Not in my treatment center: Leadership’s perception of barriers to MOUD adoption

1. Introduction

The best treatments we have to combat the public health crisis of opioid use disorder are FDA-approved medications to treat opioid use disorder (MOUD): buprenorphine, methadone and naltrexone (Committee on Medication-Assisted Treatment for Opioid Use Disorder et al., 2019). Despite their established safety and effectiveness, many specialty substance use treatment facilities are unable or unwilling to offer MOUD (Mojtabai et al., 2019). Only one in three individuals in the United States with opioid use disorder (OUD) receive any OUD specialty treatment, and only a third of substance use treatment organizations offer these lifesaving medications (Jones & McCance-Katz, 2019; Mojtabai et al., 2019). While several state and provider-level efforts have been successful at increasing capacity among MOUD-providing organizations, their success in getting non-MOUD-providing organizations to change is varied (Brooklyn & Sigmon, 2017; Darfler et al., 2020; Miele et al., 2020). This issue is particularly urgent in the face of an increasingly dire fentanyl-based opioid epidemic during which deaths have soared during COVID-19, especially among people of color and in big cities (Friedman & Akre, 2021).

Philadelphia, an urban epicenter of the opioid epidemic, is the first municipality in the country to mandate the provision of MOUD in all publicly funded treatment organizations (Stewart et al., 2021). This mandate represents a coordinated effort to promote the availability of MOUD by alleviating key financial, regulatory, and access barriers while providing training and technical assistance to specialty substance use treatment organizations.

A recent investigation finds that agency leaders’ and clinicians’ attitudes towards MOUD may be as or more important as these logistical and structural barriers in whether the agency adopts MOUD, even in the context of Philadelphia’s MOUD mandate (Stewart et al., 2021). Similarly, a qualitative study within an ongoing randomized controlled trial of implementation strategies to increase MOUD adoption found that attitudes were a critical predictor of MOUD adoption and implementation (Jacobson et al., 2020). Both studies reinforce the importance of stigmatizing attitudes towards both individuals with opioid use disorder and the medications to treat opioid use disorder, which has been raised by others (Knudsen et al., 2011; Knudsen & Roman, 2014). However, neither study quantified the importance of specific attitudes in MOUD adoption, nor did either examine the relative contributions of attitudes versus other types of barriers to adopting MOUD. This information is critical towards the design of future public health initiatives and implementation strategies for combatting the opioid epidemic through expanding MOUD.

The current study adapted an established framework (Knudsen & Roman, 2014) to survey leadership of substance use treatment organizations in Philadelphia about barriers to adopting and implementing MOUD, with the goal of quantifying the relative importance of barriers related to workforce, organization, funding, regulation, and beliefs about MOUD. Consistent with prior studies in this area, we examined the extent to which these barriers distinguished between high and low-MOUD-adopting agencies.

2. Methods

2.1. Participants and Procedure

Our organization sample includes all substance use disorder treatment agencies funded by the Philadelphia Department of Behavioral Health and Intellectual disAbility Services and Community Behavioral Health, the Philadelphia Medicaid payer for behavioral health treatment. Between March and July 2020, we solicited participation from executive directors or identified leaders registered in the Community Behavioral Health network from 53 substance use disorder treatment organizations. We recruited one representative per organization using the Tailored Design Method (Dillman et al., 2014), a schedule for survey recruitment and follow-ups that enhances participation. Participants completed study procedures electronically and received a $25 gift card for participating. Data was deidentified and its use was approved by the City of Philadelphia’s Institutional Review Board.

2.2. Survey

The survey contained questions about the barriers to implementing the MOUD mandate. Agency directors answered questions about their demographic background, work experience, and their organizational characteristics, including types of services provided, the percentage of staff in recovery, and the percentage of OUD-diagnosed patients receiving MOUD. Respondents also completed a 4-point Likert scale rating the extent to which they endorse each of 22 barriers to MOUD implementation. The list was adapted and expanded from previous literature (Knudsen et al., 2011; Stewart et al., 2021) and spans five areas: including workforce (4 items), organization (2 items), funding (3 items), regulation (2 items), and beliefs about MOUD (10 items).

2.3. Statistical Analysis

First, we summarized the characteristics of the responding organizations and their leaders. Next, we dichotomized organizations based on their leader’s approximation of the percentage of their patients with OUD receiving MOUD. We categorized an organization as “high-MOUD-adopting” if more than 50% of OUD patients treated in that organization received a MOUD, otherwise they were considered a “low-MOUD-adopting.” Then, we used chi-square tests to compare high and low adopters on their endorsement of each barrier. We characterized endorsement as a rating of any significance to the question, “How significant are the following barriers to implementing MOUD in your agency?” An alpha of .05 was used as a threshold for significance. Statistical analyses were completed in SAS, version 9.4.

3. Results

3.1. Characteristics of organizations and their leaders

Leaders from 45 (85%) organizations in Philadelphia, representing 78,795 (88%) of the patients in the Community Behavioral Health network in 2019, completed the survey. Most respondents (N=31) held a directorship position in their organization (e.g. executive director, program director, medical director). Ten respondents held executive positions (e.g. chief executive officer, vice president), and five held other administrative or clinical positions (e.g. clinical coordinator, program manager, hospital administrator). Most respondents were White (64%), female (66%), and led agencies that provided outpatient services (79%). Respondents were well-experienced with, on average, 26 years of work in human services and 14 years serving at their current organization. We excluded two respondents from further analysis because they did not report on our primary variable of interest, the percentage of patients with an OUD diagnosis on MOUD. Twenty-three organizations (51%) were considered “low” adopters of the mandate (and of MOUD) because respondents reported that less than half of their patients with OUD were receiving a MOUD.

3.2. Endorsement of MOUD Barriers

Of the 22 barriers, only five were endorsed by most agency leaders: inadequate reimbursement for physician time (financing; 73.8%), diversion concerns (MOUD-belief; 67.4%), inadequate reimbursement for lab tests (financing; 64.3%), concerns around patients mixing MOUD with other medications, (MOUD-belief; 61.0%), and inadequate reimbursement for costs of purchasing MOUD (financing; 59.5%).

For nine out of the ten MOUD-belief barriers, respondents who endorsed the barrier were significantly more likely to lead organizations that adopted MOUD at low rates compared to respondents who did not endorse the barrier. For instance, agency leaders who endorsed the statement, “MOUD causes cognitive impairments in patients that interfere with their treatment,” were eight times more likely to lead low-MOUD-adopting organizations (χ2 = 10.83, p<.01). Endorsement of diversion concerns, fear that these medications may interact poorly with patient physical and mental conditions, and the idea that MOUD causes negative cognitive or physical consequences were more common among leaders who lead low-MOUD-adopting agencies (See Table 1). In addition, endorsement of two of the four workforce barriers, “Our counselors do not support the use of medications for OUD” and “Lack of staff with expertise in MOUD”, were more frequently endorsed among leaders of low adopting organizations (χ2 = 5.70, p=.02; χ2 = 8.28, p<.01). Of note, rates of endorsement for regulatory, organizational, and funding barriers were not significantly different between leaders from high and low-MOUD-adopting agencies.

Table 1.

High level of MOUD adoption among organizations whose leaders do and do not endorse barriers to implementation

Category	Barrier	Total	Leaders who endorse barrier %, N		Leaders from high-MOUD-adopting organizations who endorse barrier %, N		Leaders from high-MOUD-adopting organizations who do not endorse barrier %, N		χ2a	p-value
MOUD-belief Barriersb	Cognitive impairment in patients that interferes with their treatment	42	30.9%	13	7.7%	1	62.1%	18	10.83	<.01
	Too many patients with medical conditions that make MOUD clinically inappropriate for them	43	23.3%	10	10.0%	1	57.6%	19	7.03	.01
	Too many patients with psychological conditions that make MAT clinically inappropriate for them	43	20.9%	9	11.1%	1	55.9%	19	5.70	.02
	Negative physical consequences for patients (i.e. skeletal, dental, hormonal)	41	46.3%	19	15.8%	3	72.7%	16	11.02	<.01
	Using medications to treat addiction is substituting one drug for another	43	25.6%	11	18.2%	2	56.3%	18	4.77	.03
	Our patients are not interested in using MOUD	43	39.5%	17	23.5%	4	61.5%	16	5.92	.02
	There are better alternatives to using medications to treat OUD	43	37.2%	16	25.0%	4	59.3%	16	4.77	.03
	Too many patients divert or sell buprenorphine	43	67.4%	29	34.5%	10	71.4%	10	5.17	.02
	Too many patients mix MOUD with other medications to get high	41	61.0%	25	36.0%	9	68.8%	11	4.18	.04
	Not enough evidence that OUD treatment medications are clinically effective	43	20.9%	9	33.3%	3	50.0%	17	0.79	.37
Workforce Barriers	Our counselors do not support the use of medications for OUD	43	20.9%	9	11.1%	1	55.9%	19	5.70	.02
	Lack of staff with expertise in MOUD	43	48.8%	21	23.8%	5	68.2%	15	8.28	<.01
	Having medications like buprenorphine on-site is triggering to our staff	43	18.6%	8	50.0%	4	45.7%	16	0.05	.83
	Having patients on medications like buprenorphine is triggering to our staff	43	18.6%	8	50.0%	4	45.7%	16	0.05	.83
Regulatory Barriers	State regulations limit our ability to prescribe MOUD	42	33.3%	14	28.6%	4	57.1%	16	3.04	.08
	Federal regulations limit our ability to prescribe MOUD	43	37.2%	16	31.3%	5	55.6%	15	2.39	.12
	X-waiver requirements limit our ability to prescribe MOUD	42	42.8%	18	38.9%	7	54.2%	13	0.96	.33
Organizational Barriers	Medications for treating OUD are inconsistent with this center’s treatment policy	43	18.6%	8	25.0%	2	51.4%	18	1.83	.18
	Inadequate information about how to implement MOUD	43	18.6%	8	25.0%	2	51.4%	18	1.83	.18
Funding Barriers	Inadequate reimbursement for the costs of purchasing MOUD	42	59.5%	25	40.0%	10	58.8%	10	1.43	.23
	Inadequate reimbursement for the physician time needed to implement MAT	42	73.8%	31	45.2%	14	54.5%	6	0.29	.59
	Inadequate reimbursement for the laboratory tests needed to implement MAT	42	64.3%	27	48.1%	13	46.7%	7	0.01	.93

^adf = 1.

^bBeliefs people have about the medication, its efficacy, and its effects on their patients.

4. Discussion

For many substance use treatment organizations in the United States, the switch to MOUD requires substantial changes to how agencies are staffed, organized, funded, and regulated. Less discussed has been the ideological shift in treatment towards medications and away from abstinence-oriented conceptualizations of recovery that must happen simultaneously.

In our survey and consistent with prior national studies, we find that the leadership of most agencies endorse financial barriers to implementing MOUD. Researchers and policy makers have repeatedly documented these barriers, and there are currently tests of interventions underway nationwide to address these and other workforce challenges (Molfenter et al., 2017). Our results indicate that high MOUD adopting organizations have found ways to address these barriers even in difficult financial climates, such as the publicly funded behavioral health system. However, our findings suggest that what differentiates high and low-MOUD-adopting agencies are their leadership’s beliefs about the efficacy and effects of medications, anticipation of MOUD misuse, and perceptions of negative attitudes towards MOUD within their organization. These findings, along with recent others (Stewart et al., 2021), indicate that addressing financial and structural barriers to increasing access to MOUD is necessary but not sufficient. The result of the current study highlights the importance of developing organizational strategies that target leadership of treatment organizations in order to specifically address misconceptions about the side effects of MOUD, negative attitudes, and stigma surrounding the use of MOUD as a treatment for OUD. This set of beliefs is a type of “intervention stigma,” which is a stigma associated with a particular medical treatment (Madden et al., 2021), in this case the treatment of OUD with medication. As this study supports, agency leaderships’ attitudes towards new practices have particularly strong influences on the adoption and transitions to evidence-based practices in behavioral health (Friedmann et al., 2010). A key strategy that many policymakers have leveraged to increase MOUD capacity has been to educate clinicians about MOUD’s effectiveness. However, these findings showcase the importance of disseminating this information to the administrative leadership involved with MOUD implementation, not just medical professionals.

This study is limited by its narrow scope of one behavioral health system within one city with a municipality-wide mandate. However, studying low adopters in a large behavioral health system under the first MOUD mandate illuminate the barriers that most hinder MOUD implementation.

5. Conclusions

Deaths from overdose soared during the COVID-19 pandemic. MOUD is a safe and effective treatment for OUD, yet the traditional strategies for increasing accessibility of MOUD are not sufficiently addressing beliefs and knowledge about MOUD within treatment organizations, which we have shown differentiates low and high-MOUD-adopting organizations. Ultimately, multi-level strategies, including MOUD stigma reduction interventions and public education initiatives, must be developed to address beliefs about MOUD at the organizational, clinical, patient, family, and population levels to better address and inform knowledge, attitudes, and stigma surrounding this vital OUD treatment.