Utilization of medications for opioid use disorder (MOUD) has not been widely adopted by primary care providers. This study sought to identify interprofessional barriers and facilitators for use of MOUD (specifically naltrexone and buprenorphine) among current and future primary care providers in a southeastern academic center in South Carolina.
Method
Faculty, residents, and students within family medicine, internal medicine, and a physician assistant program participated in focus group interviews, and completed a brief survey. Survey data were analyzed quantitatively, and focus group transcripts were analyzed using a deductive qualitative content analysis, based upon the theory of planned behavior.
Results
Seven groups (N = 46) completed focus group interviews and surveys. Survey results indicated that general attitudes towards MOUD were positive and did not differ significantly among groups. Subjective norms around prescribing and controllability (i.e., beliefs about whether prescribing was up to them) differed between specialties and between level of training groups. Focus group themes highlighted attitudes about MOUD (e.g., “opens the flood gates” to patients with addiction) and perceived facilitators and barriers of using MOUD in primary care settings. Participants felt that although MOUD in primary care would improve access and reduce stigma for patients, prescribing requires improved provider education and an integrated system of care.
Conclusions
The results of this study provide an argument for tailoring education to specifically address the barriers primary care prescribers perceive. Results promote the utilization of active, hands-on learning approaches, to ultimately promote uptake of MOUD prescribing in the primary care setting in South Carolina.
HserYIMooneyLJSaxonAJ, et al.
High mortality among patients with opioid use disorder in a large healthcare system. J Addict Med2017;
11: 315–319.
3.
RuddRSethPDavidF, et al.
Increases in drug and opioid-involved overdose deaths – United States, 2010–2015. MMWR Morb Mortal Wkly Rep2016;
65: 1445–1452.
ArnoldJFArshonskyJHBlochKA, et al.
Opioid abuse prevention and treatment: lessons from South Carolina. J Public Health Manag Pract2019;
25: 221–228.
6.
Substance Abuse and Mental Health Services Administration.Behavioral health barometer: South Carolina, Volume 5: Indicators as measured through the 2017 National Survey on Drug Use and Health and the National Survey of Substance Abuse Treatment Services.
Rockville:
Substance Abuse and Mental Health Services Administration, 2019.
7.
BahorikALSatreDDKline-SimonAH, et al.
Alcohol, cannabis, and opioid use disorders, and disease burden in an integrated health care system. J Addict Med2017;
11: 3–9.
8.
CrowleyRKirschnerNDunnAS, et al.;Health and Public Policy Committee of the American College of Physicians.
Health and public policy to facilitate effective prevention and treatment of substance use disorders involving illicit and prescription drugs: an American College of Physicians Position Paper. Ann Intern Med2017;
166: 733–736.
9.
NorrisL. Healthinsurance.org: a state-by-state guide to Medicaid expansion, eligibility, enrollment, and benefits, www.healthinsurance.org/medicaid/ (2019, accessed 21 February 2019).
10.
KnudsenHK.The supply of physicians waivered to prescribe buprenorphine for opioid use disorders in the United States: a state-level analysis. J Stud Alcohol Drugs2015;
76: 644–654.
11.
SalonerBKarthikeyanS.Changes in substance abuse treatment use among individuals with opioid use disorders in the United States, 2004-2013. J Am Med Assoc2015;
314: 1515–1517.
12.
JonesCCampopianoMBaldwinG, et al.
National and state treatment need and capacity for opioid agonist medication-assisted treatment. Am J Public Health2015;
105: e55–e63.
13.
MillerNGoldM.Management of withdrawal syndrome and relapse prevention in drug and alcohol dependence. Am Fam Physician1998;
58: 139–146.
14.
WakemanSBarnettM.Primary care and the opioid-overdose crisis – buprenorphine myths and realities. N Engl J Med2018;
379: 1–4.
RoweTAJacapraroJSRastegarDA.Entry into primary care-based buprenorphine treatment is associated with identification and treatment of other chronic medical problems. Addict Sci Clin Pract2012;
7: 22.
17.
ChiFWParthasarathySMertensJR, et al.
Continuing care and long-term substance use outcomes in managed care: early evidence for a primary care-based model. Psychiatric Serv2011;
62: 1194–1200.
18.
OberAJWatkinsKEMcCulloughCM, et al.
Patient predictors of substance use disorder treatment initiation in primary care. J Subst Abuse Treat2018;
90: 64–72.
19.
BarryCLEpsteinAJFiellinDA, et al.
Estimating demand for primary care-based treatment for substance and alcohol use disorders. Addiction2016;
111: 1376–1384.
20.
BrownRGassmanMHetzelS, et al.
Community-based treatment for opioid dependent offenders: a pilot study. Am J Addict2013;
22: 500–502.
21.
SteinMDCioePFriedmannPD.Buprenorphine retention in primary care. J Gen Intern Med2005;
20: 1038–1041.
22.
SoeffingJMMartinLDFingerhoodMI, et al.
Buprenorphine maintenance treatment in a primary care setting: outcomes at 1 year. J Subst Abuse Treat2009;
37: 426–430.
23.
WuLTZhuHSwartzMS.Treatment utilization among persons with opioid use disorder in the United States. Drug Alcohol Depend2016;
169: 117–127.
24.
RosenblattRAAndrillaCHCatlinM, et al.
Geographic and specialty distribution of US physicians trained to treat opioid use disorder. Ann Fam Med2015;
13: 23–26.
25.
DeflavioJRolinSNordstromB, et al.
Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians. Rural Remote Health2015;
15: 1–11.
26.
WakemanSEPham-KanterGDonelanK.Attitudes, practices, and preparedness to care for patients with substance use disorder: results from a survey of general internists. Subst Abus2016;
37: 635–641.
HutchinsonECatlinMAndrillaCH, et al.
Barriers to primary care physicians prescribing buprenorphine. Ann Fam Med2014;
12: 128–133.
29.
BarryDTIrwinKSJonesES, et al.
Integrating buprenorphine treatment into office-based practice: a qualitative study. J Gen Intern Med2009;
24: 218–225.
30.
WalleyAYAlperenJKChengDM, et al.
Office-based management of opioid dependence with buprenorphine: clinical practices and barriers. J Gen Intern Med2008;
23: 1393–1398.
31.
NolanMBehiR.Triangulation: the best of all worlds?Br J Nurs1995;
4: 829–832.
32.
PowellRASingleHM.Methodology matters V – focus groups. Int J Qual Healthc1996;
8: 449–504.
33.
KitzingerJ.Introducing focus groups [electronic version]. BMJ1995;
311: 299–302.
34.
GillPStewartKTreasureE, et al.
Methods of data collection in qualitative research: interviews and focus groups. Br Dent J2008;
204: 291–295.
WilkinsonS.Focus group methodology: a review. Int J Soc Res Methodol1998;
1: 181–203.
37.
FrancisJJEccles Mp JohnstonM, et al. Constructing questionnaires based on the theory of planned behavior: a manual for health services researchers.
Newcastle upon Tyne:
Centre for Health Services Research, University of Newcastle upon Tyne, 2004.
38.
AjzenI.The theory of planned behavior. Org Behav Hum Decis Process1991;
50: 179–211.
39.
GottschallACWestSGEndersCK.A comparison of item-level and scale-level multiple imputation for questionnaire batteries. Multivar Behav Res2012;
47: 1–25.
40.
GrahamJW.Missing data: analysis and design.
New York:
Springer, 2012.
41.
SchlomerGLBaumanSCardNA.Best practices for missing data management in counseling psychology. J Couns Psychol2010;
57: 1–10.
42.
HsiehHFShannonSE.Three approaches to qualitative content analysis. Qual Health Res2005;
15: 1277–1288.
43.
BraunVClarkeV.Using thematic analysis in psychology. Qual Res Psychol2006;
3: 77–101.
44.
BradleyEHCurryLADeversKJ.Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res2007;
42: 1758–1772.
45.
HillCEKnoxSThompsonBJ, et al.
Consensual qualitative research: an update. J Couns Psychol2005;
52: 196–205.
46.
MeyrickJ.What is good qualitative research? A first step towards a comprehensive approach to judging rigour/quality. J Health Psychol2006;
11: 799–808.
47.
DriskoJ.Writing up qualitative research. Fam Soc2005;
86: 589–593.
48.
WuYPThompsonDAroianKJ, et al.
Commentary: writing and evaluating qualitative research reports. J Pediatr Psychol2016;
41: 493–505.
49.
TongASainsburyPCraigJ.Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care2007;
19: 349–357.
50.
CohenDJCrabtreeBF.Evaluative criteria for qualitative research in health care: controversies and recommendations. Ann Fam Med2008;
6: 331–339.
51.
MarinoLACampbellANNunesEV, et al.
Factors influencing buprenorphine prescribing among physicians in New York state. J Addict2019;
2019: 7832752–7832755.
52.
MolfenterTSherbeckCZehnerM, et al.
Implementing buprenorphine in addiction treatment: payer and provider perspectives in Ohio. Subst Abuse Treat Prev Policy2015;
10: 13–10.
53.
Andraka-ChristouBCaponeMJ.A qualitative study comparing physician-reported barriers to treating addiction using buprenorphine and extended-release naltrexone in US office-based practices. Int J Drug Policy2018;
54: 9–17.
54.
KomaromyMDuhiggDMetcalfA, et al.
Project ECHO (extension for community healthcare outcomes): a new model for educating primary care providers about treatment of substance use disorders. Subst Abus2016;
37: 20–24.
55.
EganJECasadontePGartenmannT, et al.
The physician clinical support System-Buprenorphine (PCSS-B): a novel project to expand/improve buprenorphine treatment. J Gen Intern Med2010;
25: 936–941.
SalvadorJBhattSFowlerR, et al.
Engagement with project ECHO to increase medication-assisted treatment in rural primary care. Psychiatr Serv2019;
70: 1157–1160.
