Barriers to opioid agonist therapy among persons with high-risk opioid use

AMERSA 2015Washington, DC

Judith I. Tsui, MD, MPHActing Assistant Professor

Division of General Internal MedicineUniversity of Washington

Seattle, WA

Co-Authors

• Caleb Banta-Green (PI)• Anthony Floyd• Joseph Merrill

Conflicts of Interest

• The authors do not have financial conflicts of interest to declare

Background

• Opioid use disorders (prescription opioids and heroin) have emerged as a major public health concern in the past decade.1,2

• Opioid agonist therapy (OAT) with methadone and/or buprenorphine have been shown to decrease illicit opiate use.3

• Yet treatments for substance use disorders in general, and OAT specifically, are underutilized.4,5

1 Warner M, Chen LH, Makuc DM, et al. National Center for Health Statistics. 2011.2 Paulozzi L, Jones C, Mack K, et al. MMWR Morb Mortal Wkly Rep. 20113 Mattick RP, Kimber J, Breen C, Davoli M. Cochrane Database Syst Rev. 20084 Volkow ND, Frieden TR, Hyde PS et a. NEJM 20145 National Survey of Drug Use and Health 2013

Background

• Barriers to OAT occur at many levels (systems, providers, patients).

• Much current research has focused on provider and system level barriers to OAT.1-4

• Given efforts to expand OAT, it is important to recognize patient level barriers, and how individual attitudes toward OAT contribute to lack of engagement treatment.

1 Walley AY, Alperen JK, Cheng DM, et al. JGIM 2008.2 Becker WC, Fiellin DA, Merrill JO, et al. Drug Alcohol Depend. 20083 Ducharme LJ, Abraham AJ. Subst Abuse Treat Prev Policy 20084 Knudsen HK, Ducharme LJ, Roman PM. Drug Alcohol Depend. 2007

Study Aim and Design

• Objective: To understand access and barriers to OAT in a sample of persons high-risk opioid use (heroin and/or prescription opioids).

• Secondary analysis of data from an RCT. • Descriptive and qualitative analyses of baseline

questionnaire data.

Parent Study: Project OOPEN

• “Opioid Overdose Prevention, Education and Intervention” (R01DA030351); PI: Banta-Green

• RCT of an intervention to prevent overdose among high risk patients using opioids

• Intervention includes risk assessment, feedback, education, and take-home intranasal naloxone.

• Recruitment occurred 2013-2015 from Emergency Department and post hospitalization respite setting of Harborview Medical Center, Seattle WA.

Eligibility Criteria• Current heroin or prescription opioid users with one of

the following:– Opioid overdose is reason for hospital encounter

– Concurrent use of other opioids, alcohol, benzodiazepines or stimulants

– Average daily dose of prescribed opioids >10 mg MEQ

• Age 18-70, living in WA state, speaks English• No active SI, psychiatric or cognitive impairment• No current naloxone

Research Questions

• What proportion sought treatment with OAT in the past 3 months but were unsuccessful?

• What proportion did not seek treatment with OAT?

• Of those who sought OAT but were unsuccessful, what were the barriers?

• Of those who did not seek OAT, what were the barriers?

Questions

• “Have you been in opioid drug treatment that include buprenorphine or methadone?” – Never– More than a year since treatment– In treatment in the past year, but not currently– Currently in treatment

Questions

• “Have you tried to get opioid drug treatment that include buprenorphine or methadone in the past 3 months?” – Yes, I got into treatment– Yes, but I didn’t get into treatment– No

Questions• (Tried but did not get treatment) “Why didn’t you

go into treatment?”– Changed my mind Patient (readiness)– Don’t know how to find treatment Patient (education)– Worried someone would find out Patient (stigma)– Was on waitlist, but did not get in System (access)– Could not find a buprenorphine provider Provider– Could not afford treatment System (coverage/cost)– No insurance System (coverage/cost)– Transportation problems System (access)

Questions• (Did not try get into treatment) “Why didn’t you

try to go into treatment?”– I don’t need treatment– I don’t like buprenorphine– I don’t like methadone– I don’t like the rules/requirements of buprenorphine– I don’t like the rules/requirements of methadone– Treatment didn’t work previously

Baseline Demographic Characteristics of Sample (n=256)

Characteristic Overall (%)

Median age (range) 40 (19-65)

Female 74 (29%)

Nonwhite 90 (35%)

Employed 22 (9%)

Homeless 129 (50%)

Ever heroin use 232 (91%)

Ever prescription opioid use 243 (95%)

Current (90 day) heroin use 227 (88%)

Current (90 day) prescription opioids use 212 (82%)

Results

• 74/256 (29%) reported current treatment with buprenorphine or methadone for opioid use disorders.

• 182 were not currently on OAT.

Results: OAT Seeking Behaviors Among Participants

“Have you tried to get opioid drug treatment that include buprenorphine or methadone in the past 3 months?” n = 182 (%)

Yes, I got into treatment 5 (2.75%)

Yes, but I did NOT get into treatment 51 (28%)

No, I didn’t try to get into treatment 126 (69%)

Reasons Why Participants Tried But Did NOT Get OAT

n = 51 (%)

Changed my mind 3 (6%)

Don’t know how to find 0

Was on waitlist 14 (28%)

Couldn’t find buprenorphine provider 0

Transportation problems 3 (6%)

Couldn’t afford 5 (10%)

No insurance 5 (10%)

Worried someone would find out 0

Other 36 (71%)

*multiple responses allowed

Reasons Why Participants Did Not Seek OAT

n = 126 (%)

Don’t need treatment 29 (23%)

Don’t like buprenorphine 3 (2%)

Don’t like methadone 18 (14%)

Don’t like rules of buprenorphine 2 (1.5%)

Don’t like rules of methadone 11 (9%)

Treatment didn’t work before 4 (3%)

Other 94 (75%)

*multiple responses allowed

Analysis of “Other” Responses

• “Other” responses transcribed verbatim by research assistants

• Responses coded for emergent themes• Reviewed for most common themes

OAT is Another “Addiction”

• “It's just switching one addiction for another.”

• “Methadone is just as bad as heroin.”

• “Methadone creates more problems and is harder to stop than heroin.”

• “I don’t want to trade one drug for another drug.”

OAT Constitutes Loss of Control

• “I didn't want to be in treatment, I don't like someone having that kind of power over me.”

• “It's liquid handcuffs.”

• “I don't want to be a slave to methadone.”

Complex or Unstable Co-Morbidities

• “I got in but never went due to my hospitalization.”

• “My surgeries got in the way.”

• “I was going to start suboxone on (date), but I was in the hospital.”

• “Can’t give a benzo-free urine due to my seizure disorder.”

Interference with Pain Management

• “It doesn’t meet my needs for pain.”

• “I don’t want to. I’m already on methadone for pain.”

• “I don’t need treatment, I need pain management.”

• “I don't really know how, and I just want pain treatment. I don't know that they would help me.”

Conclusions

• In a sample of patients using heroin and/or prescription opioids, more than one quarter had attempted to get treatment with OAT in the past 3 months, but were not successful.

• Among those who sought but did not get OAT, the most common response category selected was the existence of a waitlist.

• Of those who did not seek treatment with OAT, the most common reason selected was belief of not needing treatment.

Conclusions• However, most participants identified “other” reasons for

not receiving OAT.• Open ended responses identified themes that have been

previously reported in the literature1,2 such as fear of loss of control and equating OAT with “addiction”.

• Competing co-morbidities and concerns about need for treatment for pain emerged as additional reasons why participants did not seek out OAT.

• Results adds to literature demonstrating that pain plays an important role in substance use treatment outcomes.3

1 Brown BS, Benn GJ, Jansen DR. Am J Psychiatry 19752 Schwartz RP, Kelly SM, O’Grady KE. Am J Addict 20083Larson MJ, Paasche-Orlow M, Cheng DM Addiction 2007

Limitations

• Recruitment from single healthcare setting.• No clinical assessment for diagnosis of opioid use

disorders.• Limited qualitative data on barriers (single open

ended question).

Next Steps/Future Research

• Immediate access to OAT is still an issue for patients with opioid use disorders: alternatives to waitlist needed.

• Pain and co-morbidities are barriers—interventions needed to address pain and addiction for complex medical patients.

• Research needed to understand why negative beliefs about OAT persist among patients, and whether these beliefs are fixed or can be changed.

Thank you!