Background
Opioid use disorder involves continued misuse of opioids despite recurrent problems occurring from use [
1]. Due to the sizable incidences of nonmedical prescription opioid initiation [
2] and the harm associated with opioid use including rising rates of overdose [
3], there is alleged to be a national opioid epidemic in the United States [
3‐
5]. Opioid misuse is also a noteworthy problem in the state of Alaska, which consistently ranks in the top ten states of the nation for illicit drug dependence [
6]. Moreover, fatal drug overdose rates, the majority of which include prescription drugs, increased by 55% between 1999 and 2010 in Alaska [
7]. Particularly, in Alaska, the unmet treatment needs of citizens with drug dependence have consistently registered above the national average [
6]. Moreover, disparities have been found in the services patients with co-occurring disorders receive, with those presenting for substance abuse, as opposed to mental health, treatment receiving less mental health care despite having the same diagnoses [
8]. The rapidly rising rates of opioid misuse and the harm associated with nonmedical prescription opioid use compound the foregoing unmet needs of people who would benefit from behavioral health services.
Medication-assisted treatment (MAT) for opioid use disorders, which use psychotropic drugs usually combined with psychosocial treatment, has been empirically indicated to reduce withdrawal symptoms, opioid abuse, and the harm associated with opioid use [
9‐
14]. For opioid use disorders, MAT has frequently been associated with the long-time “standard” replacement therapy: methadone [
9]. While methadone is an empirically validated medication that has illustrated efficacy in increasing the viability of recovery by improving treatment retention and reducing opioid use compared to non-pharmacological alternatives in people with opioid dependence [
14], it may not be the treatment of choice for some patients.
In 2002, the FDA approved buprenorphine as a new MAT for opioid use disorders under the Drug Addiction Treatment Act of 2000 [
15]. Buprenorphine (Subutex®) and the buprenorphine/naloxone combination (Suboxone®) are established as effective, safe, and well-tolerated pharmaceutical treatments [
10,
11] that increase patient engagement and retention while reducing symptoms associated with opioid use disorders [
11,
13]. Compared with methadone (which must be dispensed at designated opioid treatment programs), buprenorphine is prescribed by a qualified general physician in an office-based setting and may increase access to treatment [
13]. Although the effectiveness of buprenorphine is established, less is known about the treatment-seeking behavior of those who would benefit from buprenorphine treatment.
Project rationale
It is important to understand the attitudes and perceptions of those who would benefit from treatment (now referred to as consumers) as these factors influence the utilization of services. Studies assessing treatment-seeking tendencies for addictive disorders highlight barriers including stigma, misattunement to patient needs (i.e., lack of gender-specific services), and financial cost [
16,
17]. While few qualitative studies have explored what treatment consumers identify as being relevant to their treatment-seeking process, one such qualitative study explored motivations for seeking treatment among a broad array of substance users [
18]. Such motivations included dissatisfaction with oneself, influences of friends, family, and spiritual interventions. As one systematic literature review accentuated, the majority of the research on individuals’ reasons for entering substance misuse treatment has been quantitative, which regrettably deemphasizes the patient’s perspective [
19]. As such, the use of qualitative methodology is recommended for extending such understanding [
19]. The current study explores consumer perspectives of the MAT-seeking experience using qualitative methodology.
Understanding treatment seeking from the consumer perspective has implications for policy. For instance, restrictive federally imposed limits on the number of buprenorphine patients a provider can treat may serve as a barrier for receiving services [
15], particularly in communities with limited provider availability. With all of this in mind, there remains a need to understand the subjective treatment-seeking process of consumers with self-identified opioid use disorder who would benefit from MAT. Such an understanding can help policy leaders and interventionists make decisions that facilitate, rather than stymie, individual treatment seeking in addition to illustrating how existing policies and protocols affect the lives of consumers.
Method
This research was based on a larger mixed-methods study that explored how both treatment providers and potential treatment consumers understand MAT. The aim of the current project was to explore what factors influenced Alaskan MAT consumers (including those who sought or considered using MAT) treatment-seeking process.
Community involvement and ethical considerations
The study was conducted in Fairbanks, a city of about 32,000 people in the Interior region of Alaska [
20]. Although this population meets criteria for an urban area according to the United States Census Bureau [
21], the Fairbanks and Interior region has many qualities of rural life (e.g., higher rates of substance abuse, limited access to health care, travel barriers, and stigma associated with behavioral health services) [
22]. This project utilized community-based participatory research principles including shared ownership, community analysis of social problems, a strength-based and collaborative approach, a focus on action, and an iterative process [
23,
24]. As such, it operated under the guidance of Turning Point Counseling Services (a local private counseling and substance abuse center), the Alaska Advisory Board on Alcoholism and Drug Abuse, stakeholders in the community, and MAT professionals. It was approved by the University of Alaska Fairbanks Institutional Review Board (523384–9) and funded by the Alaska Mental Health Trust Authority.
Participants
The study sample included people 18 years or older living in Alaska who: (1) met criteria for an opioid use disorder at some point in their life, and (2) had been impacted by medication-assisted service delivery (e.g., received services, been denied of services, encountered barriers to obtaining services, or avoided seeking services). Exclusion criteria included individuals that were actively suicidal, experiencing psychosis, or who directly received services from the researchers who collected data.
Focus groups and semi-structured interviews explored participants’ perceptions relevant to MAT. There were a total of 11 participants; the majority were female (64%, n = 7). Nine participants had received MAT at some point in their lives, seven had been or were currently in a methadone treatment program, and two had been in a buprenorphine treatment program.
The first focus group was conducted with four patients who were currently engaged in MAT. Subsequently, three interviews were conducted with individuals who were opioid-free at the time of the interview. Finally, a second focus group, which included four individuals in recovery who were receiving support from a mutual self-help group, was conducted. All study participants had considered using buprenorphine treatment at some point in their recovery.
Procedure
Recruitment strategies included word-of-mouth, flyer, and networking techniques. Individuals who participated in the study were asked if they knew others who might be interested in participating. This snowball sampling procedure was utilized to build relationships, trust, and gain entry into the community. Individuals were screened for study criteria and, after obtaining written informed consent, all interviews and focus groups were audio-recorded. Upon completion of data collection, participants were screened for distress, debriefed, thanked, and compensated with $30 gift certificates.
Participants were queried about the following: (1) experiences seeking treatment including barriers to entering and remaining in treatment (e.g., “Some people report that they had a hard time receiving medication-assisted services for a number of reasons. When you were seeking treatment, did you experience any barriers?”) (2) treatment preferences (e.g., “what would the ideal program consist of?”), (3) success in MAT (e.g., “What successes have you experienced after engaging in medication-assisted treatment?”), and (4) beliefs about the cause of addiction (e.g., “What are the most important factors that contribute to your addiction?”). Participants were also asked about perceptions and attitudes related to MAT for themselves and for others (e.g., “What do you think about buprenorphine?”, and “What attitudes do you think community members have toward Medication-assisted treatment?”).
Following the grounded theory techniques of theoretical sampling [
25], data collection was informed by participant responses. After each interview or focus group was conducted, researchers discussed impressions, which informed subsequent prompts. After each phase of data collection, raw data in the form of interview and focus group audio recordings was transcribed and input into Nvivo
10 software.
Data analysis
Using grounded theory, data were coded using open, axial, and selective coding techniques [
25]. The researchers evaluated their biases and mitigated these by consulting with an expert in qualitative analysis that had limited knowledge of opioid use disorders.
The first two authors collectively coded each transcript into the major content domains, developed an initial codebook for each domain, and began to code the domains using the initial codebook. After agreeing on the dependability of the codebook, they independently coded the domains and routinely checked for agreement. Discrepancies were collaboratively discussed. These strategies served to enhance reliability and protect against coder drift.
Discussion
The current study is one of the few studies to examine the attitudes and perceptions of consumers who may benefit from the MAT, buprenorphine. It illustrates the individual and systemic factors that affect the treatment-seeking process and elucidates the importance of contextual factors, such as stigma, access to resources, and support. Ecological systems theory [
26] provides a useful framework for conceptualizing this study’s findings. It posits that each individual exists within a nest of systems that contextualizes and influences individuals’ behaviors [
26].
In our study, each person’s addiction, treatment-seeking process, and recovery can be framed within the nested systems. These systems include macrosystem (e.g., cultural norms, protestant values, abstinence-only orientation), exosystem (e.g., mass media as a source of stigma, public policy), mesosystem (e.g., insurance, communication between providers), microsystem (e.g., consequences of drug use on family, employment, social supports), and individual (e.g., motivation to change, willpower).
The important role ecological factors play in the development, maintenance, and treatment of substance abuse is well established [
27] and is also considered in the National Institute of Drug Abuse’s [NIDA] principles of effective treatment [
28], which includes consideration of treatment and biopsychosocial individual factors. Results from the present study expand upon NIDA’s principles for effective treatment by considering broader ecological influences including societal attitudes, cultural norms, access to resources, and policy that influences how treatment is delivered.
The role individual and systemic factors play in MAT seeking found in this study corroborates with the construct of recovery capital [
29‐
31]. The construct of recovery capital proposes that the accumulation of internal and external resources affect one’s ability to recover from addiction. It is suggested that professionals working with people in treatment for addiction can facilitate recovery on three levels of recovery capital: personal recovery capital, family/social recovery capital, and community recovery capital [
31]. This study’s findings demonstrate similar constructs are relevant to MAT seeking while revealing the interactional relationship of these resources.
For example, macrosystem, exosystem, and mesosystem (e.g., cultural assumptions, policy and funding) influences frequently served as barriers, whereas participants’ individual and microsystem resources (e.g., motivation to change, having support from family and treatment programs) more frequently served as facilitators to treatment and recovery. As such, policy makers might take these findings into consideration by creating policy and allocating funds that support microsystems from the bottom-up, rather than dictating the operation of treatment from the top-down. This may include providing funding for rural areas or in areas that are affected by opioid misuse, or allowing treatment programs to decide their own treatment operations (including the number of patients a provider can serve) as opposed to having to meet a federally imposed standard. Also, treatment practitioners may want to focus on individual strengths that can serve as personal resources for recovery.
Importantly, the source of power affecting MAT seeking could originate in any system and could change overtime. For instance, someone may originally seek MAT because of their children (microsystem level influence) yet remain in treatment because of their children and their own individual motivation (microsystem and individual level influences). Likewise, practitioners should keep in mind that the source and degree of motivation fluctuate, and refine interventions accordingly, flexibly drawing on shifting sources of recovery capital.
Participants in our study discussed willpower, believing in one’s ability to change, and motivation to change as individual factors important for seeking treatment and maintaining recovery. Similarly, self-efficacy [
32‐
34], defined as confidence in one’s ability to do something (e.g., be abstinent or not use), and perceived locus of control [
35], defined as the belief that change is within one’s power, play important roles in overcoming substance use disorders. Participants viewed buprenorphine as a tool for gaining such control – a stepping-stone to recovery. This is consistent with Miller and Rollnick’s [
36] work positing that three conditions are necessary for change: being ready, willing, and able. For some participants, MAT was a tool in their process of cultivating readiness (helped them prioritize and feel capable of quitting), willingness (helped them believe that change is important), and ability (helped them manage withdrawal symptoms, which built confidence and investment to change).
In this study, specific individual factors, including self-efficacy and motivation to change, facilitate MAT seeking. Thus, interventionists should target their efforts with self-efficacy and motivation to change in mind. Perhaps a practitioner could work to increase self-efficacy by taking a strength-based approach and cater treatment to the consumer’s motivation to change by using a motivational interviewing approach. Additionally, a community psychologist could emphasize these individual strengths when developing community interventions.
Participants in this study also emphasized the importance of contextual factors in treatment-seeking decisions, including support from family, others in treatment, treatment providers, and the broader community and context. Family history and social support are recognized as important external factors that affect addiction and treatment [
35]. In one study with people with opioid use disorders, a lower quality of social support related to higher perceived stress, which in turn was associated with greater opioid misuse [
37]. While the negative consequences of poor social support was mentioned by our participants, they primarily emphasized positive aspects of social interactions, including the way compassion and positive social support facilitated their treatment-seeking process.
Because some factors of the community and cultural context could serve as facilitators or barriers, it is important for interventionists to take this into account when working with people in MAT. For instance, therapists should consider the individual in their cultural context. Additionally, societal stigma should be addressed by considering the cultural context in which it is nested.
Health literacy and the treatment environment also influenced participants’ ability to get what they needed out of treatment. Many participants described being “uninformed” when seeking treatment. While health literacy can combat some barriers, societal stigma must also be addressed by challenging attitudes. Thus macrosystem interventions should inform those who would benefit from MAT about treatment options and educate people globally about MAT to challenge attitudes and fight societal stigma.
While MAT facilitated recovery for some participants, it was also described as a barrier to furthering recovery when consumers felt trapped in the system. This corresponds with findings from a previous qualitative study where participants described methadone as “liquid handcuffs” that prevented them from actualizing recovery [
38]. Thankfully, a supportive and collaborative therapist and treatment structure were described as significant facilitators to staying in treatment and maintaining recovery. Similarly, the therapeutic alliance, which is patient-therapist agreement on goals, task, and the bond [
39] has been shown to improve outcomes for those with opioid dependence [
40]. Thus, providers and treatment facilities should cultivate a supportive treatment environment and encourage consumer autonomy.
Finally, there are unique challenges that rural citizens face due to distinctive cultural and geographical context, including higher rates of substance abuse, limited access to health care, travel barriers, and stigma associated with behavioral health services [
22]. The participants of this study accentuated the geographical and availability barriers in Alaska. Even when participants are motivated to change, long waiting lists and limited treatment availability can close a valuable window of opportunity. In rural settings with limited providers and geographical challenges that make it difficult to obtain treatment elsewhere, federally imposed caps on patient limits [
15] for buprenorphine providers can be seen as an even bigger barrier to treatment. Policy makers may consider advocating for making exceptions to the provider limit on patients, particularly in rural areas.
These barriers to access have significant practical implications for society because, while substance abuse may commonly be assumed to be an individual disease, its social impacts on health and judicial systems exceed $510 billion annually [
2]. MAT is only accessible to a limited number of individuals who would benefit from treatment [
2], and contextual factors (including socioeconomic status and rural location) affect treatment access [
22].
Strengths, limitations, and future directions
A major limitation of this study is that it included a small sample. While we used snowball-sampling procedures to attempt to reach a broad range of those who would benefit from MAT, most participants were aware of some treatment services, and we were limited in our ability to reach individuals who do not access treatment services. Thus, this convenience sample may not be representative of those who are very limited in resources. The limited sample warrants caution for generalizing results. Additionally, our model is derived from a sample that has contextual factors that may not generalize directly to other communities. Therefore, specific influences that affect MAT treatment seeking may vary. Future research exploring MAT treatment seeking in underserved communities should attempt to obtain larger, diverse and representative samples of those who would benefit from MAT.
However, like another qualitative study [
41], the sample size was sufficient for illuminating consumers’ central themes and concerns related to the research questions of this study, and therefore reaching data saturation. Additionally, our study provides an in-depth perspective of MAT treatment seeking, using participants’ own words to illustrate their struggles and successes, and offering treatment providers and policy makers insight regarding participants’ lived experiences through their own eyes [
42]. It integrates a community-based approach in a real-world setting, which increases validity through drawing on community expertise, builds empowerment, and facilitates the utilization of findings [
43‐
45].
While research has explored attitudes towards methadone, this is one of the few studies to qualitatively examine the perceptions of those who would benefit from buprenorphine treatment. Although this treatment has demonstrated efficacy [
9‐
14], the full potential of services cannot be actualized unless the consumer is at the forefront of treatment. Moreover, these consumers’ perspectives may inform considerations for buprenorphine policy. Future research can extend on the current project by investigating the difference between methadone and buprenorphine in facilitating recovery, the meaning of success in buprenorphine treatment, and the role of systemic barriers, including funding and systemic support of buprenorphine MAT.
Acknowledgements
We would like to thank The Alaska Advisory Board for Alcohol and Drug Abuse, Gunnar Ebbesson, and Turning Point Counseling Center for their guidance in this project. We also thank Ellen Lopez for consultation on qualitative analysis. Most importantly, we would like to acknowledge and thank the participants of this study for boldly sharing their wisdom.