Introduction
Methods
Study Setting and Participants
Data Collection
Characteristic | n (%) or mean (SD) |
---|---|
Age in years, mean (SD; range) | 47.8 (12.4; 28–66) |
Female, n (%) | 5 (38.5) |
Race, n (%) | |
Hispanic White | 6 (46.2) |
Black or African American | 3 (23.0) |
Non-Hispanic White | 2 (15.4) |
More than one race | 2 (15.4) |
Psychiatric diagnosis1, n (%) | |
ADHD | 1 (7.7) |
Bipolar disorder | 5 (38.5) |
Major depressive disorder | 11 (84.6) |
Other anxiety disorder | 7 (53.8) |
PTSD | 3 (23.1) |
Schizophrenia | 3 (23.1) |
Told by doctor that they have OUD, n (%) | 7 (53.8) |
Prescription opioid misuse over the past 12 months, n (%) | |
Never | 6 (46.2) |
1 time per month or less | 1 (7.7) |
2–4 times a month | 2 (15.4) |
2–3 times a week | 1 (7.7) |
4 or more times a week | 3 (23.1) |
Heroin use over the past 12 months, n (%) | |
Never | 7 (53.8) |
1 time per month or less | 2 (15.4) |
2–4 times a month | 0 (0.0) |
2–3 times a week | 0 (0.0) |
4 or more times a week | 4 (30.8) |
Intention to quit opioid medication or heroin, n (%) | |
Quit | 7 (53.8) |
Trying to quit | 1 (7.7) |
Considering trying to quit | 4 (30.8) |
Not trying to quit | 1 (7.7) |
Other substance use over the past 12 months1, n (%) | |
Marijuana | 9 (69.2) |
Methamphetamine | 7 (53.8) |
Amphetamine-type stimulants | 5 (38.5) |
Powder cocaine or crack | 4 (30.8) |
Sedatives or sleeping pills | 4 (30.8) |
Preferred method of MOUD administration1, n (%) | |
Injection | 6 (46.2) |
Oral | 5 (38.5) |
Sublingual | 4 (30.8) |
Qualitative Analysis
Results
Health belief model construct | Major and minor themes identified in data | Sample quotes |
---|---|---|
Severity/susceptibility | Readiness to quit is critical for consideration of MOUDs | “[For someone to be receptive of MOUDs] it has to be somebody that’s really determined to get sober” [Participant 13] |
“One reason [that addicts would not want to take an MOUD] is they just don’t want to stop. They like having a high feeling and taking that next score” [Participant 4] | ||
Benefits | MOUDs are used to substitute for opioids or stave off withdrawals, not for OUD treatment | “I started using Suboxone, I was getting off the streets. All the [MOUDs] you mentioned, they sell them on the streets as dope, because you get high off them. I had the desire to stop the dope, and I started buying the Suboxone, doing it and everything but the problem is, I started getting abuse” [Participant 13] |
“[Using methadone is] not to avoid [opioids], they just do it for the high” [Participant 7] | ||
“[Addicts around me] would take [methadone] and still go use [opioids] a little bit. It’s like they were matching their personal use to get through the day” [Participant 2] | ||
MOUDs can assist with withdrawals | “The flip side of that would be these medications are helping opiate users not feel the withdrawal. Therefore, withdrawing becomes not a battle… Once you go through [withdrawals], you don’t want to go through that again” [Participant 3] | |
Decreased pill burden of MOUDs is desirable | “[The doctor] said, “I have something that is long-acting. That you won’t have to take so many pills. That you will be not 100% pain-free but you will be in a comfortable place as to where you can function for 12 hours”. That sounds good to me. I don’t have to take all of these pills. At some point in time, they stop working so you just needed more” [Participant 1] | |
MOUDs are not effective for achieving sobriety | “After I discovered Suboxone, I was like, “Oh, no. This is such a crutch. No one’s going to get sober like that”. They’ll take it one day and be sober maybe for that day, but they don’t feel the withdrawal, so they go on to using the very next day” [Participant 3] | |
“I was buying [methadone] off the street to help me, and it wasn’t doing anything. That’s why I was like, “Oh, that’s not going to help me [quit] either” [Participant 9] | ||
Costs (as harms or burden) | Negative perceptions about methadone and methadone clinics are prevalent | “Methadone is bad for people, I think it’s worse than heroin. Because I feel like people get worse with that…You know, from your bones, you lose your teeth, you lose everything. You know what I mean?” [Participant 12] |
“I feel like sometimes the staff [at the methadone clinic] is not knowledgeable on the way that [an addict] might feel. I would just [see the staff] toy with their addiction, and that really makes you not want to go back there or even try alternative or a plan to stop. It would actually make you want to just use more” [Participant 6] | ||
Concerns about interactions between psychiatric medications and MOUDs | “Well, it’s better if they tell me if it’s okay to take with the mental medication that I’m taking right now, the milligrams…That’s the main important thing. Don’t take my mental medication away for this medication. No, that’s not going to work” [Participant 7] | |
Potential MOUD side effects | “I got a bad liver and I don’t want to take something that’s going to harm me even more if I’m going through treatment” [Participant 9] | |
Need for ongoing use of MOUDs is undesirable | “When I was coming up, Methadone was only issued for two or three weeks just to wean you. Now, these people get it all the time. I totally don’t like that” [Participant 11] | |
Locus of control | MOUD use feels like “cheating” | “Well, I think that [taking MOUDs] would show a sign of weakness. Because I was being controlled by [opioids] and [now] I need something else to control [me]” [Participant 10] |
“I don’t see [the point of MOUDs]. You get more in the dirt. You get deep in a hole. That’s how I believe. The best thing that you can do, as a human being, is quit for yourself” [Participant 12] | ||
“There’s also a real element of my own pride that I’ve successfully gotten sober cold-turkey and not been on anything in the past and been able to do that for 2 years. I look at that and say, “Well, I did it then. I should be able to do it now. I shouldn’t need this crutch” [Participant 5] | ||
“Sometimes, some of [the 12-step sponsors] will say something to their sponsee [taking an MOUD]… Well, you’re still taking dope” [Participant 11] | ||
Helpful when willpower is difficult | “…would be great for [people] who don’t have the will, power, and mental acuity [to quit on their own]” [Participant 13] | |
“Basically, what it came down to is I knew I didn’t have enough self-control at the time with opioids. At the time I knew Suboxone makes it better. I didn’t have to rely on only willpower and self-control, which is not something I'm particularly good at, at the time” [Participant 4] | ||
Cues to action | Desire for OUD treatment in the mental health setting | “I think it’d be good [to get OUD treatment in the mental health clinic] because I’m getting helped in both ways, with my mental health and the use of opiates. It’s like killing two birds with one stone” [Participant 8] |
“I don’t know how much [mental health clinics] deal with the actual giving out [of] medications. I think that’d be awesome [if they did] because opioid use addiction and mental health go hand-in-hand” [Participant 10] |
HBM Constructs and Corresponding Major Themes
[HBM Construct: Severity/Susceptibility]: Theme: Readiness to Quit is Critical for Consideration of MOUDs
[HBM Construct: Benefits]: Theme: MOUDs are Used to Substitute for Opioids or Stave Off Withdrawal Symptoms, not for OUD Treatment
This sentiment was prevalent among those who were familiar with MOUDs. One participant summed up their knowledge about MOUDs by calling them “a cheap way of getting high” and spoke about methadone as a way to “still go use [opioids] a little bit” [Participant 2]. Some observed that methadone clinics were a good place to obtain methadone for getting high when they did not have enough money to buy opioids. As one stated:Suboxone, I used it here and there when I couldn’t find any [opioids]. That’s always the first thing that people have a lot to give away. I never saw it as a way to stop…it would just hold you over till you can find something [Participant 3].
Perhaps due to these perceptions and experiences, some participants voiced disbelief regarding the effectiveness of MOUDs for promoting sobriety. A few spoke about needing to feel withdrawal symptoms in order to gain motivation to reduce opioid use. As one stated: “I was like, ‘Oh no, this is such a crutch. No one’s going to get sober like that.’ They’ll take it one day and be sober maybe for that day, but they don’t feel the withdrawal, so they go onto using the very next day” [Participant 3]. Another participant echoed these thoughts by saying: “The pain of the withdrawals is what keeps you from wanting to do it again. If you take the experience of the pain out of it, you don’t learn the lessons” [Participant 13]. However, some voiced support for MOUDs, indicating that it was comforting to know that “I wasn’t going to go through withdrawals or the pain of withdrawal sickness” if MOUDs were taken [Participant 4] and that “If I’ve got something that can take away the sickness [of withdrawals] then I’m all for it” [Participant 5].To tell you the truth, when I didn’t have money [the methadone clinic is] where I would go to get my fix on. I would get the methadone and that would keep me cool until I do get money to go get heroin. So it really wasn’t that I was trying to get off [heroin], it was just that I needed [methadone] to keep my day going [Participant 8].
[HBM Construct: Costs as Harm or Burden]: Theme: Negative Perceptions About Methadone and Methadone Clinics are Prevalent
One participant with a history of methadone use summarized it this way:I feel like sometimes the [methadone clinic] staff is not knowledgeable on the way that [an addict] might feel. The patient or person seeking help might snap in terms of getting mad or very irritated or seeming like in a rush. I would see sometimes that the staff would make them even wait longer. I would just say – just toy with their addiction, and that really makes you not want to go back there [Participant 6].
These views about methadone made about half of the participants (n = 6) wary about other MOUDs, but 3 others disclosed that they had success with non-methadone MOUDs. Two participants were unaware of the existence of other MOUDs.I personally used methadone and I do not recommend it at all. It’s 10 times more addicting than heroin. The withdrawal is worse than heroin as well. For some reason, clinics only like to give you dosage in the early, early morning, one location. If you miss that dose, you’re almost doomed to have to go use because of that withdrawal, because of that craving. It’s like the lesser of the evil would be heroin in my eyes. I don’t recommend methadone. Would never use that again [Participant 3]
[HBM Construct: Locus of Control]: Theme: MOUD Use Feels Like “Cheating”
Participants commonly expressed similar views about 12-step programs, with one participant noting that they worried about disclosing their Suboxone use to other members of their Narcotics Anonymous program because: “I felt like I would be considered I was not free of opiates. I would say that I wasn’t taking [Suboxone], but in reality, I was” [Participant 6]. Another participant observed: “Twelve-step programs, their definition of sober is not being on anything at all. Like anything. Ibuprofen and stuff like that” [Participant 4].There’s this weird resistance to it. I’m not laying blame or pointing fingers, I just think I spent a lot of years in AA [Alcoholics Anonymous] and have absorbed some of the thinking that’s in the air around drugs like Suboxone [buprenorphine and naloxone] I’m not saying - …AA as an organization doesn’t have anything to say about [MOUDs] other than basically, “If these are things that you need to guarantee that you stay alive and to protect your health then that’s fine”. But there’s this undercurrent, I feel like, in the rooms of like, “Well it’s sort of like cheating, or you’re not really sober if you’re on Suboxone” [Participant 5].
[HBM Construct: Cues to Action]: Theme: Desire for OUD Treatment in the Mental Health Setting
Others also noted that mental health and OUD “go hand in hand” [Participants 10, 13] and spoke about the importance of treating both at the same time.That would be a one-stop-shop. If it was available [at their mental health clinic] that would be perfect. I do believe that…opioids go along with mental health because everything is centered in the mind. If I can treat my mind and my body in one place, then that would be nice. That would be nice. It would cut out travel time, money, gas [Participant 1].