Gallo, Rachel M, MPH

Jimenez, Frances, BA

Richards, Mark, BA

Rosingana, Katie, BA

Smith, Mary Lindsey, PhD

English

University of Southern Maine: Digital Commons@USM

University of Southern Maine USM Digital Commons Substance Use Research & Evaluation Cutler Institute 2019 Addressing the Treatment and Recovery Support Needs of Individuals with Opioid Use Disorder: Patient Perspectives Mary Lindsey Smith PhD University of Southern Maine, Cutler Institute, m.l.smith@maine.edu Katie Rosingana BA University of Southern Maine, Cutler Institute, katherine.rosingana@maine.edu Rachel M. Gallo MPH University of Southern Maine, Cutler Institute, rachel.gallo@maine.edu Frances Jimenez BA University of Southern Maine, Cutler Institute, frances.jimenez@maine.edu Mark Richards BA University of Southern Maine, Cutler Institute, mark.f.richards@maine.edu Follow this and additional works at: https://digitalcommons.usm.maine.edu/substance-use-research-and-evaluation  Part of the Substance Abuse and Addiction Commons Recommended Citation Smith, M. L., Rosingana, K., Gallo, R., Jimenez, F., & Richards, M. (2019). Addressing the Treatment and Recovery Support Needs of Individuals with Opioid Use Disorder: Patient Perspectives. Issue Brief. University of Southern Maine, Muskie School of Public Service, Cutler Institute. This Issue Brief is brought to you for free and open access by the Cutler Institute at USM Digital Commons. It has been accepted for inclusion in Substance Use Research & Evaluation by an authorized administrator of USM Digital Commons. For more information, please contact jessica.c.hovey@maine.edu.       Maine Health Access Foundation’s Addiction Care Program Addressing the Treatment and Recovery Support Needs of Individuals with Opioid Use Disorder: Patient Perspectives  Mary Lindsey Smith, PhD, MSW; Katie Rosingana, BA; Rachel Gallo, MPH; Frances Jimenez, BA and Mark Richards, BA University of Southern Maine, Muskie School of Public Service       INTRODUCTION  In Maine and across the nation, the high rate of opioid misuse and subsequent addiction is an ongoing public health crisis. Despite numerous statewide efforts to reduce rates of opioid prescribing, prevent diversion, and increase access to treatment for opioid use disorder (OUD), rates of opioid-related overdoses and deaths in Maine remain high. Maine Health Access Foundation’s (MeHAF) Expanding Patient-Centered Addiction Care Program focuses on addressing opioid related morbidity and mortality by supporting capacity building efforts to increase Medicated Assisted Treatment (MAT) in primary care settings.  Ten organizations throughout Maine were selected in 2017 to expand access to  MAT with the goal of engaging a broad-based network of partners in their planning and implementation activities to ensure the necessary referral relationships and wrap-around services to promote sustained, long-term recovery for people in treatment.  EVALUATING THE PROGRAM  In order to assess successes, challenges and learning in the work to increase access to MAT within their organizations, an evaluation team from the Muskie School of Public Service at the University of Southern Maine collected data at the participating Addiction Care Program sites between May of 2017 and May of 2019. The primary sources of data for the program evaluation included administrative and clinical data, surveys, key informant interviews with stakeholders (e.g. practice leadership, support staff, health care providers), and focus groups with individuals in recovery from OUD. Given that one of the primary focuses of the Addiction Care Program is to expand capacity to provide patient-centered care with an emphasis on increased access for the uninsured or those who are medically underserved, data gathered through focus groups with individuals in recovery was a critical component of the program evaluation. Focus groups were designed to elicit feedback from individuals in recovery on key domains of interest including: how could the delivery of MAT be enhanced to reduce access barriers; what types of support do persons in recovery need; what have been some of the challenges patients have faced in accessing MAT services; and patient recommendations for enhancing patient-centered care. A total of 45 individuals participated in 9 focus groups conducted at grantee organizations in the last two quarters of Year One (N=34) and Year Two (N=11).  Qualitative data analysis was done iteratively to identify reoccurring themes. The primary high-level themes that emerged from the focus groups included:    unmet needs and service gaps;  barriers and facilitators to treatment initiation, engagement, and recovery maintenance;  desired MAT components for patient-centered care; and  mechanisms for promoting patient-centered approaches to addressing OUD.  PATIENT-LEVEL BARRIERS TO TREATMENT INITIATION AND ENGAGEMENT  Prior to the implementation of the Addiction Care Program, the majority of patients described difficulty obtaining both OUD treatment and medication consistently and reliably. Overall, patients cite a number of reasons why initiating and engaging in treatment can be difficult even when they are ready to seek help. The majority of patients indicated that there are often no clear paths for individuals seeking treatment for OUD. In addition, limited detoxification and treatment options, coupled with the lack of MAT providers in certain areas of the state, makes identifying and accessing treatment difficult for patients.   Among persons interviewed, the cost of treatment services and prescription medications was by far the most prohibitive barrier to accessing and engaging in treatment for OUD. The costs of treatment and medication associated with MAT are often compounded by the lack of health insurance or insufficient insurance coverage for MAT services.         In addition, patients reported facing a variety of other barriers to treatment initiation and engagement including:    long wait times for services;  lack of awareness of available resources;  time commitments for appointments such as needing childcare or time out of work;  inflexible treatment program policies;  an absence of safe and reliable transportation; and  stigma around OUD from community, family, and providers.  Once patients are able to initiate treatment, they face a number of additional barriers to engaging in ongoing treatment for OUD. Other than the costs associated with MAT, the largest patient-reported barrier to successfully completing treatment, particularly at the intensive outpatient (IOP) stage, was the time commitment of the program. IOPs are treatment programs that do not require detoxification or round-the-clock supervision, thus enabling patients to continue with their day-to-day lives. However, patients stated that the time commitment was burdensome.  Particularly in Year One of the Addiction Care Program, patients were seeking greater flexibility within program policies and requirements. As with other chronic relapsing conditions, the clinical course of OUD includes periods of exacerbation and remission, but the patient is never disease-free.  Patients reported past recurrences, missing appointments or group therapies, and changes in insurance that often put them back at “square one” in an intensive outpatient program. The time associated with programmatic policies remains an issue even when individuals transition to less intensive treatment regimes. Multiple medical appointments, group and individual therapy sessions, and random screenings each week, often held during work hours, make maintaining employment or finding childcare challenging for patients. Moreover, respondents indicated that it was often difficult for them to find safe, reliable and/or affordable transportation to treatment programs, particularly in rural areas that lack robust transportation systems, which makes meeting program requirements challenging. In fact, patients reported that unreliable transportation was the primary cause of treatment non-compliance (e.g. missing appointments, pill counts, urine screens). Given these challenges, patients clearly articulated the need for a spectrum of treatment and recovery services that allow for multiple points of entry and accommodate the chronic relapsing nature of OUD. Finally, patients also reported the need for increased training and education on OUD pathology for medical providers, community members, families, and people with OUD to combat stigma. Patients acknowledged that stigma remains a major barrier to accessing treatment for OUD. Patients reported that stigma related to their OUD adversely impacted many domains of life such as treatment engagement, employment, housing, and social relationships.     DESIRED MAT PROGRAM FEATURES   Given the challenges patients reported related to accessing and utilizing treatment and recovery services, patients offered feedback on what an ideal MAT program would look like. These patients’ suggestions indicated areas where grantees could enhance wrap-around services to promote a more patient-centered approach to address barriers to accessing and engaging in treatment. Patients described a number of treatment program features they felt necessary for success to enhance treatment engagement and support long-term recovery such as reliable and affordable access to medication; flexible program polices; productive individual and group counseling; as well as support and trust from family members, friends, and medical staff (see infographic, next page).  “The last thing you need when you're working on recovery and you have a relapse or a bad day… is to be kicked out. That doesn’t work.”           A large majority of patients who participated in focus groups reported that the medication component of MAT programs was the greatest advantage of MAT, compared to other OUD treatment options. Patients spoke of the life changing effect of buprenorphine on their daily lives, primarily because the absence of withdrawal symptoms has brought stability to their lives. In addition to consistent, reliable, and affordable access to MAT and quick access to treatment programs, all patients described the need for community supports and integration, including employment opportunities, sober activities, counseling, and peer supports in order to maintain recovery.  GRANTEE STRATEGIES FOR PROMOTING PATIENT-CENTERED CARE Patient feedback about barriers to treatment engagement has enabled grantee sites to make adjustments to their MAT programs. Understanding the barriers patients face has allowed grantee organizations to be better prepared to make course corrections in their programs to better meet the needs of the patients and families they serve. In the second year of the MeHAF Addiction Care Program, grantees increased their emphasis on creating treatment protocols and policies to include interventions specific to the tasks and challenges faced by their patients at each stage of treatment, maintenance, and recovery. Grantees understood the importance of regularly assessing patient feedback and utilizing that information to refine program requirements to meet the unique needs of participants.  Patients in both Years One and Two described being part of a care team within the MAT programs operated by Addiction Care Program grantees. Patients reported that they had meaningful engagement in their treatment planning, leading them to feel more personally accountable for their recovery, which had not been their experience in previous treatment programs. Patients interviewed in Year Two also described a sense of responsibility to work with their care team to positively create a treatment and maintenance plan stressing their appreciation for accountability within a flexible, accessible program.  As indicated from the patients’ perspective, creating low-barrier access to MAT is a critical component to ensuring treatment initiation and engagement for persons with OUD. Several grantees in Year Two leveraged funding to help reduce barriers to accessing care and treatment within their programs and to address stigma, which was seen as a major barrier by both patients and providers. Patient feedback was utilized to address barriers around treatment access, cost, program format, education, and auxiliary supports (see infographic on next page).   “With this program, you’re held more accountable. You have to be involved more. I don’t think I’d be where I am right now if it wasn’t for this Suboxone program and the staff where I go.” “So now I look at Suboxone like taking my blood pressure medication every day. I do the same thing and I just feel normal. It makes me operate, function day-to-day. It’s like I was never on opiates ever before.” “Three days a week, four hours. I found that to be a bit much for me and for my needs. They modified it for me. I'm self-employed. They worked with me on that.”         SUMMARY Maine is among the states hardest hit by a national trend of non-medical uses of opioid prescription drugs and heroin, with subsequent increases in opioid-related morbidity and mortality. Addressing the opioid epidemic in Maine is particularly challenging given the rural nature of the state which creates unique challenges for those with OUD who are seeking treatment. Feedback from patients has played a key role in informing the planning and implementation activities of the Addiction Care Program grantee organizations. Quick access to treatment programs, consistent access to MAT, insurance coverage, auxiliary recovery supports (e.g. transportation, safe and stable housing), peer and family support (e.g. group support meetings, supportive families/friends, a peer recovery coach), as well as opportunities for community integration (e.g. social activities and employment), were the most frequently mentioned factors necessary to support ongoing maintenance and recovery. In an effort to address these challenges, during the first two years of the program, grantee organizations have trained providers as well as staff on treating persons with OUD, readjusted staff and workflows to increase rapid access to treatment, and initiated recovery coaching programs. Moreover, grantee organizations have made adjustments to program requirements in an effort to reduce barriers to access and promote a more patient-centered approach to treating OUD (see infographic, left).  The comprehensive planning   efforts undertaken by grantee organizations have allowed them to greatly increase their capacity to address OUD  while at the same time ensuring that the MAT services being implemented as part of the  Addiction Care Program focus on addressing patient needs.  “I think it’s [MAT] really changed my life. I don't have to worry about being sick every day. I don't have to go out and find it every day. I'm able to be a mother to my daughter.” 

Addressing the Treatment and Recovery Support Needs of Individuals with Opioid Use Disorder: Patient Perspectives

https://digitalcommons.usm.maine.edu/cgi/viewcontent.cgi?article=1000&context=substance-use-research-and-evaluation

Addressing the Treatment and Recovery Support Needs of Individuals with Opioid Use Disorder: Patient Perspectives

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