Treating opioid use disorder in veterans with co-occurring substance use: a qualitative study with buprenorphine providers in primary care, mental health, and pain settings

Abstract

Background Most people with opioid use disorder (OUD) have co-occurring substance use, which is associated with lower receipt of OUD medications (MOUD). Expanding MOUD provision and care linkage outside of substance use disorder (SUD) specialty settings is a key strategy to increase access. Therefore, it is important to understand how MOUD providers in these settings approach care for patients with co-occurring substance use. This qualitative study of Veterans Health Administration (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) perspectives on barriers/facilitators to MOUD receipt for this population, and (3) support needed to increase MOUD receipt for this population. Methods We interviewed a purposive sample of 27 clinicians (12 primary care, 7 mental health, 4 pain, 4 pharmacists) in the VA northwest network. The interview guide assessed domains of the Tailored Implementation for Chronic Diseases Checklist. Interviews were transcribed and qualitatively analyzed using inductive content analysis. Results Participants reported varied approaches to identifying co-occurring substance use and addressing OUD in this patient population. Although they reported that this topic was not clearly addressed in clinical guidelines or training, participants generally felt that patients with co-occurring substance use should receive MOUD. Some viewed their primary role as providing this care, others as facilitating linkage to OUD care in SUD specialty settings. Participants reported multiple barriers and facilitators to providing buprenorphine care to patients with co-occurring substance use and linking them to SUD specialty care, including provider, patient, organizational, and external factors. Conclusions Efforts are needed to support clinicians outside of SUD specialty settings in providing buprenorphine care to patients with co-occurring substance use. These could include clearer guidelines and policies, more specific training, and increased care integration or cross-disciplinary collaboration. Simultaneously, efforts are needed to improve linkage to specialty SUD care for patients who would benefit from and are willing to receive this care, which could include increased service availability and improved referral/hand-off processes. These efforts may increase MOUD receipt and improve OUD care quality for patients with co-occurring substance use.

Providers’ Experiences and Perspectives in Treating Patients With Co-Occurring Opioid and Stimulant Use Disorders in the Hospital

“…33,39,40 Previous research has identified both stigma and a lack of provider knowledge of clinical guidelines as reasons patients experience opioid withdrawal in healthcare settings. 23,28 Our study advances these findings by highlighting the difficulty some hospital providers had differentiating specific withdrawal symptoms, which could delay appropriate opioid withdrawal treatment. Taken together, these findings are worrisome, as stigma and untreated withdrawal are likely causes of patient-directed discharge.…”

“…A recent qualitative study of Veterans Affairs primary care providers' experiences and perspectives treating patients with multiple SUDs identified barriers at the patient (e.g., life instability, stigma), provider (e.g., lack of knowledge or clear guidelines), and system levels (e.g., low accessibility to specialty SUD clinics providing MOUD). 23 However, patient presentations and healthcare delivery in the hospital may be substantially different than outpatient settings. Therefore, a deeper understanding of hospital providers' experiences and perspectives is needed to inform the development and implementation of targeted services for hospitalized patients with co-use.…”

“…Informed by relevant literature, 10,13,22,23,[26][27][28] we developed a semi-structured interview guide, including open-ended key questions and detailed follow-up probes. Seventeen key questions focused on hospitals' current procedures for treating patients with opioid or stimulant use disorders, existing support for patients, challenges treating patients with co-use, and suggestions for additional services or resources.…”