Marcia Frellick
August 14, 2023
Four themes in responses to a survey describe the multilevel barriers that make it difficult for primary care teams to incorporate medication for opioid use disorder (MOUD) in their practices, according to research published in JAMA Network Open.
Elizabeth J. Austin, PhD, MPH, with the department of health systems and population health at the University of Washington, Seattle, and colleagues describe the four major themes in the answers:
- Structural barriers delay or limit primary care team responsiveness to patients needing opioid-related care.
- Patient engagement was more challenging than expected.
- Prescribing physicians needed tools and to be able to see the patients on an ongoing basis.
- Teams had conflicting views on expanding MOUD care.
The survey
The researchers used a cohort of 12 clinics diverse in geography and structure and explored the experiences multidisciplinary primary care teams had in expanding MOUD services, such as use of buprenorphine and naltrexone.
A sample of 62 team members completed the survey for a response rate of 77%. Two-thirds (66%) identified as female and 46 (74%) identified as White. Evaluation of responses occurred between 2020 and 2022 in a sample of primary care clinics that agreed to participate in the Collaborating to Heal Addiction and Mental Health in Primary Care (CHAMP) study. The trial is ongoing.
Rigid scheduling a barrier
Some respondents said inflexible scheduling tied their hands.
One clinician responded, “[M]y practice has been really busy right now … it’s been tough to find openings for my current patients as it is.”
Others described closed or limited patient panels, often set by their health systems. Twenty clinicians (32%) said they were worried their clinic couldn’t accommodate the volume of patients seeking OUD treatment.
Some reported productivity pressure from their health systems to keep the schedule full, which doesn’t allow for walk-in patients needing MOUD.
Frustration with no-shows
Some responses indicated frustration in locating patients and with no-shows.
One responded, “[W]e can’t find these people for months and months. […] I’m spending 3 weeks, 4 weeks, trying to get them in.” Another said, “[I]t’s frustrating when patients don’t show up when they have been referred.”
Margret Chang, MD, a primary care doctor at Tri-River Family Health Center of Worcester, Mass., who was not part of the study, said the four categories the authors describe ring true.
Stigma for providers and patients
Dr. Chang said the biggest overarching part of those barriers comes down to stigma, but she says it’s not just a problem for patients, but for providers as well.
In fact, a responder in the Austin et al. survey wrote, “Our faculty group as a whole has expressed that that’s not the direction they want for our clinic; we already provide more psychiatric care and addiction medicine than other clinics, but we can’t be like the addiction medicine clinic in town either.”
Dr. Chang’s clinic, on the other hand, recruits addicted patients to their primary care practice by making a local drug court, addiction-support services in the community, and their colleagues in the UMass Health System aware that their services are available. Patients also refer their friends to the clinic and the clinic has a steady influx.
“I honestly feel that primary care is the discipline that really should be involved in substance disorder treatment,” says Dr. Chang, who is an assistant professor of medicine and the addiction curriculum director for internal medicine at the UMass Chan Medical School, Worcester. “In medicine there’s a huge stigma around even being able to help these patients even though we have medications that are pretty effective.”
She runs a medication-assisted treatment program and said her semirural clinic and one other are the only two primary care clinics in the Worcester area with such a program.
Patients also have “huge inertia around taking a medication to recover from addiction or substance abuse,” she says.
Confidence lacking in treating patients
Dr. Chang said primary care residents in recent years are coming out of medical school with knowledge about treating OUD, but they often run into more experienced physicians who didn’t get training in the treatment so they feel intimidated about initiating the treatment.
At their clinic, Dr. Chang says, they have a nurse dedicated to OUD, which helps alleviate some of the barriers described in the survey. Patients know they can contact a particular person at the clinic who is dedicated to their needs. The nurse can track down patients who may miss appointments or be hard to locate so physicians don’t have to add that to their workload. They can collect fluid samples and connect patients to services.
Dr. Chang says a nurse might say, “I see we had you on (buprenorphine-naloxone) for opioid use disorder but I see you also have cocaine in your urine. How can we keep you safe?”
Having a health team member, whether a nurse or medical assistant or social worker, designated to help with people who need OUD treatment really makes a difference, she says.
People living with addiction “have a lot of needs,” she says, “and they are hard to address in the typical template a primary care provider might have.”
Family medicine, she says, has been more open to adding support staff for this population than other specialties.
Coauthor Andrew J. Saxon, MD, reported grants from the National Institute of Mental Health (NIMH) during the conduct of the study as well as personal fees from Indivior and royalties from UpToDate outside the submitted work. Coauthor John C. Fortney, PhD, reported grants from the Patient-Centered Outcomes Research Institute during the conduct of the study. Coauthor Anna D. Ratzliff, MD, PhD, reported grants from the University of Washington during the conduct of the study and royalties from Wiley outside the submitted work. No other disclosures were reported.
This story originally appeared on MDedge.com, part of the Medscape Professional Network.
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