17.

Finlay

, Morse

, Stimmel

Barriers to medications for opioid use disorder among veterans involved in the legal system: a qualitative study. J Gen Intern Med. 2020;35(9):2529–2536.

18.

Chang

, Oberman

, Cohen

Increasing access to medications for opioid use disorder and complementary and integrative health services in primary care. J Gen Intern Med. 2020;35(Suppl 3):918–926.

19.

Brunet

, Moore

, Lendvai Wischik

, Mattocks

, Rosen

MI.

Increasing buprenorphine access for veterans with opioid use disorder in rural clinics using telemedicine. Subst Abus. 2020:1–8. doi:10.1080/08897077.2020.1728466.

20.

Blue-Howells

, Clark

, van den Berk-Clark

, McGuire

JF.

The U.S. Department of Veterans Affairs Veterans Justice programs and the sequential intercept model: case examples in national dissemination of intervention for justice-involved veterans. Psychol Serv. 2013;10(1):48–53.

21.

Finlay

, Harris

AHS

, Rosenthal

Receipt of pharmacotherapy for opioid use disorder by justice-involved U.S. Veterans Health Administration patients. Drug Alcohol Depend. 2016;160:222–226.

22.

Green

, McCarty

, Mertens

A qualitative study of the adoption of buprenorphine for opioid addiction treatment. J Subst Abuse Treat. 2014;46(3):390–401.

23.

Harris

AHS

, Ellerbe

, Reeder

Pharmacotherapy for alcohol dependence: perceived treatment barriers and action strategies among Veterans Health Administration service providers. Psychol Serv. 2013;10(4):410–419.

24.

, Sussell

AL.

Multiple Imputation of Family Income Data in the 2015 Behavioral Risk Factor Surveillance System. Cincinnati, OH: MidWest SAS® Users Group; 2017.

25.

von Hippel

PT.

How many imputations do you need? A two-stage calculation using a quadratic rule. Sociol Methods Res. 2020;49(3):699–718.

26.

Finlay

, Binswanger

, Timko

Facility-level changes in receipt of pharmacotherapy for opioid use disorder: implications for implementation science. J Subst Abuse Treat. 2018;95:43–47.

27.

Bunting

, Oser

, Staton

, Eddens

, Knudsen

Clinician identified barriers to treatment for individuals in Appalachia with opioid use disorder following release from prison: a social ecological approach. Addict Sci Clin Pract. 2018;13(1):23.

28.

Haffajee

, Bohnert

ASB

, Lagisetty

PA.

Policy pathways to address provider workforce barriers to buprenorphine treatment. Am J Prev Med. 2018;54(6 Suppl 3):S230–S242.

29.

Winograd

, Presnall

, Stringfellow

The case for a medication first approach to the treatment of opioid use disorder. Am J Drug Alcohol Abuse. 2019;45(4):333–340.

30.

Winograd

, Wood

, Stringfellow

et al. Implementation and evaluation of Missouri's Medication First treatment approach for opioid use disorder in publicly-funded substance use treatment programs. J Subst Abuse Treat. 2020;108:55–64.

31.

Gordon

, Drexler

, Hawkins

Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative: expanding access to medication treatment for opioid use disorder within Veterans Health Administration facilities. Subst Abus. 2020;41(3):275–282.

32.

National Academies of Sciences, Engineering, and Medicine. Medications for Opioid Use Disorder save Lives. Washington, DC: The National Academies Press; 2019.

33.

Lam

, Lee

HIS

, Truong

Brief video intervention to improve attitudes throughout medications for opioid use disorder in a correctional setting. J Subst Abuse Treat. 2019;104:28–33.

34.

Salvador

, Bhatt

, Jacobsohn

Feasibility and acceptability of an online ECHO intervention to expand access to medications for treatment of opioid use disorder, psychosocial treatments and supports. Subst Abus. 2020:1–8. doi:10.1080/08897077.2020.1806184.