Psychosocial challenges affecting patient-defined medication for opioid use disorder treatment outcomes in a low-income, underserved population: Application of the social-ecological framework

Abstract

Introduction:

Successful engagement with medication treatment for opioid use disorder is an important focus in reducing mortality associated with the opioid crisis. Mortality remains at unacceptably high levels, pointing to a need for improved understanding of factors that affect medication for opioid use disorder outcomes. This study aims to understand how barriers co-occur and interact to interfere with outcomes in methadone treatment for a low-income, underserved patient population with opioid use disorder.

Methods:

This study was conducted at a community-based drug treatment center that serves a predominately low-income, racially diverse population. Guided by the social-ecological framework, we analyzed semi-structured interviews and focus groups with patients and providers working in opioid use disorder care and recovery across Baltimore City (N=32) to assess factors that influence methadone treatment outcomes, and how barriers co-occur and interact to worsen treatment outcomes. The study used patient-centered definitions to describe successful treatment outcomes.

Results:

Barriers described by both patients and providers fit into several broad levels: individual, interpersonal, institutional, community, and stigma. Participants described co-occurrence of many barriers. Further, the study identified potential interactive effects, such that interrelated barriers were seen as fueling one another and having a deleterious effect on treatment outcomes. Specifically, interrelationships between barriers were described for 1) unstable housing with social influences and mental health factors; 2) transportation with poor physical health and other competing responsibilities; 3) treatment program policies and schedule with competing responsibilities; and 4) stigma with poor physical and mental health.

Conclusions:

Understanding barriers to successful medication for opioid use disorder outcomes and considering their co-occurrence may help to identify and promote interventions to mitigate their impact. This work is intended to guide future research to adapt conceptual frameworks for understanding psychosocial and structural barriers affecting opioid use disorder treatment and ultimately intervention efforts to improve treatment outcomes.

1. Introduction

The rate of opioid overdose deaths per year in the United States more than doubled between 2010 and 2019 and, in 2020, almost 70,000 people are estimated to have died as a result of opioid overdose (Centers for Disease Control and Prevention (CDC), 2020, 2021). Increases in overdose deaths are largely fueled by the rise in heroin use after earlier proliferation of prescription opioids and subsequent increases in deaths involving synthetic opioids, especially fentanyl (CDC, 2021). The fastest growing fentanyl overdose death rates are disproportionately occurring within Black and African American populations (Wu et al., 2021). Baltimore City, where more than 90% of fatal drug overdoses involve opioids, reported a 2017 drug overdose fatality rate that is higher than any other metropolitan county in the country (Baltimore City Health Department, 2018; Maryland Department of Health, 2018).

Evidence-based approaches to treat opioid use disorder (OUD) include medications for OUD (MOUD; e.g. methadone, buprenorphine, and naltrexone) typically delivered alongside behavioral therapy as part of a comprehensive program (National Academies of Sciences, Engineering, and Medicine, 2018). Given the chronic course of OUD, long-term adherence and retention in care are crucial to prevent withdrawal symptoms that can precipitate relapse and fatal overdoses. However, fewer than half of people who initiate MOUD are retained in treatment for at least six months (Williams et al., 2019). Like most current MOUD regimens, methadone treatment involves daily dosing, but is unique in that it usually requires daily observed dosing (i.e., daily medication dispensed at the clinic and taken by patients in front of clinic staff). The necessary length of time on methadone treatment varies on an individual basis, but prior research indicates that three months on treatment is needed to reduce or stop use, and optimal outcomes (long-term prevention of relapse) occur with longer durations of treatment (NIH, 2018). People who drop out of methadone treatment experience 3.2 times the rate of all-cause mortality and 4.8 times the rate of overdose mortality compared to people who remain on treatment (Sordo et al., 2017). A serious public health need exists to identify strategies that address barriers to MOUD retention.

The factors that interfere directly with methadone treatment outcomes cannot be considered in isolation, but rather in the context of other disorders, social factors, and environmental exposures. Patients receiving methadone treatment frequently live with co-occurring psychosocial problems and stressors; psychiatric comorbidity, homelessness, and violent victimization have all been shown to be associated with worse treatment outcomes for people receiving methadone or other treatment for substance use disorder (Carpentier et al., 2009; Lo et al., 2018; Parpouchi et al., 2017). Furthermore, systemic and structural barriers have been previously described, such as stigma, negative social perceptions, and dissatisfaction with treatment delivery systems, such as program requirements (Jeske & O’Byrne, 2019; Reisinger et al., 2009; Smith et al., 2020). Despite extensive literature describing barriers to successful methadone treatment outcomes, little information is available on how the co-occurrence of such barriers affects poor treatment outcomes, and how these co-occurring factors may interact at multiple levels to further worsen methadone treatment outcomes, especially among underserved, low-income, ethnoracially diverse individuals.

The social-ecological framework was originally conceptualized by Bronfenbrenner (Bronfenbrenner, 1979) and has more recently applied to illustrate the dimensionality of the opioid crisis (Bunting et al., 2018; Jalali et al., 2020). By delineating levels of influence (individual, interpersonal, institutional, and environmental/societal), the social-ecological framework broadens the historical focus on individual characteristics and experiences. It provides a systematic approach for understanding disease, particularly among underserved and marginalized populations.

Guided by the social-ecological framework, this study examined psychosocial and contextual factors that may impact patient-centered MOUD outcomes, specifically methadone treatment, and how the cooccurrence and interaction of these factors can further contribute to poor treatment outcomes. The study used the social-ecological framework to identify how barriers exist and interact at multiple levels—individual, interpersonal, institutional, and environmental. The overall aim of this work is to better understand potential factors affecting patients receiving methadone treatment to inform future research to adapt conceptual models and to improve intervention development research, from which we can learn how best to support methadone treatment outcomes.

2. Methods

2.1. Setting

This study took place at a large, community-based, outpatient opioid treatment program in Baltimore City. A majority of patients at this program identify as Black or African American, greater than 95% receive Medicaid services, and more than 80% of patients report having earned less than $15,000 in the past year. The program is oriented to harm reduction practices and offers same-day intake and a low-threshold treatment approach. At the time of this study, conducted from September 2019 to March 2020, patients who demonstrated program fidelity (including regular attendance and negative toxicology screens for illicit drug use) were offered take-home doses. Though abstinence from drugs is not required for treatment, it was a requirement for take-home doses.

2.2. Participants and recruitment procedures

Participants in this study (N=32) included providers (n=12), both at the treatment site and peer providers working in the greater Baltimore community, and patients currently enrolled in treatment at the study site (n=20). Table 1 outlines demographic information and other characteristics of participants. A majority of participants, across patients and providers, identified as male (59.4%) and Black or African American (65.6%) and the mean age was 48.7 years (SD=10.1). We included provider perspectives in addition to patients to capture a comprehensive description of barriers to successful methadone treatment outcomes. Provider experience with many different patients, both those who have and have not remained in treatment, makes them a useful source of information to enhance and complement patient perspectives. Furthermore, many of the staff members included, and all of the peers, have their own lived experience of substance use and recovery and have an intimate understanding of the patient population. Finally, we felt that it was important to have the opportunity to investigate possible nuanced differences between patient and provider responses that may, themselves, point to barriers in treatment.

Table 1.

Participant Demographics and Other Characteristics

	n (%)
Patient Participants (n=20)
Race
Black or African American	12 (60.0)
White	6 (30.0)
Other	2 (10.0)
Male gender	14 (70.0)
Mean age (SD)	48.4 (10.0)
Mean age at first SU (SD)	17.7 (5.1)
Staff and Peer Participants (n=12)
Race
Black or African American	9 (75.0)
White	2 (16.7)
Other	1 (8.3)
Male gender	5 (41.7)
Mean age (SD)	49.2 (0.7)
Average years working in SU treatment (SD)	9.6 (7.6)
Reported SU history
Among peers	4 (100.0)
Among staff members	6 (75.0)

SD=standard deviation, SU=substance use

Providers were purposefully selected based on their roles in patient care and program administration, both at the study treatment site and peers working in clinical and community-based organizations across the City. Staff included five addiction counselors, one nurse, one social worker, and one PRS who described their role as “peer coach.” Peer participants worked across a range of roles: peer coach, state-level program administration, and “residential coach,” and “other counseling.” Any staff members (all adults) with at least three months experience at the opioid treatment program and any adult peer with experience working with people who use substances in Baltimore City were eligible. Patient participants had to be at least 18 years old and currently enrolled in methadone treatment at the opioid treatment program. Patients were largely recruited via flyers and word of mouth. Patients were also purposefully sampled who were both successfully engaged in methadone treatment as well as struggling with retention, allowing us to capture both perspectives. Staff utilized patient dosing records to identify patients who had missed at least five methadone doses in the past two weeks and flagged those patients in the dosing system to provide information about the study when they returned to the clinic.

We conducted interviews and focus groups until no new ideas central to the study question arose and responses across participants became redundant (i.e., theoretical saturation) (Pope & Mays, 2006). After recruitment of 32 participants, no new information emerged across focus groups and individual interviews.

All participants were provided gift card compensation in the amount of $25 for their time. All participants provided written informed consent prior to study enrollment. All study procedures were reviewed and approved by the University of Maryland, College Park IRB with Interagency Agreement approved by the University of Maryland, Baltimore.

2.3. Procedures

We elected to conduct both focus groups and individual interviews to capture the patient and provider perspectives as fully as possible, recognizing that we may elicit different insights from these two qualitative methodologies (Carlsen & Glenton, 2011; Carter et al., 2014). Focus groups allowed for shared ideas and consensus on most common or pervasive barriers to successful treatment outcomes, while individual interviews drew on the individual experience and captured more specific examples of barrier co-occurrence and interactions. A maximum of six participants were included in each focus group (Krueger & Casey, 2008). Providers and patients were given the choice of participating in either a focus group or an individual interview but could not participate in both. Focus groups were separated such that patients only participated in focus groups with other patients, and providers only participated in focus groups with other providers. Twenty-two participants took part in focus groups (11 provider focus group participants and 11 patient focus group participants) and ten participated in interviews (one provider interview and nine patient interviews). We conducted three provider focus groups and two patient focus groups.

We developed semi-structured focus group and interview guides to solicit feedback on co-occurring barriers to methadone treatment outcomes. Semi-structured guides were adapted in collaboration with local staff and stakeholders through early, informal conversations about questions they feel were important to address. For example, staff emphasized the need for questions that allowed for elaboration on patient-defined treatment success. Stakeholders involved in interview guide development included treatment program leadership and collaborators who conduct research at the same site. The study team further adapted guides through an iterative process based on feedback from participants. Feedback was not collected formally, but included indicators of need to clarify questions, change wording, and provide prompts/examples.

Interview and focus group guides included the same questions for each group. We used a patient-centered approach to define successful treatment outcomes before asking about barriers to these patient-defined successful outcomes in methadone treatment. Participants were asked to describe how patients define successful methadone treatment outcomes, rather than being restricted to only treatment retention or methadone dosing-related measures, which is historically the focus of much of the literature on MOUD outcomes (Biondi et al., 2020; Bradley et al., 2020). The patient guide asked about their perception of barriers to methadone treatment while the provider guide asked about how their patients experience barriers to treatment. We then probed specifically for the co-occurring and interacting effects between barriers. Participants were asked if and how they understand barriers to co-occur and affect one-another, and how these relationships affect treatment outcomes. The focus group guide utilized an interactive approach to allow participants to consider and write down their own ideas of most commonly experienced barriers to successful methadone treatment outcomes. Written responses were collected by a focus group facilitator and anonymously presented back to the group to facilitate discussion. Group-determined common barriers were used in the follow-up questions about interaction. The individual interview guide similarly asked participants to identify several common barriers to successful methadone treatment outcomes and the interviewer used that information to ask questions about co-occurrence and how they may affect one another.

Focus group leaders and interviewers did not have relationships with participants (patients or providers) outside of a research capacity and were not involved in patient care in any way. Focus groups were led by two researchers (combination of MBK, CJSB, and VDB) and interviews were conducted by one interviewer (MBK or VDB).

2.4. Analysis

All audio recordings were transcribed and transcriptions were double-checked for accuracy. We fully anonymized transcripts. Using thematic analysis, the coding team iteratively developed separate patient and provider codebooks outlining themes, subthemes, and definitions in the transcripts. The team modified codebooks as new ideas arose (Boyatzis, 1998). The coding team included two independent coders (undergraduate research assistants) and a third person who oversaw the coding process (doctoral student). Coders reviewed transcripts weekly and then the group met weekly to discuss codes and higher-level themes. Initial meetings included identification and refinement of code definitions as examples were identified and agreed upon across transcripts. Any discrepancies were discussed as a group and resolved by consensus. Codes were classified with the following: label, definition, description, qualifications/exclusions, and example quotations from raw data (Roberts et al., 2019). The team coded transcripts using Nvivo Version 12. We used thematic analysis (Brooks et al., 2015) to deductively identify themes from the interview guide (informed by the existing literature on barriers to methadone treatment) while inductively identifying additional themes.

As indicated above, in the development of the conceptual framework and organization of identified barriers, we drew upon the social-ecological framework (Bronfenbrenner, 1979). The team identified social-ecological levels of barriers inductively in the coding process and, thus, we applied post hoc the social-ecological framework chosen to organize our data.

3. Results

Intersecting themes emerged from patient and provider interviews and focus groups, based on our primary study aim: to describe barriers to successful methadone treatment outcomes and identify cooccurrence and interaction of these barriers. Overall, participants described a variety of opinions and ideas related to successful treatment outcomes, including improvements in physical and mental health, productivity and life accomplishments, social and interpersonal improvements, changes in substance use (including, but not exclusively, abstinence), and treatment engagement.

3.1. Barriers to patient-defined successful methadone treatment outcomes

While participants described methadone treatment as lifesaving and a crucial component of recovery from OUD, all participants readily shared substantial challenges faced in realizing the full benefit of treatment. Barriers to successful methadone treatment outcomes, informed by the social-ecological framework (Bronfenbrenner, 1979), include factors at the individual level, interpersonal level, institutional or structural level, and community or environmental level. Barriers within each level are described in Table 2a. Figure 1 shows direct barriers to successful methadone treatment outcomes that exist at each social-ecological level. The arrows from each social-ecological level of barriers to “substance use” and/or “missed methadone dose” represent direct effects of those barriers, as described by participants. The bi-directional arrow between “substance use” and “missed methadone dose” represents those outcomes affecting one another and both leading to poor treatment outcomes.

Table 2.

Barriers to Successful Methadone Treatment Outcomes

Table 2a – Direct Barriers to Successful Methadone Treatment Outcomes
Barriers	Description	Patient*	Provider*
Individual
Mental health	-Mental health diagnosis or description of symptoms consistent with mental health diagnosis in addition to addiction	X	X
Poor physical health or pain	-Chronic or acute physical symptoms or medical diagnosis in addition to addiction and not including opioid withdrawal symptoms	X	X
Low motivation	-Not feeling like or wanting to engage in treatment/ recovery activates	X	X
Readiness for change	-Specific mention of feeling or being ready for change related to SU	X	X
Lack of perceived self-worth	-Not having meaning in life, lacking sense of purpose, and not deserving good things		X
Responsibilities and demands on time†	-Individual priorities that patients need to attend to for themselves, like sleep, self-care, and self-improvement	X	X
Interpersonal and Social
Social circle that influences use	-People in a patient’s life who influence their substance use -This only came up in the context of people who promote SU by making drugs available or otherwise making patients feel like they want to use	X	X
Lack of social support	-Not having people in their lives that support recovery	X	X
Lack of connection with care providers	-How patients feel around care providers (usually in the context of methadone treatment providers) -Difficulty in communication -Incongruence of goals between patients are care providers	X
Responsibilities and demands on time†	-Responsibilities related to work, family, or other relationships	X	X
Institutional/Structural
Lack of institutional coordination of care	-Description of needs not met between services are spread out or otherwise not accessible -Often described as mental health and social services unavailable	X	X
Program policies and schedule	-Methadone treatment policies: assigned dosing times, requirements for take-home doses, required meetings with counselors and other treatment providers, toxicology testing	X
Unstable housing	-Homelessness or other housing uncertainty	X	X
Distance from treatment/ transportation	-Lack of access to reliable transportation to the clinic -Difficulty with unreliable and complex public transportation (requiring multiple transfers) -Needing to walk	X	X
Community/Environmental
Environmental triggers of SU	-“People, places, and things” that cause patients to experience cravings or otherwise feel drawn to use drugs	X	X
Community violence	-Violence and concerns about safety in different communities, both where patients live and where the clinic is located	X	X
Stigma	-Any level of stigma (internalized, anticipated, or enacted) related to any aspect of patient’s identify or experience -SUD, methadone treatment, and mental health were all mentioned as stigmatized	X	X
Table 2b - Interrelationships Between Barriers
Barriers	Social-ecological Levels	Patient*	Provider*
Unstable housing and mental health and motivation	Institutional/Structural Individual	X	X
Unstable housing and social circle that influences SU	Institutional/Structural Interpersonal	X
Transportation and poor physical health or pain	Institutional/Structural Individual	X
Transportation and responsibilities and demands on time	Institutional/Structural Interpersonal	X
Program policies and schedule and responsibilities and demand on time	Institutional/Structural Interpersonal	X
Stigma and physical/mental health	Stigma (cross-cutting) Individual	X	X

^*Patient, provider, or both types of participants provided responses that received this code

Figure 1. Conceptual Framework of Barriers Affecting Methadone Treatment Outcomes*.

Note. Arrows representing interrelationships take two different forms, either sequential (e.g. 1) or interactive (2-8).

* Numbers in parentheses connect Figure 1 to details and representative quotes in Table 2b

† Stigma can be understood across multiple levels

‡Responsibilities and demands on time came up as individual and interpersonal barriers

3.1.1. Individual-level barriers

Participants shared a number of barriers at the individual level, including patients describing barriers they themselves experience, and staff/peers describing barriers that their patients experience, including themes of individual health (mental and physical), motivation for engagement in treatment/recovery, readiness for change, sense of self-worth, and responsibilities or demands on time. Barriers at the individual level were described as directly leading to both substance use and missed methadone doses (Fig. 1).

Patient participants explained that they miss doses or have trouble staying in recovery when they experience low mood: “sometimes I get depressed and tired and I don't come [to the treatment program]” (Interview, Patient #16, White and Filipino, Male). Much of what was shared in this theme of individual barriers related to unaddressed or undermanaged mental health concerns. Individual sense of hopelessness and low self-worth affects substance use:

If I'm feeling down about myself and depressed and someone [says] "hey, wanna get high?" And I'm down, I'm gonna go get high so I feel better, mentally.

(Interview, Patient #16, White and Filipino, Male)

Participants shared ideas about individual readiness and motivation for change. Definitions of change were different across participants as it refers to individual conceptualizations of successful treatment. However, change generally referred to initiating or increasing engagement in treatment and change (either decrease or abstinence) in substance use. One staff participant described low motivation as patients not making a commitment to themselves and looking outside themselves for reasons why treatment is not working (FG, Staff #6, Black/African American, Female). One patient participant said, “I just didn’t feel like getting up and walking down here” (Interview, Patient #14, Black/African American, Female). Similarly, but from a slightly different perspective, patient participants explained the idea of readiness for change, including different levels of engagement with treatment until they felt like they were ready for recovery. Patient participants shared the experience of being in the methadone program to avoid withdrawal symptoms, but not yet being ready for what they conceptualized as recovery. One patient participant shared, “This the third time I've been on the methadone program. The first two I walked off, because I really wasn't ready” and went on to explain that people start methadone treatment for different reasons (e.g. avoiding withdrawal, looking for help, or court ordered) and readiness for change is an individual experience (Interview, Patient #14, Black/African American, Female).

Participants also described individual priorities that patients need to attend to for themselves, like sleep, self-care, and self-improvement as a barrier (as one participant described the challenge of prioritizing her education; FG, Patient #2, White, Female). One patient shared:

It doesn't get in the way of me going to work, but sometimes if I have a moment to myself, I have to make the choice of getting here or taking a moment for myself.

(Interview, Patient #18, White, Male)

On the other hand, another participant shared her experience of idle or unstructured time as her biggest barrier to successful treatment outcomes. She explained that she needs productive activities to distract her from cravings and triggers that would make her think about using drugs.

I just need something to do with this time of mine, you know what I mean? I get so frustrated with that. I just need something to do to absorb my time.

(Interview, Patient #15, Black/African American, Female)

Meaningful use of time was common across responses. However, the way that methadone treatment and other treatment or recovery activities factor into structuring that time differed between participants.

At the interpersonal level, participants described barriers of responsibilities and demands on time, especially with employment. Though participants often described responsibilities and work as positive aspects of recovery, they included it as a reason for struggling with treatment when work or family responsibilities conflict with treatment responsibilities (i.e., dosing and meetings with providers).

I have so much to do on my job and I'm really in high demand to get it done. So sometimes I struggle to get here because I have to be here or there or, you know, people are waiting for me. Then I miss the program.

(Interview, Patient #18, White, Male)

Specifically, participants shared how it is challenging to balance employment and other interpersonal responsibilities in the context of the restrictive schedule of methadone treatment typically requiring structured, daily dosing six days per week and frequent but unscheduled toxicology testing for recent drug use.

3.1.2. Interpersonal-level barriers

Participants described barriers at the interpersonal level as directly leading to both substance use and missed methadone doses (Fig. 1).

Many participants described needing to change “people, places, and things” in recovery from OUD. When, for a variety of reasons, they are unable to change the people with whom they spend their time, proximity to other people who use substances presents substantial challenges to modifying their own substance use or maintaining abstinence from substances. As described by one participant, “because of the company that we keep, we don't know how to change our thinking to be really ready to get clean [sic]” (Interview, Patient #14, Black/African American, Female). In addition to other people using drugs, interpersonal conflict and dealing with “negativity” of others can be overwhelming and makes it difficult to focus on recovery (FG, Patient #4, White, Male). While some participants described a social circle that influenced them to use, a lack of healthy social support was another component of how social influences affected substance use in this population. One patient focus group discussion emerged around the idea that a person cannot be successful in recovery by themselves, but many people on methadone treatment do not have family or a reliable support system.

They don’t got nobody really to back them up to push them forward”

(FG, Patient #11, Native American, Male).

Another challenge that some participants described was lack of clear communication with methadone treatment providers in a way that they felt like their goals were understood. One patient participant explained that it can be difficult to express needs related to dosing, especially when methadone dose and effectiveness may be affected by other medications, such as antiretroviral medication for HIV.

A lot of people here is really sick. They got, you know, they got like HIV and they got medicine and the medicine is drawing the methadone and they gotta go up [in methadone dose] and they [treatment providers] don’t understand that. They might say, ‘you already on a high dose.’

(FG, Patient #11, White, Male)

Another patient participant described his goal of tapering off of methadone and said that he did not feel like his counselor shared that goal.

I was telling them [counselor] I was trying to detox, and they wanna know why and they was saying, cause I wanted to get off and I mean it was like-it was just too much, you know what I’m saying. She wanted to know what my agenda was.

(FG, Patient #3, Black/African American, Male)

Both participants expressed frustration with communicating needs to multiple people and not feeling like they were understood. Furthermore, and demonstrating what these patient participants described, a staff participant explained her perception of patient noncompliance. That staff participant explained her feeling that patients are willfully noncompliant with program policies and emphasized her belief in the importance of discipline and structure:

That’s your own barrier that you creating for yourself. You were told what it is that you needed to do and the times that you needed to do it. But because you want to do this your way, you’re gonna make this simple thing an issue for you.

(FG, Staff #6, Black/African American, Female)

This quotation is an example of the type of staff message that makes patients feel disconnected. Other provider participants agreed with this statement, but also said that reasons for policies need to be clearly explained “in full details” to patients and that it is important to be tolerant (FG, Staff and Peer #5, Other/not specified Race, Female).

3.1.3. Institutional- or structural-level barriers

The institutional and structural barriers that emerged, including coordination of care, program policies and schedule, unstable housing, and transportation, applied to both the treatment program at which the study took place as well as broader institutions, such as public services and other recovery programs. Barriers at this level were described as directly contributing to missed methadone doses (Fig. 1).

Participants described both the importance of coordinated, integrated services that support retention in methadone treatment and address other health and mental health outcomes, yet also the institutional limitations in coordination of these services. The types of services mentioned were health care, including mental health care, and social services such as housing and financial assistance. Of particular concern among participants was coordination of mental health services with methadone treatment. One patient participant mentioned difficulty finding a new doctor and a new therapist and said that this interfered with focusing on recovery and methadone treatment attendance. Another participant, when describing services available at the treatment center, said “[the program has] one social worker, and she can’t see everybody, right? She can only do so much” (Interview, Patient #15, Black/African American, Female). A staff member also shared his experience that it is not enough to give patients information about available resources, they need to actually help connect them, but that frequently counselors do not have the capacity to make those connections. That staff participant said “the most challenging part of it is where you’re unable to get everything that they need in one place” (FG, Staff #3, Black/African American, Male).

Multiple participants brought up methadone treatment program policies as barriers. Patient participants explained that assigned dosing times made them feel restricted as did unexpected program requirements when they arrived for dosing. One participant explained:

It seems like every week, there's something that's like holding that stops me. Because sometimes I mean, I have to get to work, and I go up to the window and they're like, ‘Oh, well, you gotta go see this person or this person, or this person.’ You know?

(Interview, Patient #19, White, Male)

The same participant described frustration with the policy of needing to have a job to qualify for early dosing since his job is “not on the books” but requires him to start work early.

Participants also described challenges associated with other institutions and programs from which they receive services. The most commonly cited structural barrier was housing services. Several patient participants described their experience with applying for housing assistance and being on the waitlist. One participant said of her experience:

I've been to housing around the corner from here and filled out an application and they said, only thing the lady said to me was ‘see you in seven years.’

(Interview, Patient #14, Black/African American, Female)

The same participant currently lives in transitional housing for people in recovery and said that she “plans [her] life around the program” because she recognized the importance of stable housing. However, meeting times and other requirements of the transitional housing program make it difficult for her to move forward with job opportunities and other things that she described as important to her independence and growth. Unstable housing and homelessness were the most frequently mentioned challenges in treatment, described as making it difficult to focus on recovery. One provider participant put it this way:

You need a place to rest… when you're not out there using anymore and somebody wants to really engage in treatment, it's hard when there isn't any stable housing

(FG, Staff #9, Black/African American, Female)

All but two participants (across patients, staff, and peers) brought up housing as a “top three” barrier to successful treatment outcomes.

3.1.4. Community- or environmental-level barriers

Participants described barriers at the environmental level as directly leading to both substance use and missed methadone doses (Fig. 1).

Participants shared the idea of community violence and concern about safety as a barrier to treatment. “You have some of those areas where there's [treatment] programs that you just don't want to be” (Interview, Patient #1, Black/African American, Male) and participants shared that they do not feel comfortable being in or traveling through some areas that have a lot of violence.

Similarly, some areas or environments were described by participants as triggering cravings.

Any kind of trigger to get high. They could see a dope dealer crossing the street. They could see a needle in the alley. I mean, any trigger can set an addict [sic] off to go use.

(Interview, Patient #17, White, Male)

One patient participant shared that he tried to avoid environmental triggers by staying at the treatment program for as long as he could, until they closed, and then he said, “I go home, you don’t see me. I don’t come out for nothing” (FG, Patient #12, Black/African American, Male).

3.1.5. Cross-cutting barrier: Stigma

Another important barrier to successful treatment that cuts across all of the levels described above was stigma. Specifically, participants provided examples of how stigma affects OUD treatment both as stigma that medical providers demonstrate toward people who use drugs as well as stigma that patients perceive around use of methadone treatment:

So much stigma, not only surrounding substance use in general but also surrounding medication assisted treatment, especially methadone

(Interview, Staff #20, White, Female)

Patient participants explained how medical providers demonstrate distrust of people who use drugs. Descriptions of stigma around methadone treatment reported by patients and providers ranged from stigmatizing remarks by City officials and authority figures to family members believing that being on methadone treatment means someone is still getting high. One provider participant said, about patients on methadone, that “they’ll let ‘em know they was using before they let ‘em know they was on methadone” (FG, Staff #4, Black/African American, Male). Provider participants explained that a common image of people on methadone treatment is nodding off and not able to function and that this idea has been perpetuated at a high level such that the stereotype applies to the entire community and people refer to Baltimore as “the city that nods” (FG, Peer #1, Black/African American, Male). The same focus group of provider participants talked about the pervasive stigma surrounding mental health in general and the community’s historical emphasis on stoicism, “we were taught to bottle those things up and what happens in this house stays in this house” (FG, Staff #6, Black/African American, Female).

3.2. Co-occurrence and interrelationships between barriers

Next, we sought to identify interrelationships between the barriers identified across the five previously described levels, guided by the social-ecological framework.

Table 2b includes descriptions of the interactions between barriers. This table is meant to provide examples of how barriers may affect one another, rather than a comprehensive depiction of all relationships between barriers across the specified social-ecological levels.

3.2.1. Unstable housing and mental health

The interaction between unstable housing and mental health and motivation reflects a relationship in which the barrier of unstable housing worsened the effect of mental health and motivation. Patient and provider participants described the mental strain and demoralization of applying for and not being able to secure stable housing. One participant shared that her housing situation led to depression saying, the housing application process “just sent me over the edge” (Interview, Patient #15, Black/African American, Female). Another patient shared the following:

It needs to be: you come from the program, you can go home, somewhere comfortable to live. And that tends to change your behaviors and your emotions… When I know that I’ve got somewhere to go and lay my head, that helps me feel better about myself so I tend to do better

(Interview, Patient #14, Black/African American, Female).

Taken together, participants’ responses indicate that housing challenges worsen mental health and poor mental health causes a further barrier to the process of finding stable housing, leading people to “give up.”

3.2.2. Unstable housing and social circles that influence substance use

Unstable housing was also described as having an impact on time spent with people who influence substance use. One patient participant described this connection in the following way:

For some people that don’t have stable housing, they’ll have no choice but to keep the same company that they hang around because they may have to stay with them or spend a night at their house.

(Interview, Patient #14, Black/African American, Female)

Despite a desire to change “people, places, and things,” as many participants described as a crucial component of doing well, circumstances do not always allow for those changes.

3.2.3. Transportation barriers, physical health, demands on time

Distance from treatment (and related difficulty with transportation) was described by patients as interacting with poor physical health or pain and responsibilities and demands on time, such that distance from the treatment program or trouble with transportation to the treatment program worsened the effect of each of those barriers (poor physical health/pain and responsibilities/demands on time) on missed methadone doses. The need to travel far or use unreliable transportation to get to the treatment program worsened the effect that poor physical health and pain had on attending methadone dosing visits. When dealing with physical health problems or pain, one participant described the following difficulty:

Because, with my health problem, whereas though the doctor said he don’t want me walking no more than 200 feet and the staff here told me that I need to park at the back of the parking lot somewhere available parking. If I get here and the handicap spot got a car in there and that car been there 5 hours already, ain’t moving.

(Interview, Patient #13, Black/African American, Male)

Distance and difficulty with transportation also exacerbated the impact that other responsibilities and demands had on dosing visit attendance, as do program policies and schedule. One patient remarked that “if I had transportation, I could definitely get here and get out of there quickly and be at work and not have any issues with that” (Interview, Patient #18, White, Male).

3.2.4. Program policies and responsibilities/demands on time

Program policies interacted with other demands on time. For instance, one patient shared:

If you know it's already a problem trying to get here and now you have to get here at a certain time, what if that messes with your schedule? That was a big issue. So, I mean, that was the only thing I can really come up with that was an issue… I've seen people move you know, because of that schedule issue. Just say ‘screw it,’ not even, you know, end up leaving and they go get high.

(Interview, Patient #19, White, Male)

This experience reflected the effect that program policies, in this case dosing schedule, had on the challenges of other demands on time. The larger context of this participant’s quotation was a discussion about employment responsibilities and trying to keep a job. Another patient reflected:

My dose is at eight o'clock. But I have an appointment at eight o'clock that I can't miss. I go to my appointment of course, that means I'm not going to be able to get dosed until later in the day, again, you start feeling bad, things start going up in your head, thinking about going and getting something out there to make you feel better.

(Interview, Patient #20, Black/African American, Female)

That participant was referring to the program policy that required patients to return in the afternoon, after all scheduled dosing times were finished, to receive dosing if they missed their dosing time window. Other program expectations that patient participants mentioned as challenging in the context of demands on their time included unexpected or unscheduled meetings with counselors and others on the treatment team that were required before receiving medication.

3.2.5. Stigma and physical/mental health

Regarding stigma that medical providers have around substance use and methadone treatment, patient participants shared experiences with or beliefs about not being able to get medication for debilitating pain due to stereotypes of people who use drugs. Since pain is a barrier to attending methadone dosing appointments, stigma and resulting inadequate medical care have a worsening effect.

They [medical providers] look at me like I am gonna, you know, take their medicine and like shoot it or something and not everybody in the methadone program shoots. There’s a lot of stereotypes that go along with it and I just don’t think that it should be judged because there’s people that do need the pain medications and because of the opioid epidemic they can’t get the pain medicines that they need because of all the stuff that’s happening around them.

(FG, Patient #6, White, Male)

Also, a range of patient and provider participants described the effect that stigma around methadone treatment had on sense of self-worth and mental health such that “they always felt less than because people would plant the seed that if you’re on a prescribed medication, you’re still getting high” (FG, Peer #1, Black/African American, Male). This can have a further worsening effect on low self-worth and pre-existing mental health conditions. The focus group in which that statement was made went on to have a conversation about hopelessness that comes from the stigmatization of methadone treatment.

4. Discussion

This qualitative study presents a detailed description of barriers to patient-defined successful methadone treatment outcomes and interrelationships between barriers. We utilized the social-ecological framework (Bronfenbrenner, 1979; Bunting et al., 2018; Jalali et al., 2020) to organize the levels of barriers that emerged from participant responses (individual, interpersonal, institutional, and environmental). Barriers occurred across all previously described levels and a theme of stigma came up as a cross-cutting barrier across all levels (Fig. 1). We relied on definitions of successful treatment that were dictated by patients themselves. This approach allowed us to incorporate patient perspective and voice into how we understand treatment success and the experience of barriers at multiple levels. Descriptions of barriers to successful methadone treatment outcomes in this study align with previously published challenges associated with MOUD outcomes. Past studies have demonstrated the association of psychiatric comorbidity (Kidorf, 2018), homelessness (Lo et al., 2018), and stigma (related to methadone treatment and/or substance use) (Spector et al., 2021; Tsai et al., 2019; Woo et al., 2017) with poor MOUD outcomes and treatment discontinuation. The current study extends this prior work with a focus on interrelationships between barriers, drawing from a social-ecological framework, to identify co-occurrence and potential interaction of barriers across social-ecological levels

Patient and provider participants largely had complementary responses across primary themes, and the identified co-occurrence and interaction between barriers were supported by a combination of patient and provider responses. However, patient participants described some barriers and relationships between barriers that did not come up in provider participant interviews or focus groups, for example, specific challenges with program policies and competing demands on their time. Although comparison of responses across participant groups was not an aim of this study, we found it important to capture both patient and provider perspectives on barriers and identify the contrasts in these perspectives. In some cases, provider responses directly opposed patient opinions on the arbitrary nature of program policies, with some providers emphasizing the importance of structure and accountability and not mentioning other responsibilities or demands on time. Also, divergent responses around methadone treatment goals indicated a barrier related to patient and provider communication, as well as stigma and judgement that contribute to an unwelcoming and potentially harmful environment. This disconnect in communication between patients and some treatment staff indicates an important area for possible intervention and a means by which to address other, institutional/structural-level barriers. This is especially the case if patients face transportation and scheduling barriers (institutional) and yet staff hold beliefs like “that's your own barrier that you creating for yourself.”

The current analysis identified the co-occurrence of several barriers and the potential interaction of barriers across social-ecological levels. Each of the five interrelationships of barriers across social-ecological levels should be further investigated and fleshed out in future research. Future quantitative research can test these relationships and consider intervention options that most efficiently target the effect of unique relationships between barriers. When looking at the descriptions of interrelationships between barriers (i.e., in Table 2b), it appears that much of the overlap between levels involves institutional/structural-level barriers. This could provide important direction for development of high-impact targets for future interventions aimed at supporting successful methadone treatment outcomes. Recent qualitative work by Spector and colleagues (Spector et al., 2021) also found a strong and recurring theme of the impact of structural barriers, specifically housing and economic insecurity, on OUD treatment seeking behavior, indicating that barriers at this social-ecological level play an important role, even at early stages in the cascade of care for OUD.

Also in-line with previous findings (Spector et al., 2021), our findings emphasize the fact that barriers interfering with MOUD outcomes cannot be considered in isolation, as barriers compound one another, interacting with social-cultural environments to shape patients’ experience of treatment for OUD (Jalali et al., 2020; Maina et al., 2021). Participants provided examples of how patients receiving methadone treatment frequently live with co-occurring psychosocial problems and stressors. Other qualitative research has similarly undertaken evaluation of the interactions between structural, social, and individual factors effect on adverse SUD outcomes (Kahn et al., 2022; Nydegger & Claborn, 2020). Kahn and colleagues applied the social-ecological framework to qualitative interviews with people who had recently survived opioid overdose and identified interconnectedness between and across individual, interpersonal, community, and society levels of barriers to OUD treatment engagement (Kahn et al., 2022). Our qualitative approach looking specifically at methadone treatment outcomes differed from past research in the way that we solicited feedback on co-occurrence of factors leading to poor outcomes. We prompted participants to describe the experience when two or more barriers co-occur to elicit rich responses from participants around interactions specifically and enhanced our focus on specific interactions.

How we conceptualize interactions between treatment barriers carries implications for effective means of clinical intervention. With the understanding of a multiplicative effect, an intervention targeting one factor would have a greater impact on treatment outcomes than would be expected if no interaction was present (Tsai, 2018). This rational has been used to guide modular, transdiagnostic treatment protocols to address both mental health and related psychosocial factors, including substance use, among people living with HIV (Safren et al., 2020). Implementation of such a modular-based design for people facing challenges in MOUD could be informed by future work expanding on our findings to help select the most efficient strategies to target high-impact barriers. Safren and colleagues describe the importance of integrated case management and linkage to wraparound services that holistically address complex social-structural barriers faced by patients in treatment for HIV (Safren et al., 2020). Similar recommendations were made by participants in a qualitative study informing implementation of a peer-delivered intervention to support linkage to and retention in treatment for substance use disorder (Satinsky et al., 2020). Khan and colleague’s qualitative findings on OUD treatment experience similarly support a person-centered approach to tailor treatment components to meet individual needs (Kahn et al., 2022).

Structural-level interventions would likely enhance the effect of individual-level interventions and may include expansion of services such as supportive housing and policy-level changes that increase the flexibility and accessibility of MOUD programs (e.g. dosing requirements and transportation). Of note, and stated above, housing was the most common barrier to successful treatment outcomes mentioned by patients and providers and emphasized as an overwhelming challenge for patients at this treatment site. Further research that includes a broader representation of stakeholders is important to better understand the types of structural-level interventions and changes that can have the widest-reaching impact.

4.1. Limitations

Findings must be considered in the context of methodological limitations that should be addressed in future research expanding on this topic. Though we employed procedures to reach a diverse sample of patient participants (both consistently and inconsistently attending dosing visits), inclusion criteria necessitated that patient participants be actively enrolled in the methadone treatment program. Therefore, we were unable to capture perspectives of patients who discontinued and have not returned to treatment. We also recognize the limitations given this study recruited patients and staff from just one treatment program and one MOUD modality.

Small sample sizes within each group (i.e., patients, providers) did not allow for formal comparisons across groups, and within the provider group, which may have limited the scope of responses captured in this study. Nonetheless, we feel confident in the validity of our findings based on indication of theoretical saturation and our ability to capture and integrate perspectives of individuals often neglected in research participation (i.e., underserved, low-income, ethnoracial minority patients struggling with methadone treatment retention and peer providers whose perspectives are not often included as part of the care team).

An important aspect of how the interview and focus group guides solicited feedback from participants is the way that successful treatment outcomes were defined. Participants were asked to share their own, personal definitions of successful methadone treatment outcomes. Therefore, the study had no pre-set, common definition of successful treatment nor consensus on how ongoing substance use fits into that definition. Thus, based on varying participant descriptions, we included substance use as a mediator between other barriers and successful treatment outcomes in the preliminary conceptual framework. However, depending on individual participant beliefs, substance use and/or treatment retention may also be conceptualized as independent barriers affecting treatment outcomes or component of the definition of poor treatment outcomes. We hope that future research can help to advance a better of understanding of patient-centered treatment goals. Finally, although we use language describing barriers as affecting treatment outcomes based on participant responses regarding their perceptions of these barriers, we recognize that we are not able to make substantiated claims about causality using a cross-sectional, qualitative design.

5. Conclusion and future directions

This study applied the social-ecological framework to understanding OUD treatment outcomes from the perspectives of both patients and providers. While retention is a persistent challenge in MOUD programs broadly, even lower retention rates are documented among low-income, ethnoracial minoritized populations (Manhapra et al., 2017; Samples et al., 2018; Stahler & Mennis, 2018; Weinstein et al., 2017), and understanding how barriers to methadone treatment co-occur and interact is of upmost importance in this population. We found that barriers exist, co-occur and interact across all levels: individual, interpersonal/social, institutional/structural, and community/environmental. The use of this framework to understand relationships between barriers to successful methadone treatment outcomes has strong public health implications and provides a basis for future study and intervention development to enhance outcomes of methadone treatment for people living with complex psychosocial, interpersonal, and structural challenges. Such research may include institutional/structural-level interventions in conjunction with transdiagnostic cognitive-behavioral interventions that address individuals’ barriers at multiple levels. We hope that our qualitative description of patients’ experiences with methadone treatment in this setting and assessment of the relationships between barriers across social-ecological levels will be used to inform future research to investigate the potential interaction of barriers in relation to MOUD outcomes (methadone treatment and more broadly) and subsequently inform intervention work.

Highlights.

• A social-ecological model was used to understand poor methadone treatment outcomes

• Barriers fit several broad levels: individual, interpersonal, institutional, and community

• Stigma was identified as a cross-cutting barrier across the above-mentioned levels

• Qualitative findings elucidated inter-relationships between barriers, across levels