Clinician identified barriers to treatment for individuals in Appalachia with opioid use disorder following release from prison: a social ecological approach

Abstract

BackgroundThe non-medical use of opioids has reached epidemic levels nationwide, and rural areas have been particularly affected by increasing rates of overdose mortality as well as increases in the prison population. Individuals with opioid use disorder (OUD) are at increased risk for relapse and overdose upon reentry to the community due to decreased tolerance during incarceration. It is crucial to identify barriers to substance use disorder treatment post-release from prison because treatment can be particularly difficult to access in resource-limited rural Appalachia.MethodsA social ecological framework was utilized to examine barriers to community-based substance use treatment among individuals with OUD in Appalachian Kentucky following release from prison. Semi-structured qualitative interviews with 15 social service clinicians (SSCs) employed by the Department of Corrections were conducted to identify barriers at the individual, interpersonal, organizational/institutional level, community, and systems levels. Two independent coders conducted line-by-line coding to identify key themes.ResultsTreatment barriers were identified across the social ecological spectrum. At the individual-level, SSCs highlighted high-risk drug use and a lack of motivation. At the interpersonal level, homogenous social networks (i.e., homophilious drug-using networks) and networks with limited treatment knowledge inhibited treatment. SSC’s high case load and probation/parole officer’s limited understanding of treatment were organizational/institutional barriers. Easy access to opioids, few treatment resources, and a lack of community support for treatment were barriers at the community level. SSC’s noted system-level barriers such as lack of transportation options, cost, and uncertainty about the implementation of the Affordable Care Act.ConclusionsMore rural infrastructure resources as well as additional education for family networks, corrections staff, and the community at large in Appalachia are needed to address barriers to OUD treatment. Future research should examine barriers from the perspective of other key stakeholders (e.g., clients, families of clients) and test interventions to increase access to OUD treatment.

Adaptation of a standard extended-release naltrexone (XR-NTX) protocol for rural re-entering offenders with OUD

“…It was noted in both stakeholder focus groups that stigma around non-medical opioid use in general, as well as MOUD treatment (and XR-NTX specifically), is very common in this rural area -including among a number of professional organizations (including criminal justice staff). This has been consistently noted in the literature for criminal justice organizations, particularly P&P and jails (e.g., Bunting, Oser, Staton, Eddens, & Knudsen, 2018;Friedmann et al, 2012). Being mindful of the potential stigma around medications during the recruitment and community retention is important, as well as increasing education for participants and stakeholders on the benefits of medications.…”

The Opioid-overdose Reduction Continuum of Care Approach (ORCCA): Evidence-based practices in the HEALing Communities Study

“…In addition to defining populations at high risk for overdose, the ORCCA also identifies populations that would likely warrant tailoring EBP strategy implementation. These groups include adolescents ( Bagley et al, 2020 ; Chatterjee et al, 2019 ; Lyons et al, 2019 ), pregnant and post-partum women ( Goldman-Mellor and Margerison, 2019 ; Nielsen et al, 2020 ), homeless populations ( Bartholomew et al, 2020 ; Doran et al, 2018 ; Magwood et al, 2020 ), rural populations without transportation ( Arcury et al, 2005 ; Bunting et al, 2018 ) and other factors related to poverty ( Snider et al, 2019 ; Song, 2017 ), veterans ( Lin et al, 2019 ; Mudumbai et al, 2019 ), non-English speaking and immigrant populations ( Salas-Wright et al, 2014 ; Singhal et al, 2016 ), racial and ethnic minorities ( Barocas et al, 2019 ; Lippold et al, 2019 ), people with mental health disorders ( Turner and Liang, 2015 ) and mental/physical disabilities ( Burch et al, 2015 ; West et al, 2009 ), people involved in transactional sex ( Goldenberg et al, 2020 ; Marchand et al, 2012 ), and people who have chronic pain ( Bohnert et al, 2011 ; Dunn et al, 2010 ; James et al, 2019 ). As one of the HCS requirements, communities will record the high-risk populations and community venues included in the selected EBP strategies.…”

Introduction to the special issue

“…Important patient-level barriers included privacy concerns about speaking in a group, and system-level barriers included treatment waitlists. Using the social ecological model to guide analyses, Bunting et al [14] interviewed social workers from the Kentucky Department of Corrections to identify patient-level barriers, such as lack of motivation, and system-level barriers, such as high case load and limited treatment resources. Implementation efforts to improve uptake of evidencebased substance use disorder treatment will need to tackle these barriers to ensure criminal justice involved [17] demonstrated that people with both a substance use disorder and an incarceration history had higher odds of utilizing substance use disorder treatment compared to people who had a substance use disorder without a history of incarceration.…”