Abstract
Background:
An estimated 2.7 million people in the United States ages 12 years and older suffered from opioid use disorder (OUD) in 2020; during the same period, approximately 68,000 people died due to an opioid overdose. In recent years, with support from federal funding, medication for opioid use disorder (MOUD) has emerged as a viable treatment option. The partial-opioid-agonist buprenorphine/naloxone (brand name, Suboxone) is the most used MOUD and is commonly administered as a daily oral dose. Naltrexone is an opioid antagonist primarily administered as a slow-release monthly injection formulation (brand name, Vivitrol).
Objective:
This study aimed to explore clients’ perceptions and experiences of using oral Suboxone and injectable Vivitrol for OUD treatment.
Design:
This was a cross-sectional qualitative study.
Methods:
We conducted semi-structured interviews with 65 clients from 2 residential treatment facilities in Tennessee between August 2019 and October 2020. Data were analyzed in Dedoose qualitative software using thematic analysis.
Results:
Clients shared perspectives on facilities’ tapering protocols for Suboxone and generally considered the lack of tapering a favorable attribute for Vivitrol. Both prescriptions were praised for reducing opioid cravings. Pharmacological side effects sometimes hindered clients’ ability to continue MOUD treatment and were more common with Suboxone. Clients reported that MOUD gave them confidence and helped them focus on treatment, though concerns were raised about Suboxone’s capacity for diversion, the cost of continuing Vivitrol, and the possibility of backsliding when the MOUD prescription was complete. Participants’ views on MOUD ranged from enthusiastic to stigmatizing.
Conclusion:
Our study provides valuable insights drawn from clients’ experiences using oral and injectable MOUD in substance use treatment facilities. The findings will be useful for healthcare providers and policymakers to consider the pros and cons of these medications in substance use treatment settings.
Keywords
Introduction
Chronic misuse of prescription and illicit opioids often leads to opioid use disorder (OUD), a major public health issue affecting healthcare providers, policymakers, and communities, and people who use drugs (PWUD) across the United States (US). 1 In 2020, an estimated 2.7 million people ages 12 years and older suffered from OUD 2 and approximately 70% of the 100 000+ overdose deaths in the US between April 2020 and April 2021 were attributable to opioids. 3 Furthermore, poisoning linked to fentanyl, a synthetic opioid, is now the leading cause of death for Americans between the ages of 18 and 45. 4 For every overdose fatality in the study area (the state of Tennessee), there are 12 to 13 non-fatal overdose events. 5 Survivors are prone to many serious health risks, including overdosing again. 6 The combined economic burden of OUD and fatal opioid overdose in the US is estimated to be $1.02 trillion. 7
Despite the large number of people diagnosed with OUD, just 10% to 25% receive treatment, with substantial treatment disparities impacting racial and ethnic minority groups and rural and/or economically disadvantaged populations. 8 In recent years, with support from federal funding, medication for opioid use disorder (MOUD) has emerged as an effective treatment option for people with OUD, especially when accompanied by counseling and psychosocial support services. 9 MOUDs are broadly classified in accordance with each medication’s relationship with the mu opioid receptors, the proteins in the human nervous system responsible for the physiological effects of opioids, such as analgesia, euphoria, and dependence 10 ; classifications are described as agonist, partial agonist, and antagonist, according to the degree to which each medication binds and interact with the mu opioid receptors. 11 Two of the 3 medications currently approved by the Food and Drug Administration (FDA) for OUD treatment are buprenorphine, which is a partial opioid agonist in oral, injectable, patch, or implant forms, and naltrexone, an opioid antagonist in oral or injectable forms.12-14 Buprenorphine (available in tablets and buccal film) is the most widely used MOUD in the US. 2 As a partial opioid agonist, it does not fully substitute for other opioids, like heroin, in the mu receptor but does provide relief from opioid withdrawal symptoms while posing a lower risk of overdose. 15 Studies have found buprenorphine more effective than a placebo in OUD treatment, no less effective than methadone, and beneficial to reducing the risk of physical side effects, including poor health outcomes for expectant mothers and infants.16,17 However, buprenorphine is habit forming and is frequently diverted (misused); the addition of naloxone to buprenorphine (tradename: Suboxone) reduces withdrawal symptoms and the potential for diversion.15,18 Any physician with a current DEA registration for Schedule III authority can prescribe Suboxone. 19
Naltrexone is an opioid antagonist which blocks the mu receptors and is available in both oral and extended release injectable formulations (trade names: XR-NTX, or Vivitrol). 20 Initial studies of naltrexone formulated for oral use found poor adherence among patients. To reduce the burden of daily dosing and improve adherence and effectiveness, an extended-release, intramuscular injection form of naltrexone was developed and has become an increasingly popular treatment option. Studies have shown better treatment retention rates among patients receiving injectable, extended release naltrexone (henceforth Vivitrol) compared to those taking oral naltrexone.22-24 One study of people with OUD who had recently completed detoxification found that 32% of participants preferred Vivitrol over other MOUDs, in part due to the simplicity of receiving a monthly dose, with added benefit that it does not have the capacity to induce any sort of “high.” 25 Vivitrol appears to decrease opioid use, promote abstinence, reduce relapse, and increase quality of life among patients.26-28 However, because it is an opioid antagonist, patients must already have completed detoxification before receiving the first injection, which can inhibit uptake. 29 Vivitrol also has some safety concerns—including a small risk of hepatotoxicity and an increased risk of opioid overdose. 20 The high cost of this prescription may also inhibit its adoption by healthcare systems. 30
Two randomized controlled trials in the US and Europe found both oral buprenorphine and long-acting injectable naltrexone to be equally effective,31,32 though further study is needed to assess long-term treatment trajectories and questions remain about the risk of overdose following treatment remain.33,34 However, in light of evidence showing that client positive perceptions of treatment are critical for progress toward long-term abstinence 35 and that perceptions of MOUD are influenced by unique personal and social factors, scholars have increasingly called for in-depth, qualitative analyses that focus “on the beliefs and perspectives of people with OUD about the use of MOUD.”25,36-38 A review of current qualitative literature on the subject reveals several qualitative studies examining patient perspectives of just one substance39-42 and a few studies researching perspectives on the context of MOUD treatment (ie, patience-centered or integrated care, or in an emergency department setting).43-46 We found only 2 qualitative studies that gather the perspectives on more than one form of MOUD among people who are or have been in treatment. Victor et al 47 crowdsourced 52 participants who had previously used either methadone or an oral buprenorphine formulation and analyzed their experiences with MOUD, finding that while their experiences were largely positive, they also experienced challenges with maintaining treatment and abstinence. Sharp et al 37 interviewed 12 OUD clients participating in an inpatient detoxification program at a facility located in Tampa, Florida; the authors examined clients’ general perceptions of MOUD (ie, not limited to any specific medication) as they considered their post-detoxification treatment options. Study findings indicated that participants held more negative than positive views of MOUD, with several clients suggesting that it was merely a substitute for their drug of choice and may be detrimental to their long-term recovery. 37
The present study builds upon and extends upon existent studies in multiple ways. First, this study includes a large number of clients (N = 65) recruited from 2 different residential treatment facilities serving communities across Tennessee. Second, we compared clients’ experiences with daily oral buprenorphine/naloxone and monthly injectable naltrexone in inpatient treatment settings, providing a nuanced perspective on both benefits and drawbacks associated with each medication and the modalities by which they are delivered. Thus, the aim of this research is to discern the spectrum of experiences of people who are using these 2 formulations of MOUD.
Methods
The study was approved by the Institutional Review Board at the first author’s home institution (PRO-FY2019-660). All manuscript authors have extensive training in qualitative methodology. Drawing from this expertise, we chose a data collection and analysis approach grounded in the interpretive perspective—that is, focusing on how participants use language to describe and make sense of their lived experiences.
Data Collection
Participants in this study were purposefully recruited from 2 licensed treatment facilities offering MOUD in Tennessee. The third author conducted semi-structured interviews with clients who were currently receiving treatment at the facilities between August 2019 and October 2020. Clients provided written consent, acknowledging that they understood their participation was voluntary and that interview data would remain confidential; they were not compensated for participating. Interviews lasted between 45 and 90 minutes. Interviews were recorded and transcribed verbatim. The interview guide was originally created by the first 2 authors and was adapted by the third author following a pilot interview. The interview guide poses open-ended questions probing for participants’ views on opioid addiction, the opioid epidemic, barriers and facilitators to treatment, and perspectives on MOUD, including clients’ past and present experiences with different MOUD formulations. Specific questions from the script, which yielded the data included in this study, are shown in Table 1.
Sample Questions From the Client Interview Guide.
Data Analysis
Data analysis began while interviews were still being conducted, allowing the research team to iteratively refine codes and analytic categories as additional transcripts became available. Data collection continued until thematic saturation was reached, defined as the point at which no new themes or perspectives were emerging from subsequent interviews. Interview transcripts were uploaded into Dedoose, 48 a qualitative analysis software program. Two authors conducted a thematic analysis of the interview data using an inductive approach. The first and third authors conducted the initial round of coding; the second author reviewed the initial codes and data, editing the codes and recoding data where applicable. Codes were reviewed and refined by the 3 team members until a final set of thematic categories were identified. Coding disagreements were reconciled in meetings between the authors. Six themes emerged from the data, among which clients shared varying perspectives about their experiences with Suboxone or Vivitrol prescriptions; specifically, clients commented on the process used by the facility to administer or taper their prescription, shared perspectives on the importance of craving reductions, discussed a variety of side effects for both medications, described the impact of MOUD on their treatment engagement and recovery prospects, and shared concerns about diversion and long-term sustainability as well as some strong reflections about the MOUD treatment (see Table 2).
Themes and Sub-Themes of Client Perspectives on Suboxone and Vivitrol During Inpatient MOUD Treatment.
We took several steps to ensure the credibility of our study’s findings. 49 First, multiple authors coded the data independently before coming together to refine the thematic categories. Second, interviews continued until the point of saturation (ie, when no new themes were emerging from study data). Third, we engaged in “member checking” by soliciting participants’ feedback on the analytic framework. 50
Results
Of the 65 participating clients, most (75%) began treatment with oral Suboxone (also used to assist with detoxification), followed by a taper and eventually a monthly Vivitrol injection. The other clients (25%) arrived at the facility post-detox and were administered a slow-release Vivitrol injection monthly for the majority of their inpatient stay, unless medical conditions indicated that they should use another form of MOUD. See Table 3 for a summary of participant characteristics. Clients had strong opinions about the ways that their treatment was being administered, the positive and negative aspects of both forms of medication they were receiving, and MOUD as a treatment modality. While some clients spoke only about either Suboxone or Vivitrol, many who had experience with both prescriptions shared commentary about both forms of MOUD throughout the interview.
Participant Demographics.
Perceptions of MOUD Protocols
Participants with a Suboxone prescription were enrolled in a 90-day+ treatment program; as a result, they experienced detoxification over 1 to 2 months, as compared to just a few days in a hospital as is often the case. Several participants reported that the longer duration of treatment with slower tapering and close monitoring was helpful, as it allowed them additional time to participate in intensive group and individual counseling. Most clients who had previously used Suboxone from an outpatient clinic, or illicitly, felt much better about their chances of achieving lasting abstinence from the slow-taper inpatient treatment process, as one client explained: I’ve come off Suboxone two different times, and it’s the most horrible experience I’ve ever went through, but I’m not even feeling bad or nothing, coming down this time. The way they’re doing it, and the coaching you have with the groups and stuff. It’s just awesome.
Some participants who had been through multiple treatment programs and had previous experience with Suboxone or other partial opioid agonists expressed trepidation about the withdrawal symptoms related to tapering off of partial-opioid-agonist medications, even though the tapering process was intended to mitigate such pain, with one client recalling a previous MOUD attempt: For me coming off Subutex was almost just as hard as coming off heroin. It was hard. I thought I was losing my mind coming off of that, and they were titrating me daily too. That was hard. Similarly, those who were not yet tapering off their prescription were concerned that the eventual reduction in their prescription could increase their relapse risk: Like I said, I’ve been on Suboxone maintenance before. I had to check back into treatment. It led to a relapse ‘cause I was withdrawing out there. It just wasn’t regulated like it was supposed to be.
On the other hand, another complaint about Suboxone was that the taper was too slow, and the amount of “clean time” left after the taper and before program completion was too short. Clients were concerned that they lacked enough time after finishing their prescription and any withdrawal symptoms to feel prepared to leave treatment; for example, one client said: I’m still gonna feel bad and stuff a little bit. It’s not gonna be as bad, but I’m still gonna feel bad. I don’t know if 20 days in [is] gonna be enough before I’m sent right back down [completed the program]. Despite their concerns regarding the pace of tapering, clients agreed that having a longer inpatient treatment stay helps mitigate withdrawal symptoms sufficiently enough to reduce relapse risk and increase chances for a sustained recovery.
The fact that clients initiating a Vivitrol prescription had already completed detoxification seemed to be an important component of their approval of the treatment. Clients appreciated that they did not need to taper off Vivitrol and would not suffer withdrawal symptoms. These perceived pros of this slow-release opioid antagonist treatment seemed to lead clients to express greater enthusiasm for Vivitrol: I’m kinda on the fence about Suboxone and stuff, but I tell everybody about Vivitrol, I really do.
Those who had used Suboxone by prescription or illicitly noted that the withdrawals can be worse than those from other opioids, including heroin. Knowing that there will not be a difficult withdrawal period seemed to incentivize clients to try Vivitrol; as one client explained: With this, the Vivitrol, it doesn’t have that one part in it that makes you literally ache and go through [withdrawals]—I mean, it sucks. I’d rather go through any type of opiate withdrawals than coming off Suboxone. It was miserable.
Craving Reduction is Perceived as Critical for Treatment Engagement and Confidence
Clients on the tapered Suboxone program reported that their prescription reduced their cravings for their drug of choice (DOC). While most clients had attempted to quit on their own or been through treatment, they did not achieve long-term sobriety—due, in large part, to what they described as persistent cravings that made it difficult for them to focus on treatment. Slow tapering reduced cravings enough to allow participants to engage in group therapy and experience the benefits of counseling: . . .the MAT program, it helps. It helps you get your mind frame back. It helps with the cravings. The Suboxone helps with all that, but then you’re put into groups. You go in there and you talk, like I’m sitting here talking to you, so instead if I don’t tell people, you get that stuff off your chest and that’s part of the program.
Clients who had experience with both partial agonists, like Suboxone, before trying Vivitrol remarked that the slow-release opioid antagonist prescription more effectively reduced cravings and “using dreams” than Suboxone. One client stated: They gave me the Vivitrol. Within one day, all the cravings have stopped. Likewise, another client shared: Well for me the benefit of the Vivitrol shot, it helps me with those cravings because I know they’re psychological. I do have, I did anyway, have a physical dependency on drugs. The cravings for the drugs themselves - it stopped that. I don’t have using dreams. Subconsciously it stopped that too. That’s a huge benefit.
Participants found Vivitrol’s capacity to reduce or eliminate cravings critical to resisting “triggers” that would have prompted them to use in the past: I’m very grateful for it. I don’t have any cravings at all, or any using dreams. When I first got on it, I went with somebody and I hung out with somebody, and they had it. They had heroin there, and I got out of there immediately, but it made me more mad than it made me want to use.
Clients described using dreams as particularly destabilizing and were grateful for their cessation with Vivitrol. Even if they felt in control during the day, waking from a night of such dreams seemed to cause frustration or discouragement, as one client explained: My thoughts about the Vivitrol are, if it was a scale 1 to 10, I’d give it a 12. Mainly because it helps with the dreams. That’s the worst I think is ‘cause what does an addict do in recovery, he catches back up on his sleep, I would say. I’ve had a lot of dreams of using. It makes recovery hard. You wake up confused, and upset, and all these other things. Vivitrol helps with those things.
Pharmacological Side Effects as a Barrier to Treatment Retention
Although side effects associated with Suboxone are uncommon, some clients reported physical and mental effects severe enough in some instances to disrupt their treatment engagement. For instance, some clients reported adverse reactions when MOUD was combined with prescriptions for co-occurring disorders: Well, from the Suboxone and I was on an antidepressant, so between the two, they were causing me to see things that wasn’t there. I’d be sitting on my front porch and I’d be seeing shadows walking all around my yard.
A few clients experienced physical side effects such as joint pain and inflammation; for example, one client said:. . .you could squeeze where my joints are at, and can feel the heat coming off of ‘em, and finally he [the doctor] said, “Well, it must be the Suboxone.” Duh, you think?”
Side effects were rarely severe enough, however, to prevent clients from participating in treatment. Generally, even clients experiencing side effects remained committed to taking the medication because they were committed to the treatment program: . . .it don’t make me feel right. I’m kind of out of my head when I take it, I don’t really like it, but I’ve gotta take it to be in this program.
Participants reported fewer side effects with Vivitrol than Suboxone. A few clients, however, reported side effects severe enough to cease using it. For example, one client said: The Vivitrol I did last year, and I had four or five seizures. They didn’t tell me the side effects. It was like 75 to 80 percent of Black men between the ages of 30 and 35 have a seizure within the first month.
Another participant reported unpleasant psychological effects while on Vivitrol: Yeah. It just put me in a daze. I was depressed the first few days, and didn’t really feel like myself at all. Just found it hard to—I felt numb. The most commonly reported side effect was temporary soreness at the injection site.
Much like with Suboxone, even those who experienced physical side effects (eg, hypertension) believed that the prescription’s benefits, combined with counseling, outweighed the temporary pain. As one participant stated: So when I got it, for one, I hated the fact that it was so sore the next day [laughter], but I would recommend it to any opiate addict.
Effectively Building Confidence During Treatment
Several clients credited their experience with Suboxone for regaining “normal” behaviors that had been lost in the throes of substance use and misuse. One client noted, for example: Well, I’m not escaping reality, I don’t feel anything but normal. I’m in my right state of mind. My common sense is comin’ back. My rationalization’s back. I’m startin’ to take care of myself.
Adhering to MOUD treatment enabled participants to focus on treatment, build coping skills, and find gainful employment. After years of dysfunction, when many clients were jobless, homeless, in constant conflict with loved ones, and in and out of the justice system, having plans for their future was a relief. For instance, one client shared the following: I don’t feel high off of Suboxone. I feel motivated. I don’t feel down in the dumps. It takes away my depression. It takes away my gloominess, my wanting to lay around the house. I’m about to go walking, jog to Kroger [grocery store] right now. I’ve got $25 in my pocket. You know what I’m wanting to spend it on? Video games.
While a few clients expressed concern over the prospects of maintaining a long-term MOUD prescription, most seemed to accept the possibility that they may need a MOUD prescription program for years to come. One such client explained why: I want to stay on the maintenance program and the reason for that is I’ve been doing heroin for 14 years.
Similarly, Vivitrol injections were reported to increase psychological confidence in treatment among many clients who frequently cited fear of failure as a psychological barrier to treatment. Those who had tried multiple treatment programs appeared skeptical about their chances of achieving long term recovery. These same clients, however, reported that the effects of Vivitrol helped ameliorate their skepticism. Clients remarked that Vivitrol was like an “insurance policy”; a client elaborated on this idea: I feel like the Vivitrol is my insurance policy. It helps to cut down the cravings and stuff like that. Then I know in the back of my head that these are the things that are just not an option right now. It helps, and it doesn’t affect my behavior, and I’m not addicted to it either.
Additionally, participants understood that Vivitrol would counteract an opioid high. This knowledge enhanced participants’ confidence in the treatment they were receiving and in themselves. As one client put it: It’s not only that it gave my brain this retraining of drugs, it’s helped me give me confidence, too. It’s helped me give me confidence with my sobriety or because when you’re sober, you regain confidence in yourself. There are so many advantages I feel with vivitrol.
Concerns About Diversion and Sustainability
One of the most commonly expressed concerns about Suboxone is the degree to which it is diverted and abused within treatment facilities and the wider community. Clients attributed Suboxone’s near ubiquity as a street drug to the proliferation of outpatient MOUD clinics in the region. One client explained: Every one of us have taken Suboxone as a street drug, if you would say that. . . .some of the girls think of the Suboxone as, “I can’t wait to get my medicine today, so I’ll feel good.
Some participants reported previously trading or selling their outpatient prescriptions for their DOC or other substances. Other clients reported purchasing Suboxone illicitly and either using it until they could find their DOC or taking enough to make themselves high. Because interviews were confidential, clients felt free to talk about diversion and protocol abuse within the facility: There’s a lotta cheating that goes on too. . . I would suggest that you keep a closer eye on me. . . . I came from the street to here. I’m an addict. . . .I’m gonna find every way I can to beat the system, hustle, manipulate and con.
Because Suboxone and other agonist and partial-agonist MOUD substances are such common street drugs, clients sometimes questioned whether it was possible to effectively use them in a controlled manner. Some felt that taking a substance they once abused could trigger a relapse.
While diversion is not a concern for Vivitrol prescription-holders, several clients identified Vivitrol’s high cost as a potential barrier to its use. Most clients were uninsured and noted that grant funding was the only reason they were able to access Vivitrol; one client, for example, stated: . . . I could never afford that [Vivitrol] myself and it being offered in a grant, I think, is huge ‘cause you gotta understand even with 12 steps and all that, if I can get Vivitrol for 6 to 12 months, that gives me a really fighting chance.
The high cost of the prescription also makes it difficult or impossible for most people to continue with it long term, which worried some clients: I’m just worried about after six months if I don’t have. . . I think there’s things around. . . They do sliding scales based on your income and stuff like that in [hometown]. Those who credited Vivitrol for saving their lives remained hopeful the drug’s cost would decrease over time, making Vivitrol more accessible to people struggling with OUD.
Many clients, for both ideological and financial reasons, expressed a strong desire to discontinue using MOUD, which led to worry about the prospects of relapse when their Vivitrol prescription ran out. Some believed their confidence about the possibility of long-term recovery was tied to Vivitrol’s effects. Participants referenced other clients’ relapse experiences to validate their concerns; in one case, a client attributed their own relapse to missing a single dose: I missed my shot by a couple of days and went out and got high. That’s when I relapsed. Yeah, ꞌcause I couldn’t make it to my appointment. I was like, “Wow, I even feel opiates right now.” Somebody gave me some meth for giving him a ride. Then I was like, “Well I wanna do my DOC if I’m gonna get messed up on this meth.” I went and got some heroin. I was supposed to have my shot two days before that.
While most participants were impressed with Vivitrol’s benefits, some wished that they had recovered without MOUD, believing they would have felt more self-assured without Vivitrol.
Strong Feelings About MOUD
Several clients credited their own survival and that of their peers to Suboxone-aided detoxification or a MOUD maintenance regimen: I mean no telling how many people could’ve died over opiates if it wasn’t for Suboxone. I mean that’s the way I look at it. It had saved a lot of people including myself. Whether they plan on staying on Suboxone, or tapering off while in treatment, these clients maintain a harm reduction perspective about Suboxone as a means to stay alive.
However, many clients with Suboxone prescriptions expressed strong, negative feelings against the concept of MOUD, and especially Suboxone. For instance, one client stated: ‘Cause I know Suboxone and all those, I look at it as no different than switching painkillers to another addiction. People are addicted to Suboxone too. The belief that using Suboxone or other agonists or partial agonists is simply “trading one addiction for another” was fairly common. While some seemed to accept that a short-term rapid taper could be needed, they maintained skepticism toward the concept that long-term use of MOUD actually constituted recovery.
I believe if you’re gonna be sober, you need to be abstinent from all mood or mind-altering substances. That’s sobriety. Maintenance is a crutch ‘cause do you really wanna be on Suboxone or methadone for the rest of your life? What happens when you don’t wanna be on it anymore?
More clients expressed sentiment that the Vivitrol shot had saved their lives than those expressing similar feelings about Suboxone. One client shared: I feel like you can help a lot of people in the long run, where other things can’t. I don’t really know about a lot of other stuff, but I do know that Vivitrol shot has saved my life. Another interviewee’s experience echoed the previous: Everybody I come in contact with, I try to bring them the message of Vivitrol. I know it doesn’t work for everybody but it’s saving my life right now. These clients’ express an extreme enthusiasm for MOUD via Vivitrol. Perhaps one of the most vivid testimonials in favor of Vivitrol came from a young female client, who shared the following: When I get my shot, it’s like whoever gives me my shot takes everything I’ve lost, everything that’s been taken away from me, everything that I freely gave away in my addiction, and puts it on a platter and hands it all back to me with the opportunity to fix it all. . . I absolutely owe my life to the Vivitrol shot. My entire life. I will advocate for that shot until I take my last breath. Absolutely.
Nevertheless, there were a few MOUD detractors who maintained a resistant perspective of all prescription treatment for OUD. As one participant who had been on both Suboxone and Vivitrol explained: ‘Cause if I’m a be clean, I wanna do it without a crutch. I don’t understand the concept of taking drugs to get off drugs; that just don’t make no damn sense to me. These strong feelings against MOUD are particularly poignant considering all interviewees were actively engaged in MOUD treatment at the time of the interview.
Discussion
Clients expressed strong, often polarized, feelings about their MOUD treatment. The treatment facilities’ management of detoxification and the withdrawal process were common subjects among clients, with many concerns raised about tapering from partial-agonist medication too quickly or too slowly. They praised both the oral partial-agonist and the slow-release injectable antagonist formulations for reducing or eliminating their cravings—noting the medication helped them focus on treatment instead of fixating on their DOC. Clients were, however, critical of side effects presented by both forms of MOUD, though partial-agonist treatment appeared to generate considerably more negative accounts pertaining to physical and mental side effects. In fact, clients seemed more confident about their treatment experience when discussing the benefits of the slow-release injectable formulation of MOUD, expressing that they felt better now than in any prior treatment attempt. Many clients maintain skepticism about Suboxone due to its potential for diversion. Although clients generally stated they would recommend Vivitrol to anyone suffering from OUD, they did express concerns about not being able to afford the prescription when their grant funded treatment period ends. Overall, clients remarking on the daily, oral formulation of Suboxone had fewer positive and more negative comments about their MOUD experience, largely attributing their dissatisfaction to withdrawal symptoms while tapering off it. Vivitrol, in contrast, had few reported side effects and no reported withdrawal symptoms, attributes that appeared to lead clients to favor Vivitrol over Suboxone. Regardless of the specific MOUD they were given, clients also credited psychosocial therapy for their satisfaction with the treatment program and their greater confidence in resisting “triggers,” emphasizing the importance of an integrated approach to treatment.
Our study is one of very few to explore OUD clients’ experiences with MOUD from an in-depth, qualitative perspective. Similar to findings of Victor et al, 47 participants in the current study report general satisfaction with their MOUD treatment experience, especially noting that integrated psychosocial support in conjunction with the prescription is important for effective implementation. This finding is in agreement with current guidance about evidence-based MOUD treatment implementation. 12 Our results differ from those of Victor et al 47 in that clients did not report widespread experiences of stigma, perhaps because they were in a supportive, inpatient facility. While there was some overlap between our findings and those reported by Sharp et al 37 —most notably, concerns regarding MOUD, and especially Suboxone’s, reputation as “just another drug” and its viability to support long-term recovery—the clients in the present study were generally concerned with more practical issues, such as the pacing of their taper, medication side-effects, and long-term costs. These divergent perspectives may be largely attributable to the differences in our study populations; that is, while Sharp et al’s 37 small sample included clients who were undergoing detoxification and considering their future treatment options, the majority of participants in our (much) larger sample had already completed detox and moved into residential treatment.
Consistent with a study by Marchand et al, 51 which found that clients who were pleased with oral methadone or injectable diacetylmorphine treatment were more likely to remain in treatment for an entire year, our findings indicate that client satisfaction with MOUD motivated positive responses regarding their current treatment progress; it also provided an incentive for clients to remain in treatment, which many clients contrasted with prior unsuccessful treatment experiences. Also consistent with Marchand et al’s findings, 51 we found clients were more satisfied with a slow-release injectable antagonist MOUD than with a daily oral partial agonist option. Our finding that clients credited MOUD for confidence in their ability to resist relapse “triggers” supports an earlier study by Zhang et al, 52 which showed that client satisfaction indicates greater odds of maintaining long-term sobriety among clients, as well as the more recent literature review of patient satisfaction with MOUD via telemedicine by Cole et al. 35 Further, we posit that an increasing population of clients having positive experiences with MOUD will contribute to the likelihood of other PWUD being willing to engage in MOUD treatment, thus increasing access to treatment via increased social acceptability.
Several quantitative studies have investigated the efficacy of various forms of MOUD, including Vivitrol and Suboxone, but none suggest that one form of MOUD treatment is significantly more effective for clients’ long-term recovery.31,32,53,54 One potential factor that may impact clients’ preference, according to our results, is withdrawal. The presence versus the absence of withdrawal symptoms appeared to influence clients’ perceptions of and satisfaction with MOUD. Avoiding severe precipitated withdrawal symptoms when initiating both partial agonist and antagonist MOUD prescriptions is of increasing concern in regard to the prevalence of powerful synthetic opioids, such as fentanyl, which are frequently mixed with other substances, including methamphetamines and cocaine. 55 Previous studies have found that weathering the process of detoxification was a barrier to opioid antagonist MOUD, 32 which was not a common topic among participants of this study. However, interviewees were very concerned about lingering withdrawal symptoms associated with tapering down their partial-agonist MOUD dosage. This finding could be seen as reflective of the growing evidence that fentanyl use demands stronger formulations of partial agonist MOUD to effectively reduce withdrawal symptoms and cravings.55-58
While access to MOUD is increasing, there are still broad gaps in both access and utilization of this evidence-based treatment option due to both systematic barriers such as insurance, funding, and physical availability, and the lack of reliable and positive information about MOUD. 59 Prescriptions for Suboxone are more affordable and accessible through outpatient clinics, though psychosocial support may not always be present in those settings 57 ; Vivitrol is costly and less available in the region outside of specific, grant-funded treatment programs. The Substance Abuse and Mental Health Services Administration (SAMHSA) government website lists 843 Buprenorphine providers in the state of Tennessee. 60 Vivitrol prescribers are not listed with SAMHSA, but the manufacturer website lists 130 providers in the state. 61 Grants supporting treatment enrollment were crucial to clients’ MOUD access, particularly Vivitrol, and clients overwhelmingly praised this financial assistance for saving their lives.
Limitations
Despite offering several noteworthy contributions to the MOUD literature, our study does have important limitations. While our adherence to qualitative rigor supports transferability to similar contexts and client populations, our results are not generalizable. The interviewees were sampled from high-intensity drug-trafficking areas of Tennessee, many of which are deeply rural, and some cultural characteristics may influence their perspectives in ways that would not be relevant in other geographic settings. We did not include clients engaged in other forms of MOUD, such as methadone, nor did we compare the experiences of MOUD clients with those in psychosocial treatment only. Sampling people with OUD who are not in treatment, or those in outpatient treatment, may also yield results distinct from the ones reported here. Additionally, as interviews were conducted with clients only while they were in treatment, we acknowledge that their perspectives may change when they have completed treatment and re-entered the community. Finally, while we are confident that our sample size was sufficient to reach thematic saturation on the perspectives reported here, we did not conduct a formal power analysis to support our sample size, which should be noted as a limitation of this study.
Future Research
Our findings provide important insights for policymakers to consider when crafting pathways for treatment intervention, and we have identified some areas ripe for further research as well. Participants’ appreciation of grant-funded programs which provided them access to long-term treatment, including MOUD, indicates that additional investigations into the role grants play in increasing treatment access and retention is critical to understanding the potential of such aid for combatting the opioid epidemic, especially among groups with lower socio-economic status. Further statistical testing of the relationship between withdrawal symptoms, synthetic opioids, and MOUD is also warranted.
Conclusion
To our knowledge, ours is the first qualitative study to analyze the perspectives of clients actively engaged in 2 forms of MOUD and investigate the distinctions in their experiences. Insights from the frontlines of the opioid epidemic are essential to inform policy decisions and interventions. Use of qualitative methods in this venue yields valuable information into how the use of partial-agonist and antagonist formulations of MOUD are being received by clients and may help healthcare providers, hospitals, and policy makers in their efforts to improve access and effective use of these medications in substance use treatment settings.
Footnotes
Acknowledgements
The authors acknowledge the clients who shared their perspectives on MOUD for this study as well as the leadership and staff at the treatment facilities for their cooperation with this research effort.
Ethical Considerations
The study was approved by the Institutional Review Board at the first author’s home institution (PRO-FY2019-660). All procedures performed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Author Contributions
Conceptualization: SK, PD. Methodology: SK, MS, CE, NA, AM, PD. Investigation (data collection): CE. Formal Analysis: SK, MS, CE, NA, AM, PD. Writing—Original Draft Preparation: PD. Writing—Review & Editing: SK, MS, CE, NA, AM, PD. Supervision: SK, PD. Funding Acquisition: SK.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported through funding provided by the Center for Drug Policy and Enforcement, Office of National Drug Control Policy, and University of Baltimore.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The data analyzed as part of the current study are available from the corresponding author on reasonable request.