What this is
- This qualitative study explores how VA clinicians manage opioid use disorder (OUD) in patients with co-occurring substance use.
- It examines their approaches, perceived barriers, and facilitators to providing medication for opioid use disorder (MOUD) like buprenorphine.
- The study highlights the need for clearer guidelines and better integration of care across different settings.
Essence
- VA clinicians reported varied approaches to treating OUD in patients with co-occurring substance use. They identified multiple barriers to providing medication-assisted treatment and emphasized the need for clearer guidelines and better support.
Key takeaways
- Clinicians generally believe that patients with co-occurring substance use should receive MOUD. However, many reported feeling unsupported due to unclear guidelines and inconsistent training on this issue.
- Barriers to providing buprenorphine include concerns about patient safety, lack of resources, and organizational policies that may discourage treatment in non-specialty settings.
- Participants recommended increased training, clearer policies, and better collaboration between primary care and specialty settings to enhance MOUD access for patients with co-occurring substance use.
Caveats
- The study's findings may not be representative due to a 30% response rate among contacted providers. Participants may have been more inclined to support MOUD for patients with co-occurring substance use.
- Low representation of certain provider groups limits the ability to assess differences in barriers and facilitators across clinical settings.
- The qualitative nature of the study means findings may not generalize to non-VA settings or other regions with different policies and substance use landscapes.
AI simplified
Background
Overdose deaths in the United States are at a record high, [1, 2] and most people with opioid use disorder (OUD) do not receive recommended treatment [3]. There are three approved medications for opioid use disorder (MOUD): buprenorphine, methadone and naltrexone [4]. Buprenorphine and methadone are considered first-line treatment and substantially reduce overdose risk [5â9]. While methadone for OUD must be administered through a federally regulated treatment center, buprenorphine can be prescribed outside of substance use disorder (SUD) specialty settings [4].
The majority of people with OUD use alcohol or other non-opioid drugs [10â13]. Studies have found that patients with co-occurring SUDs are less likely to receive MOUD than those with only OUD [12, 14â16]. Efforts to increase MOUD access have tended to overlook the role of polysubstance use, even though it is highly prevalent among people with OUD and appears to hinder MOUD receipt [10, 17]. As patients may face multiple barriers to accessing care in SUD specialty settings, [18, 19] expanding MOUD provision in other clinical settings is a key strategy to increase access [20, 21]. It is therefore important to understand how clinicians providing buprenorphine care outside of SUD specialty settings approach care for patients with co-occurring substance use, who likely make up a large proportion of their patients with OUD.
Clinical guidelines for OUD treatment state that use of other substances should never be grounds for withholding or suspending MOUD, but that a higher level of care (e.g., SUD specialty care) should be considered for patients actively using other substances, particularly patients with co-occurring SUDs and/or actively using alcohol or sedatives (which may increase risk of respiratory depression while on MOUD) [6, 22]. These guidelines also state that if a higher level of care is not available or acceptable to the patient, this should not prevent or delay the provision of MOUD. The Veterans Health Administration (VA) SUD clinical practice guidelines state that MOUD âshould not automatically be discontinued due to a patientâs use of another substance,â and promote the provision of patient-centered OUD care across multiple care settings [5].
Existing research examining providersâ perspectives on this topic is limited. Surveys of U.S. buprenorphine providers (including providers in SUD and non-SUD settings) suggest they may be less likely to prescribe buprenorphine to patients with alcohol or benzodiazepine use disorders relative to those with OUD alone, or may increase monitoring frequency for patients using benzodiazepines [23, 24]. A study that reviewed charts for a random sample of national VA patients with OUD found that clinicians were less likely to recommend MOUD for patients with co-occurring stimulant use disorder [25]. A qualitative study assessing implementation of buprenorphine provision in primary care settings found that most clinics increased monitoring or required additional psychosocial treatment for patients using other substances, and had varying âthresholdsâ at which they dismissed patients or referred them to specialty SUD care due to other substance use [26]. However, this study was not specifically focused on co-occurring substance use and did not assess providersâ experiences and perceptions that may drive clinical practices. More in-depth qualitative information from clinicians providing buprenorphine care outside of SUD specialty settings is needed to better understand varying approaches to addressing OUD in patients with co-occurring substance use, potential barriers and facilitators to treating them and/or linking them to SUD specialty care, and what support providers need to care for this population.
The VA is the largest OUD treatment provider in the country, [27] over half of VA patients with OUD have co-occurring SUDs, and those with co-occurring SUDs have lower MOUD receipt than those without [12]. Increasing MOUD receiptâincluding increasing buprenorphine provision outside of SUD specialty settingsâis a VA priority, [27, 28] and leaders have called for research that leverages the VAâs status as a learning health system (i.e., an integrated system that can broadly implement and test new interventions and care models) to improve care for patients with OUD and polysubstance use [29]. This qualitative study of VA clinicians providing buprenorphine care in primary care, mental health, and pain settings aimed to understand (1) their approach to addressing OUD in patients with co-occurring substance use, (2) their perspectives on barriers and facilitators to MOUD receipt for this patient population, and (3) support needed to increase MOUD receipt in this population. To our knowledge, this is the first in-depth qualitative study to address barriers and facilitators to MOUD for patients with co-occurring substance use among non-SUD specialist buprenorphine providers.
Methods
Study sample and recruitment
We interviewed clinicians in the VA northwest regional network (Veterans Integrated Services Network 20) providing OUD care outside of SUD specialty settings [30]. Clinicians were eligible to participate if (1) they currently provided OUD care outside of an SUD clinic, and (2) they had prescribed buprenorphine for OUD or managed buprenorphine care (e.g., clinical pharmacy specialists, at the time of the study, were unable to prescribe but could manage this care [31]) for ⼠5 patients. To identify potentially eligible participants, we obtained a list of buprenorphine prescribers in the network from VA Pharmacy Benefits Management Services. The list included clinicians who (1) had a waiver to provide buprenorphine for OUD [32] and (2) had prescribed buprenorphine to ⼠1 patient within the past 90 days on 2/16/2022. The list excluded one facility that had switched to a new electronic health record system, for which prescribing information was not available. We also employed snowball sampling to expand recruitment beyond this list [33]. Potential participants were sent a recruitment email and up to two follow-up emails. We used purposive sampling to obtain perspectives from different training backgrounds (physician, nurse practitioner/physician assistant, pharmacist), clinical settings (primary care, mental health, pain), VA facility, and clinic rurality. This study was approved by institutional review boards at the University of Washington and VA Puget Sound Healthcare System.
Data collection
Telephone interviews were conducted from 3/8/2022 to 5/26/2022 by two interviewers with experience in qualitative data collection and researching and/or providing MOUD care (MCF, CEA). The semi-structured interview guide collected cliniciansâ training and professional experience through closed-ended questions, and addressed the following topics through open-ended questions: current practices and perspectives related to providing buprenorphine to patients with co-occurring substance use; perception of how training and clinical guidelines address this topic; what factors impact MOUD receipt for VA patients with co-occurring substance use; and what support is needed to increase MOUD receipt for this patient population. The interview guide asked broadly about co-occurring substance use, which may include any use or diagnosed SUDs, in order to allow participants to respond about the type of substance(s) and severity of co-occurring use that was most salient for them. Participants were asked to specify which substance(s) would impact their decision to not provide buprenorphine and/or recommend additional support. The guide was developed to assess domains in the Tailored Implementation for Chronic Diseases (TICD) Checklist, [34, 35] an implementation science tool that organizes factors influencing provision of evidence-based care into categories including individual health professional factors, providersâ perceptions of patient factors, professional interactions, incentives and resources, capacity for organizational change, and social, political and legal factors. Interviews lasted 30â60 min, with most lasting approximately 45 min. All interviews were audio-recorded and transcribed.
Analysis
Participant characteristics were quantitatively summarized. Transcripts were qualitatively analyzed using inductive content analysis, [36] in which codes were derived from the data and added to the codebook as transcripts were analyzed. All transcripts were independently coded by two analysts with experience in qualitative analysis and substance use-related research (MCF, EMS). The analysts met regularly to review each coded transcript, resolve discrepancies, and add to/refine the codebook as needed. Transcripts were coded using Atlas.ti 22 software [37]. Data collection continued until analysts agreed that saturation of themes had been reached among the entire sample; [38, 39] at this point recruitment of primary care providers ended, but we continued our attempts to recruit all eligible non-primary care providers to increase representation of other settings. Codes and example quotations were iteratively reviewed by the full investigative team to ensure that themes were supported by the data and finalize themes by consensus. Factors impacting MOUD receipt for patients with co-occurring substance use were organized under TICD checklist domains [34].
Results
Sample description
Twenty-seven providers participated in interviews, a 30% response rate among 90 providers who were contacted (this rate excludes 9 providers who responded but did not meet eligibility criteria). Participant characteristics are presented in Table 1. Just under three-quarters of participants provided buprenorphine care at a VA medical center (larger facilities that provide a wider range of general and specialty services), and just under half provided buprenorphine care at one or more community-based outpatient clinics (smaller facilities that provide primary care and other common outpatient services; types of services provided vary across clinics) [40]. Most provided buprenorphine care in urban locations, and over one-third provided buprenorphine care in rural locations [41]. The most common clinical setting was primary care, followed by mental health and pain (pharmacists supported care across multiple clinical settings). The most common clinical training was physician, followed by nurse practitioner/physician assistant and pharmacist. Most participants had completed buprenorphine waiver training outside of the VA, and most had received some other type of MOUD education (e.g., in residency, VA meetings or trainings). Participants had been in their current position for an average of 3.5 years and had worked at the VA for an average of 6.9 years. They had provided buprenorphine care for an average of 4.9 years (ranging from 8 months to 16 years) and were currently providing buprenorphine care for an average of 20.4 patients (ranging from zero to 80).
| N | % | |
|---|---|---|
| VA workplace type(s)a | ||
| VA medical center (VAMC) | 14 | 52 |
| Community-based outpatient clinic (CBOC) | 7 | 26 |
| Both VAMC and CBOC | 6 | 22 |
| VA workplace location(s)a | ||
| Urban | 17 | 63 |
| Rural | 6 | 22 |
| Both urban and rural | 4 | 15 |
| Clinic type | ||
| Primary care | 12 | 44 |
| Mental health | 7 | 26 |
| Pain | 4 | 15 |
| Pharmacist (multiple clinic types)b | 4 | 15 |
| Clinical training | ||
| Physician | 16 | 59 |
| Nurse practitioner/physician assistant | 7 | 26 |
| Pharmacist | 4 | 15 |
| Buprenorphine waiver trainingc | ||
| Completed outside of VA | 21 | 78 |
| Completed through VA | 5 | 19 |
| Did not complete | 1 | 4 |
| Addiction certification/fellowship | 3 | 11 |
| Received other MOUD educationd | ||
| Yes | 21 | 78 |
| No | 6 | 22 |
Approaches to addressing OUD in patients with co-occurring substance use
Perceptions of co-occurring substance use among patients with OUD
Most participants reported that co-occurring substance use was common among their patients with OUD. Alcohol and cannabis were frequently described as the most common substances, and some participants reported that methamphetamine use was also common or increasing. Benzodiazepines, cocaine, and other drugs were less frequently mentioned. Some participants contrasted patients who use illicit opioids to those who use prescription opioids, perceiving that the former were more likely to use other illicit substances.
Assessment of co-occurring substance use among patients with OUD
Participants typically assessed other substance use through patient self-report (e.g., âI always ask the patient at my initial assessment, of every history of substance use that theyâve had, and if theyâre using any.â [P13, pharmacist, both urban and rural]) and/or biological tests (e.g., urine drug screens). Less common approaches included administering standardized assessments of substance use (e.g., the Alcohol Use Disorder Identification Test-Consumption screen) [42] or reviewing health record information (e.g., chart notes, documented SUD diagnoses, prescribed medications). Participants expressed mixed opinions on the value of urine drug screensâsome felt they were useful for obtaining more objective information and discouraging other substance use, while others felt repeated testing could be detrimental to their relationship with the patient.
Providing OUD treatment to patients with other substance use
Many participants reported that they prescribed buprenorphine or managed buprenorphine care for patients with co-occurring substance use. Most recommended additional services to address other substance use (e.g., treatment for other SUDs, mutual support groups). Some also provided medications for co-occurring alcohol use disorder; these participants noted that buprenorphine and naltrexone cannot be used at the same time, and some reported that they typically prioritized buprenorphine and prescribed alcohol use disorder medications other than naltrexone. Others provided injectable naltrexone instead of buprenorphine to simultaneously treat co-occurring OUD and alcohol use disorder, though some believed naltrexone was a less effective OUD treatment and required high patient motivation.
Some participants described additional measures they took when providing buprenorphine to patients with other substance use, including educating patients about potential risks, motivational interviewing to encourage reduction or cessation, and increasing monitoring through higher frequency of visits, shorter refill periods, and/or increased screening for substance use. Some reported that they sometimes prescribed a lower dose of buprenorphine to patients with co-occurring substance use due to concern about respiratory depression.
Another participant said they increased the dose for patients with co-occurring methamphetamine use due to concerns about fentanyl contamination.
Although many participants in this study provided buprenorphine to patients with other substance use, several perceived that most VA buprenorphine providers outside of SUD specialty settings do not:
Referring to SUD specialty care for OUD treatment
Several participants reported referring patients with other substance use to specialty SUD settings for OUD treatment, either for any level of use or higher severity use. Some were willing to provide a short-term prescription until the patient was able to start SUD specialty care or would consider providing buprenorphine if the patient was unwilling to go to the SUD clinic, but others indicated they would not initiate or continue prescribing buprenorphine for these patients.
Factors impacting MOUD receipt for patients with co-occurring substance use
Factors impacting MOUD receipt are organized under the TICD Checklist domains and summarized in Table 2.
| Individual health professional factors |
| Providersâ awareness of recommendations |
| â˘In general, participants reported that there are not clear recommendations around buprenorphine care for patients with co-occurring substance use in guidelines or training â˘Other information sources may shape providersâ approaches (e.g., colleagues, doing their own research) â˘Participants generally agreed that patients using other substances should receive MOUD, but varied in how they viewed their primary role (i.e., providing the care vs. facilitating linkage to higher-level care) |
| Other individual health professional factors |
| â˘Some providers may lack relevant knowledge/skills/experience â˘Providers have a range of perceptions/attitudes that may impact their approach (safety/other concerns; beliefs about appropriateness of non-SUD care setting; harm reduction philosophy; patient-centered approach) |
| Providersâ perceptions of patient factors |
| â˘Life instability related to co-occurring substance use may create barriers to receiving MOUD care â˘Fear of disclosing co-occurring substance use may be a barrier to receiving MOUD care â˘Patients may or may not prefer to receive MOUD in an SUD specialty setting, which may be impacted by addiction-related stigma |
| Professional interactions |
| â˘Collaboration with SUD experts may facilitate buprenorphine provision for patients with co-occurring substance use outside of SUD specialty settings, or facilitate linkage to SUD specialty care â˘Siloed care/expertise may make it more difficult to adequately support these patients â˘Existing VA efforts to integrate primary care and mental health may not adequately address SUD care |
| Incentives and resources |
| Within participantsâ clinics |
| â˘Lack of adequate time with patients to address complex issues may be a barrier â˘Lack of nursing and other staff may be a barrier |
| Outside participantsâ clinics |
| â˘Low accessibility of SUD specialty clinics may be a barrier to linking patients to higher-level MOUD care and/or additional care for other SUDs â˘Availability of other higher-level SUD care (e.g., detox, residential treatment) may be too low â˘Mental health and social services provided though the VA may help patients with co-occurring substance use engage in MOUD care, but there may be barriers to accessing these services |
| Capacity for organizational change |
| â˘Clinic policies/treatment agreements banning other substance use may have become more flexible in recent years to encourage increased provision of buprenorphine â˘Some SUD specialty clinics may still have strict rules around other substance use or generally require more structured care, which may present barriers for some patients with co-occurring substance use â˘Leadership in primary care, mental health and pain clinics may vary in their support of buprenorphine provision for this population |
| Social, political and legal factors |
| â˘Telehealth does not seem to greatly impact providersâ approach to treating OUD among patients with co-occurring use, but may make it more difficult to assess other substance use â˘Telehealth may have increased access to SUD specialty services for some patients in rural areas, however the COVID-19 pandemic may have also decreased provision of these services â˘Cannabis legalization/normalization may have made some providers more willing to provide buprenorphine care to patients who use cannabis â˘Concerns about overdose risk related to a rise in fentanyl use may increase providersâ sense of urgency of providing buprenorphine regardless of other substance use |
Providersâ awareness of recommendations
In general, participants reported that there are not clear recommendations around buprenorphine care for patients with co-occurring substance use in guidelines or training. About half of the participants were not familiar with formal clinical guidelines related to this issue, and some noted that providers outside of SUD specialty settings may be less likely to be aware of these guidelines compared to SUD specialists.
Similarly, most participants said this topic was not addressed in training they had received on buprenorphine care, or that they did not recall if it was addressed.
Those who did recall specific recommendations from guidelines or training described varied content, including assessing for other substance use, providing buprenorphine regardless of other substance use, being aware of potential risks and using caution when prescribing, increasing monitoring, and referring patients with other substance use to SUD specialty care rather than prescribing.
Despite reporting low familiarity with formal guidelines and inconsistent training, participants generally felt that patients should receive MOUD in the presence of other substance use. Some viewed their primary role as providing this care, while others viewed their primary role as facilitating linkage to OUD care in SUD specialty settings. Participants described other sources of information that shaped their understanding of OUD care for patients with co-occurring substance use, including modeling their practice after other providers in their facility, consulting with colleagues (including SUD specialists), and doing their own research.
Other individual health professional factors
Participants also described a range of perceptions and attitudes (both their own and their perceptions of other providers) that may influence approaches to addressing OUD in patients with co-occurring substance use. Many participants had safety concerns about combining buprenorphine with other substances, which sometimes led to extra precautions (e.g., increased monitoring) or referral to an SUD specialty setting for OUD care. Most were specifically concerned about alcohol and benzodiazepines because they may increase risk of respiratory depression.
However, some providers expressed more concern about âillicitâ substances.
Participants also described other concerns, including other substance use interfering with adherence to buprenorphine and diversion of buprenorphine to obtain other substances.
Many participants across all clinic settings endorsed a âharm reductionâ philosophy of buprenorphine provision emphasizing that it is more dangerous to let OUD go untreated than to prescribe buprenorphine to patients with co-occurring substance use. This belief was usually tied to a willingness to prescribe to these patients outside of SUD specialty settings.
One participant emphasized the role of this philosophy in driving variability in individual providersâ approaches.
For some participants, a desire to respect patientsâ preferences was another driver of providing buprenorphine for these patients outside of an SUD specialty setting.
Alternately, participants perceived that many providers outside of SUD specialty settings do not prescribe buprenorphine to patients using other substances due to a belief that SUD specialty care is the only appropriate treatment setting for this patient population.
Participants also described how lack of knowledge, skills and experience related to treating patients with polysubstance use among some providers could prevent or delay buprenorphine care.
Providersâ perceptions of patient factors
Participants perceived that instability in patientsâ lives related to other substance use created barriers to engaging in MOUD care in both their clinic and SUD specialty settings. They described several sources of instability including intoxication and withdrawal, mental health conditions, strained relationships, unemployment, housing instability, and legal system involvement.
Participants also perceived that fear of disclosing other substance use may present a barrier to OUD care for patients with co-occurring substance use.
When discussing referring patients with co-occurring substance use to SUD specialty care, participants discussed their perceptions of how stigma might impact some patientsâ preferences around the setting in which they receive MOUD care. Some perceived that many patients see SUD specialty settings as stigmatizing and therefore prefer to receive treatment in other healthcare settings.
However, one participant perceived that some patients experience less stigma in SUD specialty care compared to primary care.
Professional interactions
Participants described a broad spectrum of cross-disciplinary collaboration and discussed how varying degrees of collaboration impacted their approach to MOUD care. Some participants had clinicians with SUD expertise integrated into their clinic or had regular close collaboration with themâfor example, collaboration between clinicians prescribing buprenorphine outside of SUD specialty settings and SUD clinical pharmacy specialists who manage the care, or regular meetings including SUD specialty care, primary care, mental health, and/or pain providers to discuss complex cases. This type of collaboration was reported by participants from larger and smaller as well as urban and rural facilities. Some participants discussed how collaboration and access to SUD expertise facilitated buprenorphine provision for patients with co-occurring substance use outside of SUD specialty settings.
Other participants described how cross-disciplinary collaboration led to improved handoffs to SUD specialty care rather than increased buprenorphine prescribing in their clinical setting.
Alternately, some participants at both larger and smaller as well as urban and rural facilities reported that care and expertise was siloed between disciplines, which made it more difficult to adequately support patients with co-occurring substance use.
Several primary care providers felt that the VAâs Primary Care-Mental Health Integration model (PCMHI), a national effort to formally integrate mental health into primary care, did not adequately support substance use-related care.
Some participants providing care at rural facilities reported that they were the only buprenorphine provider in their clinic. These participants were prescribing buprenorphine to patients with co-occurring substance use, suggesting that this isolation was not necessarily a barrier to doing this. However, some noted they would like to have more information about what other providers are doing.
Incentives and resources
Participants reported a lack of resources within their clinic needed to provide MOUD to patients with co-occurring substance use, including nursing staff, support personnel, and lack of adequate time to address more complex issues with patients. Some described how turnover contributed to lack of time and staff.
Participants also discussed resources outside of their clinic. The accessibility of SUD specialty clinic services was described as an important barrier or facilitator to caring for patients with co-occurring substance use, with respect to referring patients there for MOUD and/or for additional services to address other SUDs. Many mentioned specific barriers including far distance, limited hours of availability, and wait times. Alternately, some participants in urban facilities described these services as more accessible when they were located at the same facility as their clinic and had same-day access.
Some participants also described the low availability of other higher-level SUD services needed to support some patients with co-occurring substance use, including detoxification services and residential treatment.
Finally, some participants described how the availability of other VA services, including mental health and social services, helped patients with co-occurring substance use engage in MOUD care.
However, some mentioned barriers to accessing these services including distance and wait times for mental health services (particularly in rural facilities) and complex processes for signing up for social services.
Capacity for organizational change
Participants discussed how policies in primary care, mental health and pain clinics impacted MOUD care for patients with co-occurring substance use. Some participants in rural facilities reported that their clinics employed OUD treatment agreements that require or strongly recommend abstinence from other substances, but that the language and/or enforcement had become more âlenientâ in recent years.
Some linked changes in their clinicâs policy to broader policies encouraging expanded provision of buprenorphine.
Participants also discussed the impact of clinic leadership. One participant felt that leadership in their clinic did not support buprenorphine provision for people with co-occurring substance use.
Alternately, another participant described how their current VA clinic was more supportive of treating patients with co-occurring substance use compared to the lack of support from leadership in a non-VA setting they had previously worked in.
Several participants reported that some SUD specialty clinics have restrictive policies around other substance use (e.g., requiring negative urine drug screen results to receive MOUD), or generally require more structured care (e.g., more frequent visits). Some discussed how these restrictions might result in patients with more complex needs who have âstepped upâ to receive care in an SUD specialty setting being lost to follow-up or âstepping offâ (i.e., ending up in a lower-level setting for MOUD care).
Social, political and legal factors
Finally, participants described factors external to the VA healthcare system impacting MOUD care for patients with co-occurring substance use. Many participants were providing buprenorphine via telehealth due to the COVID-19 pandemic and reported that telehealth generally did not change their approach to treating patients with co-occurring substance use. However, some reported that it was more challenging to assess for other substance use via telehealth.
Some participants said that telehealth had increased access to specialty SUD services for patients in rural areas but noted limitations, including some patientsâ lack of internet/phone access or preference for in-person care. However, some reported that the pandemic had negatively impacted availability of SUD services (e.g., reduced provision of SUD specialty clinic services and residential treatment).
Participants also described how changes in the substance use landscape had impacted MOUD care for patients with co-occurring substance use. Some discussed how the legalization and normalization of cannabis use had made them more willing to prescribe buprenorphine for patients who use cannabis, but this change was challenging for some.
Participants also believed that a sharp increase in fentanyl use, and other opioids being contaminated with fentanyl, had increased risk of overdose for their patients with OUD. They discussed how this made a harm reduction approach to buprenorphine provision in the presence of co-occurring substance use more urgent.
Support needed to increase MOUD receipt among patients with co-occurring substance use
Participants were asked what support they felt was needed to increase MOUD receipt for patients with co-occurring substance use. Support recommended by participants is summarized in Table 3.
Participants recommended providing education/training to providers outside of SUD specialty settings related to treating OUD among patients with co-occurring substance use. Some suggested specific content including monitoring, buprenorphine dosing, providing injectable vs. oral/sublingual buprenorphine, referral, and motivational interviewing. They also suggested providing data on the risk of death associated with providing vs. not providing buprenorphine when patients are using other substances, and education on harm reduction principles.
Participants also recommended increasing collaboration between clinicians providing buprenorphine care outside of SUD specialty settings and SUD specialists. Suggestions included having experts available for consultation and regular meetings to discuss cases.
Participants recommended giving clinicians who are providing buprenorphine care outside of SUD specialty settings more time to spend with each patient, increasing nursing and other staff in their clinic, and increasing same-day access in their clinic. They also recommended increasing the availability of SUD specialty services and improving linkage to these services through integrating more SUD care into other care settings, locating SUD clinics at the same physical location as other clinics, and improving referral and warm hand-off processes.
Finally, a few participants recommended creating clear institutional policies or guidelines related to providing buprenorphine to patients with co-occurring substance use. They discussed how this would help providers feel more supported in taking a harm reduction-informed and patient-centered approach to care.
| â˘Create clear institutional policies/guidelines related to providing buprenorphine to patients with co-occurring substance use â˘Provide more specific education/training to providers outside of SUD specialty settings related to treating OUD among patients with co-occurring substance use â˘Increase collaboration between buprenorphine providers outside of SUD specialty settings and SUD specialists â˘Give buprenorphine providers outside of SUD specialty settings more time to spend with each patient â˘Increase nursing and other staff â˘Increase same-day availability â˘Increase availability of SUD specialty services â˘Improve linkage to SUD specialty services (integrate SUD care into other settings, co-locate SUD clinics with other clinics, improve referral and warm hand-off processes) |
Discussion
This qualitative study examined the experiences and perspectives of VA clinicians providing buprenorphine care in primary care, mental health, and pain clinics related to addressing OUD among patients with co-occurring substance use. Although they reported that this topic was not clearly addressed in clinical guidelines or training, participants generally felt that patients should receive MOUD in the presence of other substance use. Some viewed their primary role as providing this care, while others viewed their primary role as facilitating linkage to OUD care in SUD specialty settings. Participants described multiple barriers and facilitators to providing buprenorphine to patients with co-occurring substance use, as well as barriers and facilitators to linking them to SUD specialty care.
Consistent with the concept of stepped care, patients with OUD who have co-occurring substance use may benefit from receiving MOUD in higher-intensity (e.g., SUD specialty care) rather than lower-intensity (e.g., primary care) settings, particularly those with co-occurring SUDs or who are actively using alcohol or sedatives [20, 43]. However, participants in this study pointed out multiple reasons why many of these patients may not initiate or be retained in MOUD care in SUD specialty settings. As non-SUD specialty settings may be the only viable option for MOUD care for many patients, [19] it is important that clinicians providing this care outside of SUD specialty settings are supported in caring for patients with co-occurring substance use. Although many participants in this study prescribed buprenorphine for this patient population, they perceived that most providers outside of SUD specialty settings do not and described multiple barriers.
In this study, we broadly asked participants about treating patients with co-occurring substance use. Most participants did not clearly distinguish between co-occurring substance use and co-occurring SUDs when describing their approach to MOUD care (whether they tended to provide MOUD or refer the patient to specialty SUD care for MOUD in the presence of other substance use). When asked how they assessed other substance use, participants did not describe using structured SUD assessments to identify co-occurring SUDs, and rarely described reviewing the medical record for SUD diagnoses (though these methods of assessment were not asked about directly). Thus, providers may benefit from training on how to assess for the presence and severity of co-occurring SUDs and implications for MOUD care. Pragmatic SUD assessment tools, such as symptom checklists, may help MOUD providers regularly assess for co-occurring SUDs as is recommended in clinical guidelines [44â46]. Additionally, participants in this study reported varied approaches to assessing co-occurring substance use among patients with OUD. Using validated screening tools to assess for other substance use is recommended for office-based MOUD care, [47] and MOUD providers may benefit from access to and training in using these tools.
Findings suggest that clinical guidelines related to providing buprenorphine to patients with co-occurring substance use should be made more visible to clinicians providing this care outside of SUD specialty settings, and that these clinicians may benefit from more detailed and directive guidance. Many providers may not be familiar with national guidelines or may find them vague. Specific, consistent and clear guidelines/policies communicated at the clinic or facility level may help providers feel more comfortable and supported in caring for patients with co-occurring substance use.
Participants also noted the need for specific training on how to most effectively treat OUD in patients with co-occurring substance use (e.g., monitoring, dosing), and suggested that providers outside of SUD specialty settings may benefit from education on the relative harms of providing vs. not providing buprenorphine and harm reduction principles. This information could be more systematically included in buprenorphine trainings and continuing education materials. As some providers may gain more information from interactions with colleagues and experience treating patients compared to reading clinical guidelines or attending trainings, these concepts could also be integrated into multiple care improvement activities such as cross-disciplinary meetings or clinical decision-support tools. Efforts are needed to improve the integration of SUD care and expertise in non-SUD specialty settings, such as increasing capacity to provide SUD care in PCMHI clinics, [48] testing collaborative care models for patients with polysubstance use, and creating other opportunities for buprenorphine providers in these settings to collaborate with SUD specialists. Additionally, lack of adequate provider time and staffing, consistently reported as barriers to expanding MOUD care, [49, 50] remain important problems to be addressed.
Simultaneously, efforts are needed to improve access to SUD specialty clinics and other higher-level SUD care (such as supervised detoxification and residential treatment) for patients who would benefit from and are willing to receive this care. These efforts may include devoting funding and resources to provide these services in more locations and during expanded hours, as well as clarifying referral pathways and creating warm handoff processes. Increased telehealth provision of SUD specialty treatment may increase access for patients living far from VA facilities, and work is needed to continue assessing and improving the quality of this care [51, 52]. Co-locating SUD specialty services with other clinics and use of warm handoffs may facilitate linkage and reduce stigma for patients. Finally, SUD specialty clinics should adopt flexible policies around providing MOUD to patients with ongoing substance use (e.g., not requiring abstinence from other substances to receive MOUD) and may consider other ways to increase flexibility in care for patients who struggle to meet clinic requirements.
These findings should be considered in the context of research assessing perspectives on MOUD access among people who use multiple substances. People with polysubstance use have reported that it can worsen health and social situations, [53] which may create barriers to treatment, and have reported being discharged from MOUD treatment due to other substance use, [54] barriers that align with providersâ perspectives in this study. People who use both methamphetamine and opioids have reported feeling a âbalancingâ effect of the two drugs that improves their functioning, [54, 55] which for some might decrease interest in receiving MOUD treatment, and this is a perspective that providers may be less aware of. Further research assessing the perspectives VA patients who have OUD and co-occurring substance use is needed.
This study has strengths and limitations. While a qualitative approach allowed us to obtain rich, detailed information and discover unanticipated factors affecting this care, findings cannot be considered representative of all buprenorphine providers in the regional network given the response rate of 30%. Specifically, providers who agreed to participate may have been more willing to provide buprenorphine care to patients with co-occurring substance use than those who did not participate, a possibility supported by the finding that many participants perceived that most other providers outside of SUD specialty settings were not willing to prescribe for these patients. This study was also limited by low representation of certain groups with a smaller number of eligible providers, which prevented us from systematically assessing differences in themes across clinical settings and provider characteristics. Primary care, mental health, pain, and pharmacy settings differ in their practice structure, clinical scope, and training, and further qualitative research with larger and more evenly balanced samples is needed to rigorously assess potential differences in barriers and facilitators across settings and provider characteristics. Three participants in this sample had an addiction certification or addiction fellowship training, and future research should assess whether there are differences for providers with these credentials compared to those without. Findings from this study could also inform future quantitative surveys that can compare the prevalence of different barriers and facilitators overall and across different clinic settings and provider characteristics. Asking broadly about co-occurring substance use limited our ability to understand whether providersâ approaches and perceptions of barriers and facilitators differ for patients with co-occurring SUDs vs. lower severity use, or for patients with co-occurring use of different substances, and future research is needed that more precisely examines these questions. Finally, findings may have limited generalizability in non-VA healthcare settings and in other regions of the country, which may differ with respect to relevant policies (e.g., cannabis legalization), the drug supply (e.g., prevalence of fentanyl), and the epidemiology of substance use and overdose.
Conclusions
In this qualitative study of 27 VA clinicians providing buprenorphine care in primary care, mental health and pain clinics, participants reported varied approaches to assessing other substance use and varied approaches to treating OUD for these patients. Participants reported multi-level barriers and facilitators to providing buprenorphine care to patients with co-occurring substance use, as well as barriers and facilitators to linking these patients to care in SUD specialty settings. Specifically, they reported a lack of clear recommendations in guidelines and training, and discussed their perceptions of how provider factors (e.g., knowledge and attitudes), patient factors (e.g., life instability related to other substance use and preferences around treatment setting), organizational factors (e.g., cross-disciplinary collaboration, resources, and clinic policies/leadership), and external factors (e.g., the COVID-19 pandemic and changes in the substance use landscape) impacted MOUD receipt for these patients. The majority of people with OUD use other substances, and the VA and other healthcare systems need to address barriers to MOUD for these patients. Efforts are needed to support clinicians outside of SUD specialty settings in providing buprenorphine care to patients with co-occurring substance use, as well as to improve linkage to SUD specialty clinics and other higher-level SUD care. These efforts may increase MOUD receipt and improve OUD care quality for patients with co-occurring substance use.
Acknowledgements
The authors thank the providers who participated in interviews, Rachel Smith for transcribing interviews, and VA Pharmacy Benefits Management Services. An abstract reporting these findings was presented at the NYU Langone Center for Opioid Epidemiology and Policy Polysubstance Use Symposium in October 2022.
Abbreviations
Author contributions
The study was conceived and designed by MCF, EJH, JEG, KAH, and ECW. Data were collected by MCF and CEA. Analyses were led by MCF and conducted by MCF and EMS. MCF led preparation of the manuscript; all authors assisted with interpretation of findings, contributed revisions to the manuscript, and read and approved the final manuscript. Funding for the study was acquired by MCF. All authors read and approved the final manuscript.
Funding
This work was supported by a small grant from the University of Washington Addictions, Drug & Alcohol Institute. Dr. Frost was supported by a predoctoral training award from the Veterans Affairs (VA) Puget Sound Research and Development Service when this work was conducted. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. The opinions expressed in this work are the authorsâ and do not necessarily reflect those of the institutions, funders, the Department of Veterans Affairs, or the United States Government.
Availability of data and materials
Data are not publicly available due to institutional rules regarding data sharing.
Declarations
Ethics approval and consent to participate
This study was approved by institutional review boards at the University of Washington and VA Puget Sound Healthcare System. Interview participants provided verbal informed consent.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Footnotes
References
Associated Data
Data Availability Statement
Data are not publicly available due to institutional rules regarding data sharing.