Ambivalence and contingencies: A qualitative examination of peer recovery coaches' attitudes toward medications for opioid use disorder

"My Recovery and My Work Are Separate": Perceptions of MOUD Among Certified Peer Recovery Supporters

OBJECTIVES

Ongoing high rates of opioid use and overdose death have prompted expansion of care options for people with substance use disorder (SUD), including medications for opioid use disorder (MOUD) and diverse forms of care linkage and support. The utilization of Certified Peer Recovery Supporters (CPRS) in the recovery field is an evidence-based practice to improve the continuum of care for SUD and has been increasingly incorporated into the recovery field. This study examines perceptions of MOUD among CPRS and how this shapes the collaborative provision of care within local treatment and recovery ecosystems.

METHODS

Qualitative interviews were conducted with CPRS (n=22) who were recruited via snowball sampling. Eligible participants were above 18 years old and had CPRS certification and self-reported work experience in treatment ecosystems in Dayton, OH. Interviews were transcribed and uploaded to Taguette software for coding and analysis. Select codes were analyzed using Iterative Categorization for further thematic analysis and data interpretation. All 22 participants were included in the analysis.

RESULTS

Three key findings pertaining to perceptions of MOUD among CPRS were identified, including stigma against MOUD within treatment and recovery ecosystems, the value of MOUD as treatment and harm reduction, and structural frustrations within the health care system. Participants expressed multiple, complex viewpoints surrounding the utilization of MOUD, specifically related to treatment, work environments, and health care settings.

CONCLUSIONS

Results indicate that while many CPRS believe MOUD to be a successful treatment, stigma and institutional mistrust remain as barriers to both collaboration with medical providers and utilization of MOUD.

Perspectives of substance use disorder counselors on the benefits and drawbacks of medications for opioid use disorder

BACKGROUND

Medications for opioid use disorder (MOUD) are among the best tools available to combat the opioid epidemic. Yet, use of MOUD among people with opioid use disorder (OUD) remains low. Interventions to increase MOUD access in the United States have largely focused on improving organizational capacity and addressing funding barriers, yet stigma toward MOUD may inhibit uptake even where MOUD is readily available. Non-prescribing substance use disorder (SUD) treatment professionals (e.g. counselors) likely have considerable influence on a client's choice to initiate and adhere to MOUD, but beliefs that counselors convey about MOUD in interaction with clients are understudied. The current study explores what advantages and disadvantages that counselors communicate about buprenorphine, methadone, and naltrexone.

METHODS

From June to December 2021, we surveyed counselors from publicly-funded SUD treatment agencies under a municipality-wide mandate to offer MOUD to all clients with OUD. Counselors were asked to describe, in a free-response format, the most important advantages and disadvantages to communicate to their clients about taking buprenorphine, methadone, and naltrexone. Counselor responses were coded for one or more advantage and disadvantage.

RESULTS

A total of 271 SUD counselors from 29 agencies in the Philadelphia Metropolitan Area completed the survey, generating 1,995 advantages and disadvantages across three types of MOUD. The most frequently reported advantage across all three types of MOUD was their ability to reduce cravings and illicit drug use. The most frequently reported disadvantage related to the potential for some types of MOUD to develop long-term medication dependence.

CONCLUSIONS

As the availability and variety of MOUD treatment options continue to expand, it is important that SUD counselors are equipped with evidence-based recommendations for OUD care. We identified misalignments with the MOUD-prescribing evidence base and stigmatizing language toward MOUD within counselors' responses, highlighting the potential to refine training materials for MOUD and mitigate stigmatizing beliefs.

Relationship of hub and treatment characteristics with client outcomes in the initial Washington State hub and spoke cohort

INTRODUCTION

Washington State's Hub and Spoke (HS) approach aims to improve availability of opioid use disorder (OUD) treatment. Washington initially funded six hubs with expertise in medications for opioid use disorder (MOUD) that built care networks with referral and treatment partners (spokes). We assessed outcomes for the initial HS cohort, considering the role of HS and treatment characteristics.

METHODS

We conducted a cohort-based observational study using 2017-2019 Medicaid claims data for 2841 HS participants aged 18-64, excluding those with past-month MOUD, in an intent-to-treat analysis. We describe treatment characteristics (MOUD type, treatment setting, and hub type at the initial HS visit, number of outpatient services in their first HS month), and six-month outcomes (MOUD continuity, emergency department (ED) utilization, hospitalization, and intensive SUD treatment). We used multivariable regressions to assess associations with six-month outcomes, adjusting for client characteristics.

RESULTS

Two-thirds (68 %) of participants received buprenorphine, 22 % methadone, 5 % naltrexone, and 5 % outpatient without MOUD for their initial visit. Within six months, 45 % had an ED visit, 14 % any hospitalization, and 18 % entered intensive SUD treatment. Only 24 % remained on MOUD for six months. Compared to buprenorphine, the methadone sample had higher odds of MOUD continuity (aOR = 2.81, 95%CI 2.21-3.55), and the naltrexone sample had lower odds (aOR = 0.36, 95%CI 0.19-0.66). FQHC/public health treatment settings had higher odds of MOUD continuity (aOR = 1.70, 95%CI 1.17-2.47) but hub type was not significant. MOUD continuity increased with 2+ outpatient services for the buprenorphine sample (aOR range 2.55-4.73). Odds of intensive SUD treatment were lower for the methadone sample, compared to buprenorphine (aOR = 0.16, 95%CI 0.11-0.23), all settings compared to SUD settings (aOR range 0.32-0.58), and SUD + MH and medical/hospital hubs compared to SUD only hubs (aOR range 0.28-0.41).

CONCLUSIONS

Most participants did not attain six-month MOUD continuity, despite the HS approach, with variations by MOUD type and treatment setting. The number of outpatient services in the first month for buprenorphine clients was associated with greater odds of MOUD continuity and reduced odds of intensive SUD treatment. More work is needed to improve MOUD continuity for people with OUD within the HS model.

Attitudes toward and training in medications for opioid use disorders: a descriptive analysis among employees in the youth legal system and community mental health centers

BACKGROUND

Research demonstrates gaps in medications for opioid use disorder uptake (MOUDs; methadone, buprenorphine, and naltrexone) especially among adolescents. These gaps may be partly attributable to attitudes about and training in MOUDs among youth-serving professionals. We extended prior research by conducting descriptive analyses of attitudes regarding effectiveness and acceptability of MOUDs, as well as training in MOUDs, among youth legal system (YLS) employees and community mental health center (CMHC) personnel who interface professionally with youth.

METHODS

Using survey data from participants (n = 181) recruited from eight Midwest counties, we examined: (1) differences in MOUD attitudes/training by MOUD type and (2) by respondent demographics, and (3) prediction of MOUD attitudes/training by participant-reported initiatives to implement evidence-based practices (EBPs), workplace culture around EBPs, and workplace stress. Attitudes and training were measured in reference to five MOUD types (methadone, oral buprenorphine, injectable buprenorphine, oral naltrexone, injectable naltrexone) on three subscales (effectiveness, acceptability, training).

RESULTS

Wilcoxon signed-rank tests demonstrated that most outcomes differed significantly by MOUD type (differences observed among 22 of 30 tests). Kruskal-Wallis tests suggested MOUD differences based on demographics. For methadone, CMHC providers endorsed greater perceived effectiveness than YLS providers and age explained significant differences in perceived effectiveness. For buprenorphine, CHMC providers viewed oral or injectable buprenorphine as more effective than YLS employees, respondents from more rural counties viewed oral buprenorphine as more effective than those from less rural counties, and age explained differences in perceived effectiveness. For naltrexone, perceived gender differed by gender. Hierarchical ordinal logistic regression analysis did not find an association between personal initiatives to implement EBPs, workplace culture supporting EBPs, or workplace stress and effectiveness or acceptability of MOUDs. However, personal initiatives to implement EBPs was associated with training in each MOUD.

CONCLUSIONS

These results highlight a few key findings: effectiveness/acceptability of and training in MOUDs largely differ by MOUD type; setting, rurality, age, gender, and education explain group differences in perceived effectiveness of and training in MOUDs; and implementing EBPs is associated with training in MOUDs. Future research would benefit from examining what predicts change in MOUD attitudes longitudinally.

Attitudes toward medications for opioid use disorder among peer recovery specialists

Background: Peer recovery specialists (PRSs) are substance use service providers with lived experience in recovery. Although a large body of research demonstrates the efficacy of medications for opioid use disorder (MOUD), emerging research suggests PRSs' attitudes toward MOUD are ambivalent or mixed. Few studies have quantitatively assessed factors influencing PRSs' attitudes.Objectives: This study identifies personal and professional characteristics associated with attitudes toward MOUD among PRSs.Methods: PRSs working at publicly funded agencies in Michigan completed a self-administered web-based survey (N = 266, 60.5% women). Surveys assessed socio-demographics, treatment and recovery history, attitudes toward clients, and attitudes toward MOUD. Multiple linear regression was used to identify factors associated with attitudes toward MOUD.Results: A minority of PRSs (21.4%) reported a history of treatment with MOUD, while nearly two-thirds reported current 12-step involvement (62.5%). Compared to PRSs without a history of MOUD treatment, PRSs who had positive (b = 4.71, p < .001) and mixed (b = 3.36, p = .010) experiences with MOUD had more positive attitudes; PRSs with negative experiences with MOUD had less positive attitudes (b = -3.16, p = .003). Current 12-step involvement (b = -1.63, p = .007) and more stigmatizing attitudes toward clients (b = -.294, p < .001) were associated with less positive attitudes toward MOUD. Black PRSs had less positive attitudes than White PRSs (b = -2.50, p = .001), and women had more positive attitudes than men (b = 1.19, p = .038).Conclusion: PRSs' attitudes toward MOUD varied based on the nature of their lived experience. Findings highlight considerations for training and supervising PRSs who serve individuals with opioid use disorder.