A systematic review of patients’ and providers’ perspectives of medications for treatment of opioid use disorder

Abstract

Background:

The opioid epidemic is a public health crisis. Medications for opioid use disorder (MOUD) include: 1) buprenorphine, 2) methadone, and 3) extended-release naltrexone (XR-NTX). Research should investigate patients’ and providers’ perspectives of MOUD since they can influence prescription, retention, and recovery.

Methods:

This systematic review focused on patients’ and providers’ perceptions of MOUD. The review eligibility criteria included inclusion of the outcome of interest, in English, and involving persons ≥ 18 years. A PubMed database search yielded 1692 results; we included 152 articles in the final review.

Results:

There were 63 articles about buprenorphine, 115 articles about methadone, and 16 about naltrexone. Misinformation and stigma associated with MOUD were common patient themes. Providers reported lack of training and resources as barriers to MOUD.

Conclusion:

This review suggests that patients have significant misinformation regarding MOUD. Due to the severity of the opioid epidemic, research must consider the effects of patients’ and providers’ perspectives on treatment for OUD, including the effects on the type of MOUD prescribed, patient retention and adherence, and ultimately the number of patients treated for OUD, which will aid in curbing the opioid epidemic.

1. Introduction

The opioid epidemic is an urgent public health crisis; in 2017, 192 persons were dying each day from an opioid overdose (Scholl, Seth, Kariisa, Wilson, & Baldwin, 2018). The most effective treatment for opioid use disorder (OUD) is one of three FDA-approved medications: buprenorphine, methadone, or extended-release naltrexone (XR-NTX) (Kampman & Jarvis, 2015). Medications for OUD (MOUD) are effective treatments, and reduce opioid craving, relapse, and overdose (Connery, 2015). They also reduce the risk of acquiring or transmitting infectious diseases, including HIV and HCV, which are associated with sharing injection drug equipment (Woody et al., 2014). The intensifying opioid epidemic has led to a resurgence in HIV and HCV transmission (Conrad et al., 2015; Ronan & Herzig, 2016; Zibbell et al., 2018). In individuals living with a chronic infectious disease such as HIV, opioid relapse is a contributing factor to poor healthcare retention, poor medication adherence, and increased mortality rates (Connery, 2015).The benefits of increasing MOUD prescriptions to persons with OUD are twofold; they can reduce direct harms of opioids such as opioid overdose, and can treat or reduce transmission of infections.

Methadone maintenance has demonstrated efficacy in reducing opioid use, illegal activities, psychosocial and medical morbidity, including rates of HIV infection, and mortality (Soyka et al., 2011). Methadone for the treatment of OUD requires dispensing from a regulated Substance Abuse and Mental Health Service Administration (SAMHSA)–certified opioid treatment program, which is stringent and typically requires patients to visit daily to receive medication. Unlike methadone, practitioners can prescribe buprenorphine in office-based settings. The Drug Addiction Treatment Act of 2000 (DATA 2000) allows physicians to prescribe buprenorphine outside of certified opioid treatment programs after they complete an 8-hour training course. The SUPPORT Act of 2018 expanded upon DATA 2000 and allows nurses, nurse practitioners, physician assistants (PAs), and midwives to prescribe buprenorphine after they apply for and receive a waiver through the Drug Enforcement Administration (DEA) and complete a 24-hour training course (Spetz, Toretsky, Chapman, Phoenix, & Tierney, 2019). The FDA has approved two long-acting formulations of buprenorphine. A long-acting implantable form, Probuphine®, delivers buprenorphine for 6 months (J. White et al., 2009), and an injectable formulation of buprenorphine, Sublocade®, is administered monthly (Indivior, 2017; Knopf, 2019). In December 2018, the FDA tentatively approved Brixadi™, weekly or monthly extended-release injections of buprenorphine, which is awaiting final approval (Braeburn Pharmaceuticals, 2020). Extended-release naltrexone (XR-NTX) was FDA-approved in the U.S. for the treatment of OUD in 2011 (Vivitrol®) (Lobmaier, Kunøe, Gossop, & Waal, 2011) (daily, oral naltrexone is not recommended for treatment of OUD ([Minozzi et al., 2011]). XR-NTX (Vivitrol®) is effective and has been compared to buprenorphine in two large studies that suggest that they are equivalent for individuals who have previously undergone detoxification (Lee et al., 2018; Tanum et al., 2017). Despite that there are several forms of effective and FDA-approved MOUD, only 19.4% of persons with OUD are receiving them (L. T. Wu, Zhu, & Swartz, 2016); therefore, understanding patients’ and providers’ perspectives of MOUD is important to understand how we can increase access, initiation, and retention on MOUD (Rieckmann, Daley, Fuller, Thomas, & McCarty, 2007).

This systematic review focuses on published manuscripts that have assessed providers’ and/or patients’ preferences and attitudes of MOUD. We comparatively analyzed the opinions of MOUD providers and patients to help assess the scope of attitudes and beliefs about types of MOUD for the treatment of OUD. The aim of this systematic review is to disentangle the opinions about these medications to understand how patients’ and providers’ beliefs may impact choice of MOUD and the efficacy of addiction treatment.

2. Methods

2.1. Data search and inclusion criteria

We searched PubMed for human research articles (studies, editorials, opinion pieces, etc.) about providers’ and/or patients’ attitudes and beliefs of the different pharmacotherapies associated with MOUD published in English. The population studied in this review included: 1) patients with a diagnosis of OUD, opioid dependence, or patients eligible for MOUD and 2) providers, including physicians, nurses, PAs, community health workers, substance use disorder (SUD) counselors, and prison staff involved in care of patients with OUD. The phenomenon of interest studied was attitudes and beliefs of patients and providers about MOUD. The time frame included papers from 1940 to December 4, 2019, the day we conducted the search. The settings of the research reviewed included outpatient substance treatment clinics, inpatient substance treatment programs, prisons, and primary care offices. This systematic review compared different attitudes and beliefs about MOUD among providers and patients from these research studies. Given the high prevalence of addiction globally, we included papers from countries outside of the United States. This systematic review followed PRISMA guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009). Two members of the research team independently verified the search results for every step of the review, and any discrepancies between two reviewers were resolved by a third reviewer. The search criteria that we used were: “(providers OR doctors OR patient OR client OR nurses OR practitioners OR clinicians or doctor OR clinician OR physician OR physicians)) AND (attitudes OR beliefs OR perspectives OR perceptions OR views OR opinions OR position OR feelings)) AND (substance use OR heroin addiction OR opioid addiction)) AND (naltrexone OR buprenorphine OR vivitrol OR methadone OR suboxone).”

2.2. Study selection

Figure 1 depicts the consort diagram of the literature search. The original search yielded 1692 results. We narrowed the results to 1169 articles that met the further filtered criteria. The filters included: human subjects, subjects 18 years of age and older, and papers written in English. Two authors screened each of the titles of the 1169 studies and assessed them for relevance to the review, with a third author resolving any discrepancies (K.C., B.E.B, X.Z.). The reviewers excluded 894 articles that focused on chronic pain, alcohol use disorder, infectious disease, cocaine, or public policy. Of the remaining 275 articles, we screened all abstracts and we excluded 118 because they lacked the outcome of interest (patient or provider attitudes about MOUD) or focused on retention/adherence. We reviewed the remaining 157 full texts and excluded four, because they lacked the outcome of interest. A total of 152 articles were eligible and, thus, we included them in the final review.

Figure 1.

Flow Diagram

2.3. Data extraction

We extracted the following information from each article: study title, study authors, year of publication, population served (patients, staff, or specific subpopulations such as prisoners) and number of participants, type of MOUD, how data were collected (survey, interview, etc.), and a brief summary of the attitudes and beliefs of the population studied. We then divided the articles into three categories: papers that discussed attitudes and beliefs 1) among patients, 2) among MOUD providers, and 3) among both patients and providers (the three supplemental tables are based on each of these three categories). We divided each of these categories further by type of MOUD.

At least two reviewers (K.C., R.E., and A.S.) read the articles in every category, and extracted the following topics from each article: attitudes, beliefs, and/or perceptions of medications for OUD from patient and providers. We categorized the different attitudes or beliefs about types of MOUD as negative, positive, or neutral. We extractd themes that appeared in >1 article. A third reviewer resolved any discrepancies in the extraction process.

3. Results and findings

3.1. Search results

We included a total of 152 articles in the final review, 101 of which focused on patients’ perspectives of forms of MOUD and 65 focused on providers’ perspectives (86 papers focused only on the patient’s perspective, 53 focused only on the provider’s perspective, and 14 focused on the attitudes and beliefs of both patients and providers).

Study designs included: qualitative analyses (N=62), cross sectional analyses (N=58), opinion pieces (N=11), randomized control trials (N=7), case studies (N=2), narrative review (N=1), systematic reviews (N=2), a review article (N=1), and cohort studies (N=10).

A total of 66 articles focused on attitudes toward buprenorphine, 16 toward naltrexone, 31 toward buprenorphine/naloxone, and 115 toward methadone. Sixty-four papers focused solely on methadone and 25 papers focused only on buprenorphine. Nine papers discussed only naltrexone and 19 papers focused only on buprenorphine/naloxone.

Attitudes and/or beliefs were major themes in all studies, and some papers focused on stigma, provider/patient barriers to care, and individual preferences related to attitudes or beliefs. The countries that we included in the review were: United States (N=90), Australia (N=11), China (N=7), Canada (N=6), Ukraine (N=6), United Kingdom (N=5), Malaysia (N=4), Iran (N=3), Switzerland (N=3), Belgium (N=2), France (N=2), Ireland (N=2), Italy (N=2), Sweden (N=2), India (N=1), Israel (N=1), Lebanon (N=1), Moldova (N=1), New Zealand (N=1), Norway (N=1), Poland (N=1), Taiwan (N=1), and Vietnam (N=1).

3.2. Historical context & study quality

The papers that we included in the review span a wide timeframe (1972–2019). Due to the changing standards for research publications, many of the papers from the earlier time period would not meet current standards of publication in regard to sample selection, minimization of bias, methods, and data analysis. This review chose to include all articles related to the topic studied, regardless of date of publication and assessment of study quality, to examine if attitudes and beliefs of MOUD changed or were static over time. If study quality was taken into account, we would have excluded many of the earlier studies and we would be unable to comprehensively assess changes over time. The context and associated social attitudes toward MOUDs has changed over the past four decades. In the 1970s, practitioners widely held an “abstinence oriented” treatment approach. Over the past 40 years, opioid use disorder (OUD) treatment has shifted to a “harm reduction” philosophy, and patient access and exposure to methadone has increased (Hettema & Sorensen, 2009). However, this review found that certain beliefs about methadone held constant. A study from 1972 by Brown et al. found that methadone users were aggressive and low achieving (B. S. Brown, Bass, Gauvey, & Kozel, 1972). Negative social stigma associated with methadone has remained constant over time, as we found such negative beliefs in recent research (Hewell, Vasquez, & Rivkin, 2017; Klingemann, 2017; Rozanova et al., 2017). The goal of this review is not to directly compare different studies regarding attitudes and beliefs of MOUD, but to examine which attitudes and beliefs are overarching, and how these beliefs can affect aspects of the patient-provider relationship.

3.3. Patient perspectives of methadone

Eighty-six articles focused on patients’ perspective of methadone (see Tables 2 and 4). All of these articles mentioned concerns about methadone’s “addictive quality” and the difficulty of ending treatment.

Table 2.

Patients’ Attitudes and Beliefs About MOUD

Title	Author	Population	Type of Data Collection	Summary
Attitudes and beliefs of clients toward methadone prior to and during treatment	(Jansen, Brown, & Bass, 1973)	69 opioid dependent individuals from the Model Cities Addiction Program of the District of Columbia’s Narcotics Treatment Administration	Preliminary interview and follow up interview 1 month into treatment	Primary source of information about methadone was from friends 26% heard exclusively positive comments about methadone 49% recalled only seeing unfavorable articles concerning methadone in the daily newspaper 61% had been exposed to contrasting opinions about methadone After one month in MMT, clients held more favorable opinions toward methadone and more negative attitudes toward heroin
Addict attitudes toward methadone maintenance: A preliminary report	(Sutker & Allain, 1974)	207 heroin addicts	Questionnaire	It is “evident that the majority of addicts regarded methadone as an agent which gives addict-clients a new outlook and a second chance in life.” Majority agreed methadone maintenance programs helped patients maintain a steady job 85% agreed that withdrawing from methadone is worse than withdrawing from heroin
Methadone maintenance: some client opinions	(B. S. Brown, Benn, & Jansen, 1975)	Methadone maintenance and detoxification clients	Questionnaire	Ambivalence about MMT in clients- it is still a suspect drug Clients see dangers (real and unrealistic) in MMT
Clinical use of naltrexone Part II: experience with the first 50 patients in a New York City treatment clinic	(Schecter, 1975)	51 patients at Kings County Hospital	Interviews	74% of individuals dropped out of the study because they felt that they did not need the medication, or for other reasons
Patient response to naltrexone: issues of acceptance, treatment effects, and frequency of administration	(Curran & Savage, 1976)	99 subjects were eligible, 38 subjects chose to take part; 38 subjects in a double-blind clinical trial induced into placebo or naltrexone	Patient verbal report and behavioral observation	Of 99 eligible candidates, 62% did not agree to participate because patients do not feel responsible for achieving abstinence, some find the required procedures “harassing” and are “scared away” from the drug Patients report minimal disadvantages to the medications under study, namely, taste and mild stomach discomfort during the initiation phase to the drug
Naltrexone in methadone maintenance patients electing to become drug free	(Haas, Ling, Holmes, Blakis, & Litaker, 1976)	300 male patients in a methadone maintenance program who wished to become drug free and were taking Naltrexone	Patient interview	Frequent factors influencing detoxification: wish to be drug free, wish to be free of methadone maintenance, wish to disassociate from the addict identity, and family pressures People who were determined to “make it alone” were least likely to be interested in Naltrexone Those with fear of own vulnerability, made them more likely to express interest in naltrexone Most who choose detoxification from methadone dropped out of the program despite recommendations; many sought to rejoin the study
Use of narcotic antagonists (Naltrexone) in an addiction treatment program	(Lewis, Hersch, Black, & Mayer, 1976)	20 patients at the Washingtonian Center for Addictions in Boston, Massachusetts receiving naltrexone for varying periods of time	Patient evaluations and questionnaires	Patients choosing to participate in the study felt that naltrexone would give them the time needed to stabilize their lives Reasons for choosing not to receive naltrexone: aversion to use of chemical support of any kind Ambivalence about naltrexone came from: control against heroin impulses, specifically on the power to counteract the effects of heroin, leading many patients to self-test the effectiveness Patients then often experience an initial reduction in the desire for and a decrease in obsessional thinking about heroin Fear that naltrexone did not eliminate their thoughts about heroin lead some to terminate treatment Patients remaining on naltrexone struggle with the balance between the wish to get high and the fear of abstinence in a diminished intensity Many patients report a greater sense of freedom, internal control, and more opportunities to develop self-control with naltrexone treatment than methadone
Current trends in narcotic addiction treatment: Patient acceptability and clinical applicability of alternative treatment methods	(Kissin, Arnon, & Luckom-Nurnberg, 1978)	552 patients in MMT, cyclazocine treatment, or methadone maintenance to abstinence treatment	Survey	Patients who are older and who have been in MMT for longer periods of time, and who are able to approach detoxification cautiously and with realistic expectations are more likely to be able to detoxify.
The index of choice: indications of methadone patients’ selection of naltrexone treatment	(Singleton, Sherman, & Bigelow, 1984)	35 male methadone clients	Self-report inventories	“…low-dose, short-term methadone maintenance who are less certain of their ability to remain opiate free on their own without help, and who express more fear of losing the security and qualitative improvements made in their lives intend to choose, exhibit greater interest in, and subsequently select naltrexone treatment more often.”
“It takes your heart”: the image of methadone maintenance in the addict world and its effect on recruitment into treatment	(Hunt, Lipton, Goldsmith, Strug, & Spunt, 1985)	368 methadone clients and 142 narcotic users not in treatment	Structured interviews and ethnographic fieldwork	Methadone is seen as having a “low status” only used to medicate or avoid withdrawal Methadone is seen as easy to obtain There is a myth that methadone is used by those not in treatment in “emergencies” (i.e. for individuals who cannot get heroin) Methadone client is viewed as a “loser” who has “given up” Participants view that methadone is dangerous and has worse side effects than heroin, including bone and muscle aches, sexual problems, dental problems, and weight gain--fear of long-term effects of methadone Participants hold belief that methadone causes discomfort felt during detoxification Participants hold belief that methadone has a higher opiate content than heroin Having to go to a clinic every day to get methadone interferes with daily routine
Misunderstandings about methadone	(Zweben & Sorensen, 1988)	Not Applicable	Opinion	MMT clinics can serve as a point of access to prenatal care and health services for pregnant women Mentally ill patients may benefit from the structure of MMT “They come to the clinic at a frequency generally unmatched in mental health facilities, and this level of structure and contact may indeed be a major factor in helping to stabilize them.”
Naltrexone treatment--the problem of patient acceptance	(Fram, Marmo, & Holden, 1989)	15 naltrexone patients	Not Applicable	15 out of 300 patients chose to start naltrexone for opioid use disorder “Patients tended to dump naltrexone in the same category as methadone, which has a very bad name” “The likelihood of their deciding to continue narcotics use after the hospitalization was so great that they recognized that taking an antagonist was futile” Some nervous about not being able to get pain relief in the event of an accident Influence of social situation is an important aspect to consider in patients attempting to abstain from opioids
Methadone maintenance outcome as a function of detoxification phobia.	(Milby et al., 1990)	271 MMT patients from 3 populations (Philadelphia Veterans Administration methadone program; Sepulveda, VA methadone program; University of Alabama methadone clinic); 102 subjects in follow up study	Interview and follow up	Detoxification phobic subjects spent more time in MMT than those who received psychotherapy, suggesting that a more systematic effort to discover and treat detoxification phobia could improve treatment outcome
Ambivalence toward methadone treatment among intravenous drug users	(Rosenblum, Magura, & Joseph, 1991)	Jailed intravenous drug users, not in treatment at their time of arrest, admitted to in-jail MMT program, NYC (66 men, 17 women)	Interview	Anxieties about MMT exist: 34% said it’s “hard to kick”, 24% mentioned other fears like overdose, 42% had no fear regarding MMT More frequent fears by women than men 93% of individuals indicated intention to enroll in MMT, but only 52% contextually described attending the program (reflects trying to meet expectations vs. actual intentions) 45% expected to remain in treatment for one year or less Continuation of negative attitude held by participants toward MMT
Attitudes toward methadone maintenance: Implications for HIV prevention	(Zule & Desmond, 1998)	163 heroin and speedball users in San Antonio, Texas	Interviews	Opioid users who had never been on methadone maintenance were more likely to express a negative attitude than those who had been on it Negative attitudes: general societal disapproval of addictive drugs, prior experience with 12 Step groups/abstinencebased treatments, previous forced rapid detoxification from methadone in jail, observation of methadone-maintained peers who continue to use drugs, perception that methadone is more addictive than heroin Positive attitudes: prior successful treatment with methadone, observation of methadone patients who stopped using drugs Guilt associated with using methadone is due to feeling that MMT is substituting one addiction for another and judgement by peers, which is instilled by Narcotics Anonymous’ total abstinence policy MMT helps clients reach milestones like finding employment and a driver’s license The cost of methadone is a barrier to care for some
Active heroin injectors’ perceptions and use of methadone maintenance treatment: cynical performance or selfprescribed risk reduction?	(Koester, Anderson, & Hoffer, 1999)	38 active IDU individuals with methadone experience in Denver, CO	Interviews	Methadone allows them to keep jobs/not have to hustle (commit petty criminal acts, sell drugs, etc.) Methadone allows them to get through the day if they are unable to get heroin For mothers, MMT allows them to care for children Methadone gets in one’s bones and causes aches and pains Methadone is addictive, and withdrawing from it is longer and more painful than withdrawing from heroin Methadone clients were described as: “robotic”; phrases used included “pacification”, “meth-a-death”, and “taking away motivation”
The street/treatment barrier: treatment experiences of Puerto Rican injection drug users	(Porter, 1999)	38 long-term Puerto Rican heroin users recruited in North Philadelphia	Survey	Methadone maintenance (positive): respondents felt free from having to chase opiates and live a more normal life; if given adequately it prevents withdrawal and respondents no longer have to engage in illegal behavior Methadone maintenance (negative): Feelings of inadequacy of counseling in methadone programs, fear of being forced to detoxify cold turkey from MMT if arrested, complaints that methadone “ate up your bones”, complaints that doses of methadone were too low, complaint of daily trip to the clinic, need for medical card/identification, waiting period to get into programs
Withdrawal from methadone maintenance treatment: prognosis and participant perspectives	(Lenne et al., 2001)	856 methadone clients in Melbourne, Sydney, and Brisbane	Survey	Clients were more optimistic about the likelihood of being opioid free after methadone withdrawal than clinic staff and doctors, highlighting a key discrepancy in perceived outcomes There was a high level of interest in clients to withdraw from MMT
Canadian illicit opiate users’ views on methadone and other opiate prescription treatment: an exploratory qualitative study	(Fischer, Chin, Kuo, Kirst, & Vlahov, 2002)	47 primary heroin users from Toronto, Montreal, and Vancouver, Canada	Focus groups	Majority believed that methadone was harmful to the body, due to negative side effects Many held the belief that it rots bones and teeth, has a negative effect on lifestyle because it causes loss of motivation and creativity, causing laziness Methadone is harmful because it is synthetic/man- made, while heroin is organic/natural Belief that methadone is more addictive than heroin Withdrawal from methadone was painful and worse than withdrawal from heroin, which leads to fear of withdrawal effects Beliefs that methadone programs were too controlling, that rules and regulations were too strict, and the requirements were inconvenient (going to the clinic every day) MMT does not address the euphoric feelings associated with injection Benefits of methadone treatment: helped them get off of heroin, reduced need to commit crimes to get money from drugs, for women, it helped them get off the streets (sex work), provides structure and stability in their lives, cheaper and more accessible and reliable than heroin
Appreciating the user’s perspective: listening to the “Methadonians”	(Montagne, 2002)	Not applicable	Review article/Opinion piece	MMT fails to attract a large number of users Patients felt they were treated as “subhuman” at treatment centers Patients felt that heroin was a more desirable form of treatment for addiction
Beliefs about methadone in an inner-city methadone clinic	(Stancliff, Myers, Steiner, & Drucker, 2002)	315 patients waiting in line for their medication at the methadone clinic	Questionnaire	80% of patients believed methadone is bad or may be bad for their health Roughly, 80% felt that methadone has helped them make positive changes in their lives 80% of methadone patients felt that they should get off methadone Suggests that patients deal with an inner conflict regarding methadone: between successful medical care and sense of selfrespect and dignity Suggests that there is a lack of education of patients regarding safety and benefits of methadone treatment, which may interfere with patient compliance.
User views on supervised methadone consumption	(Stone & Fletcher, 2003)	New patients referred for assessment and treatment, using rating scales; the consensus view of the Methadone Alliance; and the consensus view of a local service users’ forum.	Questionnaire	The perception exists among providers and patients that supervised methadone consumption is unacceptable Results from survey imply that majority of methadone users hold positive views of supervised methadone consumption Benefits of supervised methadone consumption include: lower risk of diversion, reduced reliance on urine drug tests, lower risk of accidental overdose of a child, decreased methadone related deaths
Users’ experiences of heroin and methadone treatment	(Gourlay, Ricciardelli, & Ridge, 2005)	10 participants in an Australian community-based methadone program	Qualitative interviews	Those who did not view themselves as an “addict,” saw methadone seen as freeing from heroin Methadone has “negative appearance effects” (e.g. rotting teeth) Treatment regulations and methadone were limiting in relation to “addressing life issues,” salience of methadone as a policy of “junkie control” and as “addiction” Methadone treatment may be more beneficial if users have access to resources, and opportunities for personal development
Perceptions of methadone-maintained clients about barriers and facilitators to help-seeking behavior	(Nyamathi et al., 2007)	41 methadone clients, 65% of whom are heavy drinkers	Interviews	Clients interested in alcohol treatments in methadone clinics Clients feel stigmatized by medical providers, so they choose not to tell providers that they are on MMT Non-judgmental care is seen as important, but lacking Participants voiced concerns regarding drug programs like MMT: drug programs treat individuals and drop them back into the previous environment; judgmental environment of Narcotics Anonymous
Satisfaction guaranteed? What clients on methadone and buprenorphine think about their treatment	(Madden, Lea, Bath, & Winstock, 2008)	432 clients receiving methadone or buprenorphine at a stratified sample of 9 public opioid treatment clinics in NSW, Australia	Intervieweradministered questionnaire, with openended responses	Worst aspects of treatment included dosing hours and lack of takeaway bottles of MAT, difficulty of transportation to the treatment program, feeling dependent on medication/lack of freedom, and stigma associated with treatment and treatment location Best aspects of treatment included no longer being dependent on heroin and feeling normal
Attitudes toward buprenorphine and methadone among opioid dependent individuals	(Schwartz et al., 2008)	195 participants (n = 140 who were enrolling in one of six Baltimore area methadone programs; n = 55 who were out-of-treatment	Attitudes toward Methadone and toward Buprenorphin e Scales; a subset (n = 46) received an ethnographic interview	The in-treatment group held more positive attitudes towards methadone than the out-of-treatment group Both groups felt more positively about buprenorphine than methadone 47% of study participants answered half of more items about buprenorphine “neither agree nor disagree” suggesting that participants are still forming opinions regarding buprenorphine. The in-treatment group saw methadone more positively as an aid to behavior change than the out-of-treatment group The out of treatment group viewed methadone negatively because of health effects, long-term nature of treatment, withdrawal symptoms upon discontinuation, and impact of methadone on peers. Positive views regarding buprenorphine: belief that it has fewer side effects, and positive remarks regarding shorter detox time.
Incarceration and opioid withdrawal: the experiences of methadone patients and out-of-treatment heroin users	(Mitchell et al., 2009)	53 opioid dependent adults with incarceration experience, both in and out of treatment	Interview	Patients viewed methadone withdrawal as far worse than heroin withdrawal; this is a motivating factor for patients to not use methadone Patients’ decisions to reduce their methadone dose before an impending incarceration is based on knowledge that inmates coming from MMT are not likely to receive adequate treatment for withdrawal Some patients see incarceration as an opportunity to detox themselves
Premature discharge from methadone treatment: patient perspectives	(Reisinger et al., 2009)	42 participants in 6 Baltimore-area methadone treatment programs	Semi-structured interviews	Frustration with program structure (no consistent rule structure) and stagnation caused patients to leave 12% of discharged patients indicated that their main reason for leaving was not wanting to be on methadone Many regarded methadone as an addiction, still, and described it as “substituting one drug for another” Participants remark wanting “control” over their lives again--not chained to the structure of the clinic or to another substance Belief that methadone withdrawal is worse than heroin withdrawal Positive views: able to focus on mental health (rather than physical), removal of the financial drain
Factors associated with the prescribing of buprenorphine or methadone for treatment of opiate dependence	(Ridge, Gossop, Lintzeris, Witton, & Strang, 2009)	192 patients from 10 addiction treatment services in London	Structured interviews	Buprenorphine was more likely to be prescribed for short term purposes; methadone usually for long-term treatment Oral methadone had a higher preference rating than buprenorphine Patients who received buprenorphine believed methadone lead to increased depressed feelings; patients who received methadone believed buprenorphine lead to increased anxious feelings Patients in both groups associated methadone with sedation
Why do patients report transferring between methadone and buprenorphine?	(Winstock, Lintzeris, & Lea, 2009)	145 OST patients (buprenorphine and methadone) from 3 public clinics in Sydney, Australia 46 individuals reported transferring medications (n=38 MET to BUP; n=20 BUP to MET)	Survey	Most common reason for transferring from MMT to buprenorphine was to help with withdrawal from OST (opioid substitution treatment) 30% of transfers in each direction were due to side effects Buprenorphine is perceived as being easier to come off of Major reason for switching to methadone: side effects, buprenorphine was not holding participant between doses
Attitudes toward methadone among out-of-treatment minority injection drug users: implications for health disparities	(Zaller, Bazazi, Velazquez, & Rich, 2009)	53 African American and Latino IDUs	Survey	Respondents generally expressed negative attitudes toward methadone Most respondents believe that people should attempt to discontinue methadone treatment, that coming to clinic makes life difficult, that being on methadone means the person is not abstinent from drugs, and that people in recovery look down upon people in methadone therapy Participants held the following beliefs: methadone has a negative effect on health; mistrust in the legitimacy of MMT as a drug treatment; the cost of MMT is a barrier to treatment Persistent belief that methadone is harder to withdraw from than heroin
Heroin-dependent inmates’ experiences with buprenorphine or methadone maintenance	(Awgu, Magura, & Rosenblum, 2010)	Heroin dependent men at Rikers Island jail in NYC who were randomly assigned to methadone or buprenorphine maintenance in jail	Structured interview	90% of both medication groups agreed that the meds relieved their cravings for heroin and prevented most withdrawal symptoms Methadone patients were likely to report feeling uncomfortable the first few days, having side/withdrawal effects during treatment, and being concerned about continued dependence on medication after release In contrast, buprenorphine patients’ main issue was the bitter taste All of the buprenorphine patients stated they would recommend the medication to others, with almost all preferring it to methadone - it works, it is better, no daily prescription, works faster 93% of buprenorphine patients vs 44% of methadone patients intended to enroll in those respective treatments after release, with an added one-quarter of the methadone patients intending to enroll in buprenorphine instead
Preference for buprenorphine/naloxo ne and buprenorphine among patients receiving buprenorphine maintenance therapy in France: A prospective, multicenter study	(Daulouede et al., 2010)	53 opioid-dependent patients stabilized on buprenorphine	Interview after switching from buprenorphine to suboxone	Satisfaction rates were similar between patients receiving buprenorphine and buprenorphine/naloxone Patients preferred the buprenorphine/naloxone’s size, taste, and dissolution time compared with buprenorphine—tablet specific factors. Specifically, patients noted that buprenorphine had a bitter, medicinal taste, while buprenorphine/ naloxone has a lemon-lime flavor and sweetener. Buprenorphine/naloxone also had a shorter dissolution time. At the end of the study, 54% of patients preferred buprenorphine/naloxone, 31% preferred buprenorphine, and 15% had no preference; most patients (71%) wished to continue treatment with buprenorphine/naloxone
Symptom complaints of patients prescribed either oral methadone or injectable heroin	(Dursteler-MacFarland et al., 2010)	117 patients from OST clinics (63 on oral methadone maintenance, 54 prescribed injectable heroin (IHT)	Self-completed questionnaire	Patients believe MMT does not produce more or different side effects than injectable heroin
Why don’t out-of-treatment individuals enter methadone treatment programmes?	(Peterson et al., 2010)	26 opioid dependent adults not seeking methadone treatment or had participated in treatment in the past 12 months in Baltimore, Maryland	Interviews	Participants are put on a waiting list to enter some methadone clinics Participants noted the following barriers to starting MMT: need to have a photo ID (difficult due to chaotic lifestyle, poverty, and unstable living arrangements), lack of money or insurance to pay for treatment Participants reported not wanting to deal with onerous nature of MMT structure (daily clinic visits) for a long-term maintenance program--some prefer self-medication with street methadone Perception that withdrawal from methadone worse than withdrawal from heroin; fear of withdrawal from incarceration Belief that methadone is a crutch, equated to substituting one drug for another Myths about methadone include side effects of rotting of bones and teeth Questioning methadone’s effectiveness; enabling family members
The SUMMIT Trial: A field comparison of buprenorphine versus methadone maintenance treatment	(Pinto et al., 2010)	361 opiate-dependent individuals	Questionnaire	Buprenorphine was reported to have a bitter taste Buprenorphine was seen as more effective at blocking the effects of heroin use Buprenorphine was considered easier to stop than methadone Buprenorphine was considered faster to stop Those who chose buprenorphine held negative views of methadone Concerns regarding likeliness to crave heroin, be drowsy, less clear-headed, emotional numbness Viewed as harder to stop Swapping one addiction for another Those who chose methadone did so because of previous experience, fear of withdrawal, belief that they were on too much heroin to use buprenorphine, and issues around intoxicating effects
Attitudes toward buprenorphine and methadone among opioid dependent individuals	(Schwartz et al., 2008)	195 participants (n = 140 who were enrolling in one of six Baltimore area methadone programs; n = 55 who were out-of-treatment	Attitudes toward Methadone and toward Buprenorphin e Scales; a subset (n = 46) received an ethnographic interview	The in-treatment group held more positive attitudes towards methadone than the out-of-treatment group Both groups felt more positively about buprenorphine than methadone 47% of study participants answered half of more items about buprenorphine “neither agree nor disagree” suggesting that participants are still forming opinions regarding buprenorphine. The in-treatment group saw methadone more positively as an aid to behavior change than the out-of-treatment group The out of treatment group viewed methadone negatively because of health effects, long-term nature of treatment, withdrawal symptoms upon discontinuation, and impact of methadone on peers. Positive views regarding buprenorphine: belief that it has fewer side effects, and positive remarks regarding shorter detox time.
Therapeutic switch to buprenorphine/naloxo ne from buprenorphine alone: clinical experience in an Italian addiction centre	(Montesano, Zaccone, Battaglia, Genco, & Mellace, 2010)	43 patients with opioid dependence that had been maintained on buprenorphine alone for 6–21 months	Observational, clinical based evaluation	The majority of patients taking buprenorphine/naloxone reported that they were highly satisfied with the effectiveness of therapy 50% of patients stated that they disliked the taste, color, odor and feel of buprenorphine/naloxone The large majority considered buprenorphine/naloxone to provide good control of craving
Injection drug users’ experience with and attitudes toward methadone clinics in Denver, CO	(Al-Tayyib & Koester, 2011)	425 IDUs in Denver area	Interview	Top three reasons for being on methadone: quit using drugs, not be dope sick, and to get stability and be functional Almost ¾ of those with MMT experience believed they were effective to help them and others get off of opioids MMT helps reduce harmful effects associated with drug use Negative perceptions were held about the cost of treatment, staff treatment of clients, benefits of counseling, and satisfaction with dosing regimes
A good quality of life under the influence of methadone: a qualitative study among opiate-dependent individuals	(De Maeyer et al., 2011)	25 opiate-dependent individuals between 26 and 46 years of age who started a MMT at least 5 years prior	Interview	Patients feel methadone can help them function normally, but at the same time, stigmatization, discrimination, dependence on methadone, and the drug’s paralyzing effects on their emotions were mentioned as common negative consequences Methadone helps opiate-dependent individuals to integrate into society and to stabilize personal lives
Patient perspectives on buprenorphine/naloxo ne treatment in the context of HIV care	(Egan et al., 2011)	33 HIV + patients on buprenorphine/naloxo ne treatment	Interview	Patients generally satisfied with buprenorphine/naloxone treatment and prefer it to other opioid treatments (effectiveness, elimination of craving, and blocking of euphoric effects) Patients find it effective in controlling adverse symptoms and giving them greater ability to manage their HIV and opioid dependence treatments Overall increase in quality of life associated with buprenorphine/naloxone treatment; returning to “normal” life; feeling more hopeful Ability to self-regulate use of buprenorphine/naloxone Concerns: fear of withdrawal, relapse (social factors), desire to taper off the drug, perceived side effects
Opiate users’ perceived barriers against attending methadone maintenance therapy: a qualitative study in China	(Lin, Wu, & Detels, 2011)	30 opiate users in Zhejiang and Jiangxi Provinces in China	Interviews	Participants perceived stigma in society toward opiate users and feared discrimination in society because of going to an MMT clinic everyday There is a fear associated with registering as an opiate user with the government, and subsequently being monitored by public security MMT users were seen as “running out of money”, whereas heroin users were seen as high socioeconomic status Many fear MMT withdrawal and believe methadone causes dependence and severe withdrawal
Unfavorable attitudes toward receiving methadone maintenance therapy and associated factors among the inmates using intravenous heroin	(Yen et al., 2011)	315 intravenous heroin users	Interview	Younger heroin users had more negative views of MMT when using the client attitudes toward methadone programs scale Starting heroin earlier is associated with a more negative view on MMT Perceiving many advantages and few disadvantages of heroin use is associated with negative attitudes toward MMT (focusing on the advantages) Depression was associated with negative attitudes toward MMT in inmates
Misconceptions predict dropout and poor adherence prospectively among newly admitted first-time methadone maintenance treatment clients in Guangzhou, China	(Gu et al., 2012)	158 newly admitted first-time MMT clients in Guangzhou, China	Interview	Misconceptions about MMT predict drop-out rates/poor adherence 98% of MMT clients had at least one misconception regarding MMT (misconceptions regarding treatment goals, duration of treatment, and dosage of methadone) Educational interventions for both the patient and provider may mitigate this
A comparison of attitudes toward opioid agonist treatment among short-term buprenorphine patients	(Kelly et al., 2012)	417 participants included; 132 individuals entering short-term BT, 191 individuals entering methadone maintenance; and 94 individuals not seeking treatment	Survey	Patients had preference for a specific medication Clients entering buprenorphine treatment held more positive views of buprenorphine than methadone Buprenorphine participants had significantly more positive attitudes toward buprenorphine than both MT and OT participants Possible that attitudes toward methadone and buprenorphine were influenced by the participants’ preference for the length of treatment Offering a choice of different medications and investigating patient’s knowledge of treatment options may encourage more patients to enter treatment
Misconceptions toward methadone maintenance treatment (MMT) and associated factors among new MMT users in Guangzhou, China	(Xu et al., 2012)	300 newly admitted MMT users in three clinics in Guangzhou	Interview	Newly admitted MMT users had misconceptions about the function of MMT, showing that they were misinformed and had unrealistic expectations 92% of participants believed that MMT is primarily intended for detoxification, MMT is not a long-term treatment, and that MMT is harmful to one’s health The difference in expectations may lead to dropouts or poor compliance Peers are important in rectifying these misconceptions
Patient perspectives on choosing buprenorphine over methadone in an urban, equal-access system	(Gryczynski et al.,2013)	80 new patients starting buprenorphine treatment	Questionnaire	Patients perceived their choice of buprenorphine as a decision against methadone Buprenorphine was perceived to be a helpful medication whereas methadone was seen as harmful with many side effects Positive past experience with “street buprenorphine” was a large factor in patients’ decision to pursue buprenorphine as an MOUD Withdrawal suppression was cited as a reason for choosing buprenorphine by 32.5% of the sample “Some participants also perceived methadone as addicting and necessitating longer-term or indefinite treatment, whereas buprenorphine could be taken for a shorter duration”
Assessment of attitudes towards methadone maintenance treatment between heroin users at a compulsory detoxification centre and methadone maintenance clinic in Ningbo, China	(Liu et al., 2013)	329 detained heroin users and 112 active MMT clients from a Compulsory Detoxification Centre and MMT clinic	Self-administered survey	Participants perceived that entering the MMT program could help them with “living a normal life,” reduce craving, reduce illegal drug use, and prevent HCV and HIV/AIDS Participants viewed methadone as addictive and difficult to stop using Many believed that MMT patients are looked down upon by non-methadone patients, MMT is bad for one’s health, and family members would feel shame if they knew the patient was on MMT
Meaning and methadone: patient perceptions of methadone dose and a model to promote adherence to maintenance treatment	(Sanders, Roose, Lubrano, & Lucan, 2013)	19 patients in an urban MMT program	Semi-structured interview	Patients judge ideal dose of methadone by comfort, function, and sense of normalcy Intrinsic factors with downward pressure: disdain for getting high (seen as misuse of treatment), concerns about a new habit, ideas about doses of methadone that are too high, desire to avoid adverse effects (feeling numb, weight gain) Intrinsic factors: withdrawal symptoms Extrinsic factors: shame and stigma around MMT, medical conditions and interactions with other medicines; Family could affect the pressure in either direction Perception that methadone was a “life-long sentence” or “liquid handcuffs” (related to control in treatment)
Awareness of, experience with, and attitudes toward buprenorphine among opioid users visiting a New York City syringe exchange program	(Shah, Sohler, Lopez, Fox, & Cunningham, 2013)	186 adult opioid users visiting a syringe exchange program	Survey	Of patients who knew someone who had taken buprenorphine or had taken buprenorphine, 85.7% had positive attitudes about its effectiveness (personal experience was limited) ⅔ of patients were aware of buprenorphine Few participants viewed buprenorphine as being hard to access (study did not distinguish between illicit and prescribed BUP) Participants suggest that prescribed buprenorphine is better than illicit for MOUD Generally, patients had more positive attitudes toward buprenorphine than methadone
Consumer attitudes about opioid addiction treatment: A focus group study in New York City	(Sohler et al., 2013)	38 patients in recovery using MAT	Focus groups	Initial attitudes toward buprenorphine treatment relative to methadone treatment Buprenorphine is a feasible option only for those who are motivated to stop using (as opposed to those trying to reduce drug usage). Taking buprenorphine while using illicit opioids is recognized as having negative consequences. Methadone users have less control over their treatment than buprenorphine users—specifically with “regard to decisions that would allow patients to eventually become ‘drug free’“ Difficulty of required daily visits to methadone clinics; feelings of “captivity” to the methadone system; possessing the ability to increase the dosage of methadone liberally. Lack of trust in methadone providers--belief that providers want to chain patients to the methadone system. Buprenorphine is not easily accessible to many in New York City Shortage of providers; a need for providers to be involved in the treatment program to provide guidance and support.
Self-management of buprenorphine/naloxo ne among online discussion board users	(S. E. Brown & Altice, 2014)	13 discussion board postings from September 2010 to November 2012	Retrospective study	Many posts advocated for self-management of buprenorphine and naloxone Many self-manage buprenorphine/naloxone intake to be substance free Buprenorphine/naloxone is described as “bad tasting” There is a desire to achieve some form of euphoria There is distrust of buprenorphine prescribers and pharmaceutical companies
Methadone maintenance for HIV positive and HIV negative patients in Kyiv: acceptability and treatment response	(Dvoriak et al., 2014)	25 HIV positive and 25 HIV negative opioid addicted individuals	Observational study	Methadone was well accepted by participants 92% of participants were accepting of methadone
I heard about it from a friend: assessing interest in buprenorphine treatment	(Fox et al., 2014)	158 opioid users and syringe-exchange participants in NYC	Interview	Participants were mostly aware of and interested in treatment with buprenorphine, but few had been prescribed Indirect exposure to buprenorphine (knowing someone who used it) was most closely associated with interest in treatment Most of the participants who had never been prescribed buprenorphine were interested in it
Patient perspectives on buprenorphine/naloxo ne: a qualitative study of retention during the starting treatment with agonist replacement therapies (START) study	(Teruya et al., 2014)	105 participants recruited up to 3.5 years after a randomized clinical trial comparing the effect of buprenorphine/naloxo ne and methadone on liver function	Semi-structured interviews	Barriers to buprenorphine/naloxone retention: design of clinical trial, negative medication treatment experience, personal circumstances A number of patients left the study because they wanted the euphoric effects of opioids but were not getting it on suboxone “But if you use on this stuff, you know, you can’t really feel it that good. So, like on the weekends, I wouldn’t take it or whatever.” “I wasn’t ready to quit… I wasn’t ready to be clean-clean.” Others stated that the medication “worked well,” and patients “felt normal.” Personal determination “I didn’t wanna go back to drugs, so I was going to do what I had to do to stay clean…. So, there’s no rain or sleet of fog that would stop me ‘cause I was coming ‘cause I knew it was benefiting me and my health.”
Factors associated with willingness to take extended release naltrexone among injection drug users	(Ahamad et al., 2015)	657 HIV-seronegative individuals who inject drugs and HIV-seropositive individuals who use illicit drugs in the Vancouver	Interview	Participants had a high willingness to take XR-NTX Daily heroin use is associated with higher willingness to take XR-NTX Unwilling to take XR-NTX: not currently taking opioids, happy with methadone/suboxone, didn’t feel they could detox
Patient perspectives associated with intended duration of buprenorphine maintenance therapy	(Bentzley, Barth, Back, Aronson, & Book, 2015)	69 patients enrolled in BMT	Survey	82% of participants wanted to continue BMT for at least 12 months Intended duration of treatment was positively influenced by Age at first drug use Time in BMT Concern about pain (65%) Concern about relapse (59%) Unsuccessful attempts to taper off (35%) Physician advice (32%) Influence of family/friends (29%) Intended duration of treatment was negatively influenced by Recent discussion with treatment provider about BMT discontinuation Prior attempt to discontinue BMT Experiencing euphoria from BUP Perceived conflict with life, work, or school Also 45/69 patients said that buprenorphine makes them feel “OK”, “normal” or “level-headed” 8/69 patients reported positive feelings such as “better”, “driven”, or “motivated” 4/69 reported sedation
“Sub is a weird drug:” A web-based study of lay attitudes about use of buprenorphine to self-treat opioid withdrawal symptoms	(Daniulaityte, Carlson, Brigham, Cameron, & Sheth, 2015)	Web forum posts focused on illicit opioids/other drugs	Retrospective study	Buprenorphine is discussed online Mixed positive/ negative feelings regarding BUP Many participants advocate for lower doses of buprenorphine with a “less is more” mindset The main motivator of spacing out buprenorphine doses was to avoid the pain of withdrawal Those who express negative attitudes about buprenorphine’s effectiveness complained that it is not effective in alleviating withdrawal symptoms
Release from incarceration, relapse to opioid use and the potential for buprenorphine maintenance treatment: a qualitative study of the perceptions of former inmates with opioid use disorder	(Fox et al., 2015)	21 former inmates with opioid-use disorder recruited from addiction treatment settings	Semi-structured interview	BMT perceived as acceptable, but prior inmates are reluctant to utilize it after reentry Themes related to BMT: Reliance on willpower; acceptance of responsibility (not always sufficient to prevent relapse) Fear of dependency on medications (seen as a step backward and/or a setup for withdrawal Variable exposure to buprenorphine Acceptability of BMT following relapse (sometimes used as a “backup” to abstinence)
An exploratory qualitative assessment of self-reported treatment outcomes and satisfaction among patients accessing an innovative voluntary drug treatment centre in Malaysia	(Ghani et al., 2015)	77 current and former patients of a voluntary drug treatment center in Malaysia	Interview	Patients identified methadone treatment, psychosocial programs, religious instruction, and recreational activities as important factors contributing to treatment success for addressing both health and addiction needs Adherence to voluntary programs was determined by the degree of social support, the voluntary nature and the array of new programs available for selection
Diversion of methadone and buprenorphine from opioid substitution treatment: the importance of patients’ attitudes and norms	(Johnson & Richert, 2015)	411 patients in opioid substitution therapy	Interview	Patient reasons for diversion include: Illicit BUP/methadone saves lives It’s the right thing to do if a friend is “dope-sick” Need of money Not needing full doses Treatment staff doesn’t usually detect diversion Insufficient access to treatment, strict admission criteria, and involuntary discharges of patients who have broken program rules are other factors that can increase the demand on the illicit market Likelihood to participate in diversion depends on patient’s beliefs regarding sharing medications and believes perceiving control measures as effective
The role of gender in factors associated with addiction treatment satisfaction among long-term opioid users	(Marchand et al., 2015)	Long-term opioid-dependent individuals, who were currently or previously on OAT	Cross-sectional study, questionnaire and qualitative interviews	Based on the questionnaire: participants who were older, of Aboriginal ancestry, and currently in OAT had higher OAT satisfaction Positive perceptions from qualitative interviews included: methadone/suboxone reduces withdrawal symptoms, treatment improves physical and mental health, contributes to a sense of stability, as well as reduces stressors and criminal involvement Negative perceptions from qualitative interviews included: treatment is associated with adverse mental (e.g. “emotional numbness”) and physical health (e.g. weight gain and bone deterioration); methadone/ suboxone has a bad taste and is considered addictive; and there is a lack of freedom and autonomy in treatment decisions There was a noted difference in concerns between male and female gender; women were more concerned with emotional and physical outcomes; men were more concerned with loss of “general functioning”
Prior experience with non-prescribed buprenorphine: role in treatment entry and retention	(Monico et al., 2015)	300 African American buprenorphine patients in Baltimore, Maryland	Qualitative interview, secondary to a randomized clinical trial	Respondents noted that prior non-prescription buprenorphine use increased willingness to enter treatment (confirmed the efficacy of the medication, lower cost of prescription vs. non-prescription, convenience of obtaining medication) Respondents reported use of non-prescribed buprenorphine to avoid withdrawal symptoms Patients who used non-prescribed buprenorphine before prescribed buprenorphine were more likely to remain in treatment through 6 months
Exploring the concepts of abstinence and recovery through the experiences of long-term opiate substitution clients	(Notley, Blyth, Maskrey, Pinto, & Holland, 2015)	27 participants sampled from a study of 317 clients who had been receiving opiate-substitution therapy (OST) (methadone or buprenorphine) for 5 years or more	Qualitative interviews	OST therapy provided participants with a sense of normalcy and stability OST allows for relief from chaotic life OST mitigates fear of withdrawal Some participants did, however, feet withdrawn, lethargic, and unable to fully participate in mainstream society Recovery was viewed as a process, not a fixed goal OST can precipitate reemergence of emotions and memories which can pose a challenge if participants had not developed alternate coping mechanisms Experience of long-term maintenance For some, the OST prescription is useful when they are unable to acquire heroin (though this was the minority) Long term OST perceived as bridge between illicit drug use and recovery Escape from chaos “First time you don’t have to chase anything” Some felt bound to prescription “You do develop a distaste for the stuff. Although you need what it does for you, it’s still sort of slavery.” Interpersonal barriers “Mixing with the same crowd” and the fear that drugs have permeated so deeply into life, culture, and support systems Systemic barriers “I do feel that the service tend to treat the symptoms not the cause hugely”
Treatment readiness, attitudes toward, and experiences with methadone and buprenorphine maintenance therapy among people who inject drugs in Malaysia	(Vijay, Bazazi, Yee, Kamarulzama n, & Altice, 2015)	460 people who inject drugs in Greater Kuala Lumpur Malaysia	Survey about attitudes toward and experiences with OMT and treatment readiness	Most participants had favorable attitudes toward methadone or buprenorphine, with attitudes toward methadone were significantly more favorable 63.3% of participants thought methadone was the best option to treat opioid addiction 51.5% agreed that buprenorphine was best when asked the best way to treat opioid addiction Most participants disagreed with the statement that OMT providers treat patients poorly 55% of patients felt that buprenorphine encouraged people to use more of other drugs 79% and 76% felt that methadone and buprenorphine respectively were problematic because they were replacing one drug for another 83% demonstrated moderately positive treatment readiness
How clients’ during-treatment motivations relate to their perceptions and impressions methadone maintenance treatment: A multilevel analysis of a cross-sectional survey in Guangdong Province, China	(Deng et al., 2016)	802 patients from 12 MMT clinics	Questionnaire	74% of patients agreed methadone was a medication instead of a drug Supportive family assistance at the clinic, education, client’s perceptions of healthcare workers, and impressions of MMT were related to the patient’s desire for help score Patients who went beyond a primary school education expressed stronger during-treatment motivations Prolonging treatment hours correlates with higher treatment readiness scores
Optimizing psychosocial support during office-based buprenorphine treatment in primary care: Patients’ experiences and preferences	(Fox, Masyukova, & Cunningham, 2016)	33 buprenorphine treatment-experienced patients	Focus group with a semi-structured interview guide	Patients perceived buprenorphine treatment to be helping them achieve treatment goals, they value flexibility, accessibility, and privacy of treatment Patients feel that in addition to the physical aspects of BUP treatment, it also needed to address the psychological or “mental” components of addiction, requiring providers to have counseling skills Patients desired care delivery models that were patient-centered, created a safe space for self-disclosure, and used coordinated team-based care Good patient-physician relationships are key
Determinants of willingness to enroll in opioid agonist treatment among opioid dependent people who inject drugs in Ukraine	(Makarenko et al., 2016)	1179 participants not currently on OAT in the Ukraine	Cross sectional survey	Those willing to start OAT had previously been in prison, injected drugs for a longer period of time, injected drugs frequently, were more likely to have had an overdose in the past six months, and had family support in starting OAT Reasons for unwillingness to start OAT included: belief that OAT replaces one addiction for another, perception of negative effects on health, belief that OAT does not treat addiction and has bad side effects, and perception of difficulty of withdrawal
“I kicked the hard way I got incarcerated” withdrawal from methadone during incarceration and subsequent aversion to medication assisted treatments	(Maradiaga, Nahvi, Cunningham, Sanchez, & Fox, 2016)	21 formerly incarcerated individuals with opioid use disorder in the Bronx, NY	Semi-structured interviews	Problems with methadone during incarceration included: delays in initiating treatment, discontinuous dosing, and inattention to medical needs or withdrawal symptoms Treatment and withdrawal symptoms experienced while incarcerated deterred participants from restarting methadone and other forms of MAT after release
Factors associated with interest in receiving prison-based methadone maintenance therapy in Malaysia	(Mukherjee et al., 2016)	96 HIV positive and 104 HIV negative incarcerated men who were opioid dependent before incarceration	Structured questionnaire to examine attitudes toward MMT	43% participants were interested in receiving MMT in prison, only 18% were receiving MMT Interest in MMT was associated with greater likelihood of endorsing positive attitudes and decreased likelihood of endorsing negative attitudes toward treating opioid dependence with MMT Those with the most favorable attitudes toward MMT had 20x higher odds of interest in MMT than those with the least favorable Among those interested in MMT, 91% agreed with the statement ‘Methadone therapy is the best way to treat opioid addiction’ compared with 64% of those not interested in MMT Prisoners who have experienced more negative consequences associated with their drug use were more interested in initiating MMT
Accessing methadone within Moldovan prisons: Prejudice and myths amplified by peers	(Polonsky, Azbel, et al., 2016)	56 opioid dependent PWIDs (persons who inject drugs) both out of treatment and in treatment	Online survey	Prisoners who didn’t receive within-prison OAT (opioid agonist therapies) held more negative attitudes about OAT effectiveness and were more likely to endorse myths about OAT Individuals who were receiving OAT were less likely to report feeling safe in prison ⅔ had previously heard that methadone was not a good treatment for addiction from other prisoners (87%) and physicians (39%) Individuals are relatively well informed about OAT, but they are embedded within a stigmatizing prison culture
Attitudes Toward Addiction, Methadone Treatment, and Recovery Among HIV-Infected Ukrainian Prisoner Who Inject Drugs: Incarceration effects and exploration of mediators	(Polonsky, Rozanova, et al., 2016)	People with HIV who injected drugs 30 days before incarceration	Surveys	Incarcerated participants had higher optimism about changing their drug use, were less likely to endorse methadone, and had higher intentions to recover from their addiction Negative correlation between MMT endorsement and intention to recover, suggesting that enrollment in MMT and recovery from addiction are viewed as mutually exclusive processes MMT perceived to be an obstacle rather than a path to recovery
Perceptions Related to Pharmacological Treatment of Opioid Dependence Among Individuals Seeking Treatment at a Tertiary Care Center in Northern India: A Descriptive Study	(Prakash & Balhara, 2016)	85 treatment seeking patients (all male) admitted to an inpatient SUD (substance use disorder) management center in northern India	Questionnaire	Patients feared becoming dependent on buprenorphine Reported benefits of buprenorphine included the suppression of withdrawal and craving Patients reported frequent fear with oral naltrexone was that of experiencing a “reaction” (precipitated withdrawal) Patients reported that oral naltrexone was beneficial in preventing relapse, and that it purified or “filtered” blood Oral naltrexone was considered beneficial for periods less than a year, with the extent of benefit considered lesser after a year of use Most participants preferred drug-free treatment, and naltrexone was the most favored medication treatment Control of discomfort related to withdrawals came out to be the most frequently reported primary expectation
Patient’s Beliefs About Medications are Associated with Stated Preference for Methadone, Buprenorphine, Naltrexone, or no Medication-Assisted Therapy Following Inpatient Opioid Detoxification	(Uebelacker, Bailey, Herman, Anderson, & Stein, 2016)	372 patients in an opioid detoxification program	Interview	Preference of treatment: XR-NTX (32%), buprenorphine (28%), No treatment (22%), MMT (18%) XR-NTX and BUP were considered more effective than MMT Patients with a preference for a particular MAT were more likely to rate that MAT as more effective, safer, and generally more positively XR-NTX may correlate with the perception of “being drug free” because it does not contain a synthetic opioid MMT was perceived as the least safe, efficacious, or consistent with being drug free
Methadone, buprenorphine and preferences for opioid agonist treatment: A qualitative analysis	(Yarborough et al.,2016)	283 opioid dependent adults	Audio recorded interviews	Identified factors for opioid agonist treatment decision-making: Prior experience with MOUD In participants who had experienced both buprenorphine and methadone treatment, participants favored buprenorphine. Significantly more participants found buprenorphine to be more useful than methadone in treating opioid dependence. Need for accountability and structural support Not enough accountability when using buprenorphine treatment. Methadone treatment is disruptive to work schedules Preference to avoid methadone clinics Buprenorphine allowed for a return to a sense of “normalcy” and “privacy”. Stigma associated with methadone clinics Temptation to use opioids again due to the clientele Fear of continued addiction and perceived challenge of withdrawal (specific to methadone)
Attitudes toward medication-assisted treatment among fishermen in Kuantan, Malaysia, who inject drugs	(S. E. Brown et al.,2017)	Fishermen who inject drugs	Interview	Favorable attitude toward methadone existed because of familiarity and local acceptance of methadone use Some fishermen believe that methadone can cause harm instead of curing Methadone is difficult to take it when on long fishing trips Buprenorphine is perceived as more dangerous than other two MATs; very uninterested in buprenorphine; issues obtaining enough buprenorphine Naltrexone is least known MAT
Systemic and individual factors in the buprenorphine treatment-seeking process: a qualitative study	(Hewell, Vasquez, & Rivkin, 2017)	People who have used or considered using buprenorphine in treatment for OUD	Interview and focus groups	Negative societal perceptions of MAT guided BUP-seeking process Motivations were both individually (intrinsic attitudes, beliefs, values, and motivations in seeking and completing treatment) and systemically (broader social support, family, treatment, public policy, and culture) guided Participants describe others as having negative views including stigma and judgment about MAT Participants had variable personal beliefs about MAT: believing it is a good aid in the recovery process, trading one addiction for another, and having negative emotions associated with MAT
A qualitative study of reasons for seeking and ceasing opioid substitution treatment in prisons in New South Wales, Australia	(Larney, Zador, Sindicich, & Dolan, 2017)	46 participants from seven correctional centers in NSW, Australia	Semi-structured face-to-face interview	Benefits of OST in custody included managing opioid withdrawal and cravings and avoiding risk of injecting in prison Those not on OST had a preference to be ‘clean’ (abstaining from all substances), as many perceived methadone as replacing one addiction for another Those who wanted to continue treatment post-release perceived OST to offer stability, help them to avoid illicit drug use, and help them to maintain daily commitments Those who wanted to stop treatment before release were concerned about exposure to other drug users at OST clinics, which would lead to drug use and criminal behavior Those who wanted to stop treatment before release had family and friends who did not perceive OST to be acceptable, and believed withdrawal from methadone to be easier to endure in prison Buprenorphine was preferred over methadone because of the perception of an easier withdrawal when participants decide to end treatment, potential for less frequent dosing, and the relative lack of stigma associated with buprenorphine compared with methadone
Why People Who Inject Drugs Voluntarily Transition off Methadone in Ukraine	(Rozanova et al., 2017)	25 focus groups conducted in five Ukrainian with 199 participants who were currently, previously, or never on MMT	Focus group interview	Social control: Strictly supervised; police presence presented as a deterrent and making patients feel disempowered; patients also threatened with “administrative discharge” from the program (forced symptoms of withdrawal) Patients must travel to the treatment center 7 days a week and cannot earn “take home doses”, long wait at MMT site Wounded Identity: Negative perceptions from providers (seen as less than human, treated like animals, etc); negative perceptions from the community and employers Perceived abuse of power from physicians, which instills fear in participants Seeing other patients with whom they do not get along; patients find social support from the other patients at the center Patients expressed a desire to “return to normal life”
I Was Not Sick and I Didn’t Need to Recover”: Methadone Maintenance Treatment (MMT) as a Refuge from Criminalization	(Frank, 2018)	23 people on MMT	Interview	Patients sought methadone treatment because of the legality/criminality and difficulties of maintaining illegal drug use Methadone is seen as a legal, safe, affordable, and reliable way to acquire opiates, not as a path to recovery Participants focused on using MMT to minimize the effects of withdrawal or avoid the effects completely Many participants believe that MMT is a “privilege” that must be earned
Challenges in implementing opioid agonist therapy in Lebanon: a qualitative study from a user’s perspective	(Ghaddar, Khandaqji, & Abbass, 2018)	81 males in Lebanon on an opiate antagonist therapy (BUP)	Interview	There is a financial obstacle to participating in OAT OAT improves mental and social well-being among users who had financial access to it; treatment promoted family acceptance and support Registering in OAT protects users from arrest and reduces financial burden for some Challenges include fear of dependence, restricted access to treatment and misuse of buprenorphine, switching of one addiction to another, long term treatment schedule
At the Expense of a Life: Race, Class, and the Meaning of Buprenorphine in Pharmaceuticalized “Care”	(Hatcher, Mendoza, & Hansen, 2018)	77 patients receiving buprenorphine in primary care clinic and two outpatient substance dependence clinics	Interviews	Factors influencing Buprenorphine Medication Treatment (BMT) include more privacy and less stigma than methadone; some patients still report feeling stigmatized with BMT Reported side effects of methadone on everyday life are not present in BMT BMT allows for flexibility in patient’s schedules, which helps to secure jobs and autonomy Importance of providers increasing psychosocial awareness of patients without social resources
Buprenorphine treatment formulations: preferences among persons in opioid withdrawal management	(Kenney, Anderson, Bailey, & Stein, 2018)	339 patients entering inpatient opioid withdrawal management programs at 2 sites	Survey	55% of respondents reported willingness to use buprenorphine if it is prescribed to them Patients who were willing to use buprenorphine were more likely to have used non-prescription buprenorphine in the past In patients who were willing to use buprenorphine, there were significant preferences for taking the medication via pills, a monthly shot, or an implant
Perceived barriers to methadone maintenance treatment among Iranian opioid users	(Khazaee-Pool et al., 2018)	23 opioid users between the ages of 27 and 59 from Kurdistan provinces	Interview	Key barriers to MMT include: finances, lack of awareness, negative attitudes about methadone, worries about its side effects, social stigma, and systemic barriers to treatment The majority of patients believe that they will be able to put their drug use aside after only a few months of methadone treatment Some participants mention that they have no desire to be treated with methadone due to rate of relapse in MMT Some participants see methadone side effects as worse than heroin
A Qualitative Assessment of Attitudes About and Preferences for Extended-Release Naltrexone, a New Pharmacotherapy to Treat Opioid Use Disorders in Ukraine	(Marcus et al., 2018)	199 People Who Inject Drugs (PWID)	Focus groups	Many expressed fear about opioid withdrawal symptoms if not detoxed before starting the medication Some patients feared that they were “addicted to injecting” and receiving XR-NTX injections may fuel a desire to continue to use Many patients felt that the “ideal candidate” for XR-NTX is a younger PWID with less experience with addiction Receiving daily treatment with MMT or BMT provides opportunity for continuous support from treatment team, monthly injections of XR-NTX prevent these daily interactions Patient expressed the need for extensive, daily treatment with a health professional if starting XR-NTX Attitudes toward XR-NTX were overall positive
Barriers to progressing through a methadone maintenance treatment programme: perspectives of the clients in the Mid-West of Ireland ‘s drug and alcohol services	(Moran, Keenan, & Elmusharaf, 2018)	17 clients of one of Ireland’s Health Service Executive (HSE) Drug and Alcohol Services	Interviews	Positive views of pharmacological properties of methadone were reported, especially in the early phases of treatment Patients discussed the importance of including doctors, psychiatrists, and housing representatives as services accessible at a methadone clinic “It just gives you time, it gives you a choice, methadone actually gives you the choice to take or leave heroin.” Patient and family education regarding methadone was poor “I got given a leaflet, so I just read through that, you know.’ (I learned) a little bit off YouTube. No, no one explained to me how methadone works.”
Dissatisfaction with opioid maintenance treatment partly explains reported side effects of medications	(Muller, Bjornestad, & Clausen, 2018)	Engaged more than 1000 OMT patients, corresponding to one seventh of OMT patients in Norway	A peer-to-peer survey developed by a patient advocacy group was used	Heavier side effect burden of methadone than buprenorphine/naloxone and buprenorphine Patients reported high satisfaction with buprenorphine and methadone treatments compared to buprenorphine/naloxone treatment (reported significantly lower satisfaction)

Table 4.

Patients’ and Providers’ Attitudes and Beliefs About MOUD

Title	Author	Population	Type of Data Collection	Summary
Staff and client attitudes toward methadone maintenance treatment	(Brown, Bass, Gauvey, & Kozel, 1972)	55 patients and 23 staff members from a narcotic treatment facility in the District of Columbia Narcotics Treatment Administration	Adjective Check List surveys	Patients perceive individuals receiving methadone as being responsible, conscientious, and supportive of others “Staff members---like their clients---see the addict abstinent from all drugs as a more effective and capable person than is the addict using methadone” MMT patients see themselves as being more “self-willed” but also less insightful and having less concern for others feelings and values compared to those who do not use MOUD Staff and clients felt that the addict using heroin is characterized by being more underachieving, irresponsible, dependent, antisocial than the addict using methadone or no drugs at all Staff provide guidance and direction to clients and could communicate their attitudes to clients, even if unintentionally
Tapering from methadone maintenance: attitudes of clients and staff	(Gold, Sorensen, McCanlies, Trier, & Dlugosch, 1988)	60 clients (not currently tapering) and 30 staff members in five MMT clinics across San Francisco Bay Area	Interview/Questionnaire	Patients on MMT become phobic about voluntarily tapering off methadone and feel it interferes with ability to attain abstinence Attitudes towards tapering: 35% extremely motivated to taper Motivations for tapering: a desire to be drug free, dislike of coming to the clinic, personal growth, physical side effects of MET 28% of patients were extremely opposed to tapering, stating that methadone was a stabilizing factor and a fear of return to illicit drug use Patients view tapering from methadone as difficult Patients describe the biggest obstacle of tapering is a fear of living without methadone”. This fear is psychological in nature, which could be potentially remedied with coping strategies Both client and staff had similar attitudes toward MMT 93% of staff and 60% of clients disagree that once you’re on methadone, you have to keep taking it Over half of clients view the drug environment as the reason that they would fail treatment
Methadone maintenance in the treatment of opioid dependence a current perspective	(Zweben & Payte, 1990)	Academic sources	Opinion	General negative attitude about methadone in physicians, patients, and general public Addicts enter MMT with ambivalence or an urgency to get off of it Source of negative attitudes toward MMT is the perception that methadone treatment is “substituting one drug from another”
Buprenorphine for Office-Based Practice: Consensus Conference Overview	(Kosten & Fiellin, 2004)	Academic literature, presentations	Summary of Presentations at Conference	80% of psychiatrists were not comfortable providing office-based opiate agonist treatments, which was a barrier to moving the buprenorphine treatment forward Patients exhibited satisfaction with office-based buprenorphine
Predicting treatment retention with a brief “Opinions About Methadone” scale	(Kayman, Goldstein, Deren, & Rosenblum, 2006)	338 clients in MMT in New York City	Survey	Negative attitudes towards methadone treatment at the time of admission predicted a client’s retention in the program; negative attitudes correlate with earlier termination Specific negative attitudes toward methadone included in the survey included were “methadone is substituting one drug for another” or “it is practically impossible to get off methadone.”
Client and counselor attitudes toward the use of medications for treatment of opioid dependence	(Rieckmann, Daley, Fuller, Thomas, & McCarty, 2007)	376 counselors and 1,083 clients from outpatient, methadone, and residential drug treatment programs	Medications Opinions Survey	Methadone clients and counselors held more positive views of methadone than those in residential or outpatient settings Attitudes toward buprenorphine were neutral Social norms influenced client and counselor behaving suggesting that perceptions and beliefs play an important role in MOUD treatment Clients were generally less informed about buprenorphine
Societal perception and support for methadone maintenance treatment in a Chinese province with high HIV prevalence	(Yang et al., 2008)	411 police staff, medical health professionals, community members, and drug users	Survey questionnaires and focus groups interviews	85% of all respondents supported the MMT programs Drug users when compared to all other groups were the least optimistic about MMT 87% of all respondents believed that MMT would be effective for preventing HIV transmission
Methadone Maintenance Treatment for Youth: Experiences of Clients, Staff, and Parent	(Guarino et al., 2009)	22 clients, clinical staff, and clients’ parents	Focus groups	Clients described methadone as a “safety net” that helped them lead normal lives Clients explained that because of the physical dependence associated with methadone, MMT should be offered as a “last resort” Staff expressed frustration with provider resistance to offering methadone to clients
A qualitative inquiry into methadone maintenance treatment for opioid-dependent prisoners in Tehran, Iran	(Zamani et al., 2010)	30 prisoners (3 assistants for MMT administration) in Ghezel hesar prison, 15 others: 4 physicians, 2 nurses, 3 psychologists, 2 prison managers, 4 health policymakers	Focus group and interviews	MMT is perceived as effective by both prisoners and managing staff Prisoners and practitioners reported that MMT had health benefits MMT has alleviated financial strain on drug-using prisoners and their families Other prisoners and staff stigmatize those who use MMT The MMT program in prison significantly reduced the number of prisoners injecting drugs Some prisoners report fear of side effects of MMT
In control? Ukrainian opiate substitution treatment patients strive for a voice in their treatment.	(Golovanevskaya, Vlasenko, & Saucier, 2012)	Academic literature, 8 physicians and 20 patient advocates	Systematic review and Interviews	Methadone is heavily policed in Ukraine, and patients must be diagnosed with opiate addiction and participate in a clinical trial Doctors face the risk of arrest for not complying with the complicated documentation needed for MMT in Ukraine OST is not available by prescription or for take-home allowance in Ukraine Patients face limited clinic hours, long waiting lines, and inability to receive medication outside of work hours
Methadone maintenance treatment in China: perceived challenges from the perspectives of service providers and patients	(Wu et al., 2013)	4 focus groups: 2 with providers and 2 with patients (25 drug using patients and 14 providers)	Focus groups	Providers and patients had positive experiences with MMT but there were concerns about side effects and continued heroin use Identified barriers to care were: affordability, stigma, and accessibility Patients describe a fear of becoming addicted to methadone
Opioid maintenance therapy in Switzerland: an overview of the Swiss IMPROVE study	(Besson et al., 2014)	200 physicians and 207 opioid dependent patients	Questionnaire	Buprenorphine was prescribed most frequently by psychiatrists and internists Physicians cited barriers to care: lack of training, difficult patient group, and scarcity of resources Liquid methadone was the preferred medication in all regions “45% of all physicians interviewed reported that diversion of substances was a significant or huge problem”
Discontinuation of buprenorphine maintenance therapy: perspectives and outcomes	(Bentzley, Barth, Back, & Book, 2015)	Studies that include patient and/or provider perspectives on buprenorphine	Systematic review	Fear of relapse is a major reason for patients to remain in BMT There is a disconnect between patient impression of length of BMT and actual length of BMT One study found that the majority of physicians surveyed found long-term buprenorphine treatment beneficial
The rights of drug treatment patients: experience of addiction treatment in Poland from a human rights perspective	(Klingemann, 2017)	43 staff and 73 patients from inpatient therapeutic communities, outpatient programs, and opioid substitution programs in Poland	Focus group interviews	Patients in opioid substitution treatment (OST) experience “disrespect of privacy and dignity” Patients report feeling humiliated, belittled, and a sense of hopelessness in terms of enacting change. Staff of outpatient programs note the difficulty of gaining admission information about patients while maintaining a good patient-practitioner relationship.

Methadone is bad for your health:

There were 28 articles that discussed the negative consequences associated with taking methadone for an extended period of time (Table 2). Specifically, patients felt that methadone was associated with lower libido (Muller, Bjornestad, & Clausen, 2018), was “bad for their health” (Notley, Blyth, Maskrey, Pinto, & Holland, 2015; Stancliff, Myers, Steiner, & Drucker, 2002; Sutker & Allain, 1974), and that methadone “rots” bones and teeth (B. S. Brown, Benn, & Jansen, 1975; Rosenblum, Magura, & Joseph, 1991).

Methadone is associated with negative social stigma:

Negative social stigma associated with methadone was a central theme in 39 papers, 24 of which commented on the patients’ perspective of this stigma (Table 2). In a cross-sectional questionnaire of 315 patients at a New York City methadone clinic, 53% of patients agreed with the statement, “I am afraid to tell my family and friends [I’m on methadone]” (Stancliff et al., 2002). Additionally, a Ukrainian qualitative study found that patients expressed that taking methadone gave them an undesired label in society; that methadone users were seen as liars, thieves, and rapists, and that patients did not want to be seen by coworkers, family, or friends walking into a methadone clinic for fear of discrimination (Rozanova et al., 2017).

Methadone maintenance is often perceived as “substituting one addiction for another”, and concepts of recovery from OUD are often ill defined (Nyamathi et al., 2007; Zweben & Sorensen, 1988). Given prior experience with 12-step programs and other abstinence-based programs, patients with OUD feel isolated and judged for participating in methadone maintenance treatment (MMT) (Zule & Desmond, 1998). A survey-based study of 53 African American and Latino injection drug users found that 60% of respondents believe that “being on methadone means that a person is not abstinent from drugs” and 70% of respondents “perceived that people in [abstinence-based] recovery look down upon people on methadone therapy” (Zaller, Bazazi, Velazquez, & Rich, 2009). This study highlights the psychological and social circumstances that inform a patient’s decision to participate in MMT. In addition to the perceived loss of a 12-step support network, the patient’s own perception that MMT is a “life sentence” or “liquid handcuffs” can negatively impact treatment and recovery (Gourlay, Ricciardelli, & Ridge, 2005; Peterson et al., 2010; Reisinger et al., 2009; Roose, Kunins, Sohler, Elam, & Cunningham, 2008; Sanders, Roose, Lubrano, & Lucan, 2013).

Methadone is challenging to stop using due to fear of withdrawal:

In 20 studies, patients expressed concern about a lack of control or inability to stop using methadone due to fear of having withdrawal symptoms (Table 2). In one study, individuals with opioid dependence expressed that they feared incarceration because they believed that methadone’s withdrawal was worse than heroin withdrawal, and because prisoners often have to go through withdrawal “cold turkey” (Schwartz et al., 2008). On the other hand, two studies found that patients viewed tapering off of methadone as difficult, yet they were optimistic about their own situation and potential to do so (Gold, Sorensen, McCanlies, Trier, & Dlugosch, 1988; Lenne et al., 2001).

Methadone maintenance is inconvenient and uncomfortable due to required daily attendance at a clinic:

Sixteen studies evidenced the sentiment that methadone maintenance is both inconvenient and uncomfortable for individuals in recovery (Table 2). One qualitative study found that patients felt that it was difficult to have a job and be on time because they have to attend the methadone clinic every morning, a requirement for methadone maintenance treatment based on SAMHSA guidelines (Hatcher, Mendoza, & Hansen, 2018). In a qualitative study that interviewed opioid dependent adults, one participant said:

“I think I’d probably do better with methadone as far as cravings go, because I think it’s definitely a stronger opioid. But, at the same time, I wouldn’t want to just get dependent on methadone … If I could have like an outpatient prescription for methadone, that would be ideal. I just don’t want to go there every single day to that place.”

(Yarborough et al., 2016)

Patients often noted that methadone administration was inconvenient because they had to go to a specialized clinic every day (Fischer, Chin, Kuo, Kirst, & Vlahov, 2002; Golovanevskaya, Vlasenko, & Saucier, 2012; Hunt, Lipton, Goldsmith, Strug, & Spunt, 1985; Madden, Lea, Bath, & Winstock, 2008; Peterson et al., 2010; Porter, 1999; F. Wu et al., 2013). When patients arrived at the methadone clinic, many noted how they were uncomfortable with the environment surrounding the clinic as well as the abuse and diversion of methadone (Frank, 2018; Gold et al., 1988; Johnson & Richert, 2015; Stone & Fletcher, 2003). A Ukrainian study described methadone maintenance treatment as an environment of fear, bribery, and “less-than-human” treatment (Rozanova et al., 2017). Other studies have shown that patients dislike the structure of the clinic environment and inconsistent rule structures, specifically how a rule specifying that children are not allowed at the clinic was only enforced with some patients (Reisinger et al., 2009). A Polish study found that patients often felt that clinics disrespected their privacy and dignity, with personal medical information being discussed in public hallways and no formal system to file complaints (Klingemann, 2017).

Methadone helps patients make positive changes in their lives:

While the majority of patients’ beliefs surrounding methadone were negative, 10 papers included resoundingly positive patient perspectives on methadone treatment (Table 2). One study found that 80% of methadone patients felt that it helped them to make a positive change in their lives (Stancliff et al., 2002). In a similarly positive manner, one Puerto Rican survey-based study found that participants in MMT felt free from the need to “chase” opiates or engage in illegal behavior, and were free to lead a more normal life (Porter, 1999). Patients at a treatment center in Malaysia identified outside factors that made MMT more effective: psychosocial programs, religious instruction, and social support (Ghani et al., 2015).

Patients’ other beliefs and attitudes toward methadone:

There is a disconnect between what patients believe MOUD can accomplish and what treatment is possible. In a study following MMT patients in Guangzhou, China, 98% of patients receiving MMT had at least one misconception regarding treatment (Gu et al., 2012). These misconceptions ranged from treatment goals, to duration of treatment, to dosage of methadone. In a cross-sectional study, patients’ attitudes predicted their retention in MMT, with positive attitudes associated with greater retention (Kayman, Goldstein, Deren, & Rosenblum, 2006).

3.4. Providers’ attitudes toward methadone

As Tables 3 and 4 show, 42 articles focused on providers’ attitudes toward methadone.

Table 3.

Providers’ Attitudes and Beliefs About MOUD

Title	Author	Population	Type of Data Collection	Summary
Staff attitudes and conflict regarding the use of methadone in the treatment of heroin addiction	(Brown, Jansen, &Bass, 1974)	4 staff populations associated with five facilities of the D.C. Narcotics Treatment Administration; 25 administrators and supervisors, 21 ex-addict counselors being maintained on methadone, 22 ex-addict counselors (abstinent), 20 non-addict counselors	Questionnaires	Characterization of MMT patients as functioning more effectively than heroin users (greater degree of self-control/awareness) Significant difference between PWID on methadone and abstinent addicts, with abstinent addicts seen as functioning more effectively Staff attitudes include basic ambivalence toward MMT; positive attitude toward helping clients become independent of heroin, but long term MMT was not desired “…formerly addicted counselors who were functioning free of all drugs also saw addicts who had become abstinent as significantly more capable of relating effectively to others while methadone patients were seen as comparatively antisocial in their relationships”.
Methadone maintenance treatment: a ten-year perspective	(Dole & Nyswander, 1976)	Opinion piece	Not Applicable	The author believes that “methadone maintenance, as part of a supportive program, facilitates social rehabilitation, but methadone treatment clearly does not prevent opiate abuse after it is discontinued…” There is a noted absence of major toxicity or allergy with methadone Widely believed misinformation is continuously circulated by anti-methadone agencies on the medical effects of methadone The availability of methadone on the black markets has not increased the number of new addicts, as virtually all of the persons use methadone illicitly have previously used heroin
Methadone treatment: It ain’t what it used to be	(Newman, 1976)	Not applicable	Opinion	It is a myth that MMT is substituting one drug for another “Ultimately, effective treatment must be measured in terms of our patients’ reintegration into society, and as long as that society remains hostile, viewing the methadone patient as just another form of dope fiend, meaningful rehabilitation is precluded.”
A point of view concerning treatment approaches with narcotic antagonists	(Resnick & Schuyten-Resnick, 1976)	A Physician and a social worker	Opinion piece and case report	With naltrexone, it is essential that the staff help patients learn that treatment is not the medication alone; staff must also believe this Clinic attendance is a crucial issue and must be based on a strong desire to remain drug-free, fear of family or other external pressure, or a good relationship with their therapist Patients on naltrexone do not fear the side effects of withdrawal when compared to methadone
Love and hate in methadone maintenance	(Davidson, 1977)	A patient and staff population at a methadone maintenance clinic	Opinion	Workers in MMT are accustomed to the diminished capacity patients possess to control their emotions Patients often” choose” one staff member in the clinic and develop a dependent relationship to them The behavior we see in patients in MMT could be a manifestation of patients’ daily life and environment
Attitudes and beliefs of staff working in methadone maintenance clinics	(J. R. Caplehorn, Irwig, & Saunders, 1996a)	90 staff members working in 10 public methadone maintenance units in the Sydney, Australia metropolitan area in 1989	Survey	Staff were aware of the benefits of MMT Staff thought that addicts should not be offered indefinite maintenance treatment Many staff were led by personal beliefs that those on methadone maintenance should remain abstinent from other drug use “We conclude that support for abstinence-oriented policies was not associated with a lack of faith in the efficacy of methadone maintenance but rather was strongly associated with a generally punitive attitude to illicit drug use.”
Physicians’ attitudes and retention of patients in their methadone maintenance programs	(J. R. Caplehorn, Irwig, & Saunders, 1996b)	90 staff members working in Sydney, Australia’s 10 public methadone clinics, and 280 patients	Survey	“… doctor’s scores on a scale measuring commitment to abstinence-oriented policies were significantly associated with retention of patients in their programs.” Abstinence-oriented physicians prescribed lower doses of methadone, which contributed to lower levels of retention
Changing attitudes and beliefs of staff working in methadone maintenance programs	(R. M. Caplehorn, Lumley, Irwig, & Saunders, 1998)	90 staff in 1989 92 in 1992 33 respondents participated in both	Voluntary survey in 1989 and 1992	From 1989 to 1992, staff attitudes shifted to a commitment to MMT over abstinence-oriented treatments
Staff attitudes and retention of patients in methadone maintenance programs	(J. R. Caplehorn, Lumley, & Irwig, 1998)	Staff working in six public methadone programs in Sydney, Australia	Survey	“The stronger the commitment to abstinence-oriented policies the worse the retention” “It is estimated that 50% of ex-prisoners and 41% of other patients would have left an abstinence-oriented program in the first six months treatment compared with 9% of ex-prisoners and 15% of others treated in an indefinite maintenance program.
French general practitioners’ attitudes toward maintenance drug abuse treatment with buprenorphine	(Moatti, Souville, Escaffre, & Obadia, 1998)	1186 French GPs	Telephone interviews	Familiarity with the use of opiates for pain management is associated with a positive attitude toward buprenorphine Willingness to prescribe buprenorphine was low among GPs w/o prior experience with IDU GPs with an interest in psychoanalysis were more likely to be accepting of BMT
Methadone maintenance in general practice: impact on staff attitudes	(Langton et al., 2000)	31 General Practitioners (GPs), 23 receptionists in 23 Dublin general practices	Questionnaire sent before patient’s first visit and 6 months later	GPs held a positive attitude toward using methadone with stabilized patients 68% of participants experienced abusive or disruptive behavior 41% said their stress levels were above average At the end of the study, all participants said they would continue to prescribe methadone but would need specialist services
Office-based methadone prescribing: acceptance by inner-city practitioners in New York	(McNeely, Drucker, Hartel, & Tuchman, 2000)	71 providers from 11 sites in New York	Survey	70% said they were comfortable managing care of drug users; 72% were convinced of methadone’s effectiveness and support its usage 66% of providers would prescribe methadone HIV/AIDS providers were most enthusiastic about prescribing methadone (88%) 52% support setting no limit on the duration of MMT
Response: challenging perspectives on Methadone Maintenance Treatment	(Benton, 2001)	Opinion piece by chair of the national association of opioid treatment providers	Opinion	Different philosophies of MMT Abstinent vs. laissez-faire Authoritarian vs. paternalistic vs co-dependent vs. messianic MMT suffers a bad reputation Stigma, expectations, and social and political attitudes make what is a very effective treatment modality less effective “Current policy… puts too much emphasis on protecting society from methadone, and not enough on protecting society from the epidemics of addiction, violence, and infectious disease that methadone can help reduce” Diverting methadone is often seen as a bane for MMT services However, it is really a complex social, financial, and life-style based issue
Methadone treatment in Ontario after the 1996 regulation reforms results of a physician survey	(Fischer, Cape, Daniel, & Gliksman, 2002)	64 Ontario physicians	Interview	Over half the physicians viewed MMT through a “harm reduction” framework Two out of five physicians felt the most critical need in MMT is counseling services Many physicians felt that there was a need for a “considerable knowledge base” among methadone doctors and continuing medical education
Provider satisfaction with office-based treatment on opioid dependence: a systematic review	(Becker & Fiellin, 2005)	Academic literature	Systematic review	Bouchez and Vignnau’s study found that most GPs said their relationships with opioid dependent patients improved after buprenorphine was prescribed Fiellin’s study’s outcome was that GPs found MMT patients to be punctual, compliant, reliable to pick-up and return medication bottles, honest about illicit use, courteous with staff
Buprenorphine diffusion: the attitudes of substance abuse treatment counselors	(Knudsen, Ducharme, Roman, & Link, 2005)	2,298 counselors in community-based treatment programs 2002–2004	Questionnaires	Training is a factor in favorable attitudes toward buprenorphine Counselors are more likely to report buprenorphine as effective when receive buprenorphine-specific training Counselors with a higher educational degree were more likely to report buprenorphine as acceptable “Of the internet-related measures, the indicator of NIDA website use approached significance (p = .05), with greater NIDA website use being associated with a reduced likelihood of a ‘don’t know’ response” “… continued efforts to disseminate information about buprenorphine are needed”.
Clinic-based treatment for opioid dependence: a qualitative inquiry	(McMurphy, Shea, Switzer, & Turner, 2006)	Directors at 26 clinics in New York State, three physicians from the University of Pennsylvania	Interview	56% clinic directors expressed willingness to offer methadone, while 65% expressed interest in prescribing buprenorphine Clinic directors mentioned: difficult, manipulative, arguing, complaining, unemployed, and undesirable as words to summarize their views on methadone-treated patients 48% were concerned about bringing “street culture” into their clinic Over 90% had negative opinions on methadone-treated people
Difficulties associated with outpatient management of drug abusers by general practitioners: a cross-sectional survey of general practitioners with and without methadone patients in Switzerland	(Pelet, Besson, Pecoud, & Favrat, 2005).	352 GPs who treat MMT patients and 231 GPs who do not	Questionnaires	Most practitioners with MMT patients were interested in investing time into further training Lack of training was mentioned by providers with MMT patients as an area of improvement Both groups mentioned the need for more political support for treatment of drug-addicted patients and need for more accessible specialists
Support for buprenorphine and methadone prescription to heroin-dependent patients among New York City physicians	(Coffin et al., 2006)	770 New York Physicians, 247 respondents	Random postal survey	Willingness to prescribe methadone or buprenorphine was correlated to: More recent year of licensure Working in a hospital (as opposed to outpatient setting) Being a director of a clinic
Attending physicians’ and residents’ attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital	(Cunningham, Sohler, McCoy, & Kunins, 2006)	99 residents and attending physicians	In-person interviews and questionnaires	Most respondents knew buprenorphine as a treatment option Only 37.8 % felt that primary care providers should be able to prescribe 35.7% reported interest in prescribing buprenorphine 72.1% were motivated to prescribe if given the proper training and structural support
Experiences of a national sample of qualified addiction specialists who have and have not prescribed buprenorphine for opioid dependence	(Kissin, McLeod, Sonnefeld, & Stanton, 2006)	Random sample of 545 waivered addiction specialist physicians	Survey	Only 58% of physicians waivered to prescribe buprenorphine reported prescribing the medication Those who did prescribed buprenorphine reported high rates of treatment efficacy
Attitudes and beliefs toward methadone maintenance treatment among Australian prison health staff	(Gjersing, Butler, Caplehorn, Belcher, & Matthews, 2007)	202 staff employed by Justice Health New South Wales	Survey	“Correctional health staff tend to be more abstinence-oriented, more likely to disapprove of drug use, and less knowledgeable about the risks and benefits of methadone than Australian community methadone staff. The findings have important implications for training health staff working in the prison environment with regard to client retention on methadone treatment” Level of abstinence-orientation and disapproval of drug use among correctional health staff was higher than in the community
Nurse practitioner and physician assistant interest in prescribing buprenorphine	(Roose, Kunins, Sohler, Elam, & Cunningham, 2008)	511 non-physician providers	Questionnaire	Nurse Practitioners and Physician’s Assistants expressed more interest in prescribing buprenorphine than physician providers
A pilot survey of attitudes and knowledge about opioid substitution therapy for HIV-infected prisoners	(Springer & Bruce, 2008)	27 infectious disease nurses, case managers, social workers and drug counselor	Anonymous survey	More respondents answered “unknown” to questions regarding buprenorphine use when compared to methadone 48% of respondents agreed with the belief that opioid substitution treatment does not increase HIV risk taking behavior 59% felt that opioid substitution treatment was substituting one addiction for another
Use of buprenorphine for addiction treatment: perspectives of addiction specialists and general psychiatrists	(Thomas et al., 2008)	495 physicians: 224 non-addiction specialist psychiatrists, and 271 addiction specialists	Survey	16% of non-addiction specialist psychiatrists indicated that they had not heard about buprenorphine prior to the survey “Results indicate that most addiction specialists have adopted it, but beyond addiction specialists, few other clinicians have incorporated it into practice”. Barriers to prescribing buprenorphine for both groups included: “It does not fit in with my practice,” “It would change the patient mix undesirably,” and that “prescribing is too complex.”
Integrating buprenorphine treatment into office-based practice: a qualitative study	(Barry et al., 2009)	23 practicing office-based physicians in New England	Interviews	Physicians report feeling discomfort implementing BMT because of lack of expertise in treating addiction Physicians noted that cost of buprenorphine was a barrier to care Participants noted that office-based buprenorphine treatment offered a greater continuity of care for patients Some providers attributed lack of knowledge or interest in treating psychiatric and medical disorders that are often comorbid with OUD as barriers to implementing buprenorphine treatment “…respondents viewed [BMT] as a positive alternative to [MMT]: they emphasized the medical focus of [BMT] and its reduced stigma relative to MMT.” Providers believe patients are satisfied with BMT, especially in the primary care environment
Buprenorphine in maintenance treatment: experience among Italian physicians in drug addiction centers	(Gjersing et al., 2007; Quaglio et al., 2010)	185 randomly selected physicians from Italy with at least 6 months of experience with buprenorphine	Questionnaire	More physicians consider buprenorphine useful for long replacement periods than short replacement period An advantage of buprenorphine: it is easy to trust with take-home medication; a disadvantage: potential diversion Providers do not consider buprenorphine better than methadone in patients with dual diagnosis
Attitudes toward evidence-based pharmacological treatments among community-based addiction treatment programs targeting vulnerable patient groups	(Krull, Lundgren, & Zerden Lde, 2011)	296 program directors from community-based substance abuse treatment organizations, and 518 clinical staff	Phone interviews and web-surveys	Program directors in organizations serving clients with a high percentage of homelessness and severe and persistent mental illness had significantly more negative attitudes toward buprenorphine Directors who worked in organizations that were affiliated with a university or hospital, and had a higher number of annual admissions reported more positive attitudes about buprenorphine
Prescribers’ perceptions of the diversion and injection of medication by opioid substitution treatment patients	(Larance et al., 2011)	291 OST prescribers in Australia	Mail survey	Most prescribers perceived that their clients did adhere to their OST More buprenorphine patients were identified as diverting unsupervised doses compared to methadone patients and buprenorphine-naloxone patients
A multi-level analysis of counselor attitudes toward the use of buprenorphine in substance abuse treatment	(Rieckmann, Kovas, McFarland, & Abraham, 2011)	1093 counselors from 234 facilities in 40 states	Survey	Counselors were more likely to perceive buprenorphine as acceptable if their facility had already adopted buprenorphine Counselors with buprenorphine-specific training were more likely to see it acceptable Counselors employed in programs with national accreditation were more likely to view buprenorphine as an effective treatment
Clinician beliefs and attitudes about buprenorphine/naloxone diversion	(Schuman-Olivier et al., 2013)	369 American clinicians	Completed a 34-item survey during two national symposia on opioid dependence	Providers’ preconceived beliefs about diversion correlated to the level of perceived danger about buprenorphine/naloxone (B/N) Education level of the provider was not associated with level of perceived danger of B/N diversion
Barriers to primary care physicians prescribing buprenorphine	(Hutchinson, Catlin, Andrilla, Baldwin, & Rosenblatt, 2014)	92 physicians	Interview	Most respondents reported positive beliefs about buprenorphine but only 28% reported actually prescribing it Most new prescribers were family medicine doctors No institutional support was cited as a reason for not prescribing buprenorphine
Diversion of methadone and buprenorphine from opioid substitution treatment: a staff perspective	(Johnson & Richert, 2014)	25 professionals working in OST (7 nurses, 7 counselors/case workers, 6 physicians, 3 department heads, 1 psychiatric aide, and 1 psychologist) in southern Sweden	Qualitative interviews	22 out of 25 interviewees voiced negative opinions about diversion One stated that methadone can be more dangerous than heroin (because of longer half-life) 15 considered methadone and buprenorphine safer than heroin “Buprenorphine is more highly sought after since it gives you a greater kick, if taken in small doses, and in particular if the user hasn’t developed any tolerance…” Many voiced concerns about diversion damages the legitimacy of OST, that methadone is seen as part of the general narcotics supply
Buprenorphine diversion and misuse in outpatient practice	(Lofwall et al., 2014)	Discussions from expert addiction medicine providers from 3 different countries of a theoretical case of a patient in office-based treatment for OUD	Clinical case conference and 3 commentaries	Supervised dosing is an uncommon method of diversion prevention in the U.S, but is widely used in France and Australia In France: those with risk factors are strongly encouraged to have supervised dispensing for as long as possible In Australia: supervised dosing is required for the first three months of methadone or buprenorphine treatment, the cost of this is higher than oxycodone or morphine; specialist addiction clinics are often stigmatized and associated as services for heroin users
Preliminary survey of office-based opioid treatment practices and attitudes among psychiatrists never receiving buprenorphine training to those who received training during residency	(Suzuki, Connery, Ellison, & Renner, 2014)	93 psychiatrists	Survey	Those who completed buprenorphine training were more likely to be male and to report confidence in treating OUD Those who completed buprenorphine training were less likely to report barriers to prescribing buprenorphine 81 % of psychiatrists felt all psychiatry residents should be offered buprenorphine training
Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians	(DeFlavio, Rolin, Nordstrom, & Kazal, 2015)	108 family physicians practicing in Vermont or New Hampshire	Survey	Most commonly cited barrier to providing BMT was a lack of staff preparedness Barriers to BMT treatment included inadequately trained staff, insufficient time, inadequate office space, and cumbersome regulations Approximately half (52%) of family physicians felt that there should be special remuneration for prescribing buprenorphine
Implementing buprenorphine in addiction treatment: payer and provider perspectives in Ohio	(Molfenter et al., 2015)	18 County board participants and 36 provider agency participants in Ohio	Interviews	County boards stated support for use of buprenorphine because of escalating rates of opioid dependence/opioid crisis, need for better care, integration with general health care Desire for better clinical care for opioid misuse was expressed Some providers believe that using MOUD is substituting one drug for another Providers believe more training and better understanding of buprenorphine would make it more readily accepted Some physicians did not want to prescribe buprenorphine because of concerns of working with addicted clientele
Methadone maintenance treatment programs in prisons from the perspective of medical and non-medical prison staff: a qualitative study in Iran	(Moradi et al., 2015)	MMT providers including prison directors and managers, physicians and nurses, consultants and psychologists	Focus group discussions	Participants said MMT program reduced entry of drugs into the system as well as the demand for trade of drugs and cigarettes Participants held the belief that the MMT program could keep addicts calm in prison and decrease crime Belief that MMT increased addicts’ desire to quit drugs in prisons View that MMT reduced transmission of disease through shared injections MMT programs improve addicts’ personal and social lives, bringing them back in the community MMT made training and counseling programs more effective for addicts
Extended-release naltrexone: a qualitative analysis of barriers to routine Use	(Alanis-Hirsch et al., 2016)	Addiction treatment center staff and health plan personnel	Interview	Cost of XR-NTX affects patient’s willingness to use it Participants report difficulty in initiation of treatment XR-NTX is not included in many health plans, which leads to frustration at lack of access Treatment centers struggle with staffing
Counselor training and attitudes toward pharmacotherapies for opioid use disorder	(Aletraris, Edmond, Paino, Fields, & Roman, 2016)	Administrator and clinical director of 307 treatment programs	Interview	Participants had higher acceptance for BUP than MMT Stigma of opioid agonist medications (especially MMT) were due to concerns of diversion, drug substitution, and negative side effects Proper training is associated with higher acceptance of MOUD
How to overcome hurdles in opiate substitution treatment? A qualitative study with general practitioners in Belgium.	(Fraeyman, Symons, Van Royen, Van Hal, & Peremans, 2016)	General Practitioners in Antwerp, Belgium	Focus groups and interviews	General practitioners (GP) often feel anxious about treating patients with addictions with OST (opiate substitution treatment) because of the reputation of patients who misbehave General practitioners cite lack of experience and/or collaboration with addiction centers as a barrier to prescribing OST; the same physicians also showed no willingness to participate in training/ information sessions about prescribing OST Practitioners see the advantage of providing OST outside of addiction centers (safe, private, and less stigmatizing), but patients must pay a fee at the GP office
Shifting blame: buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America	(Hatcher, Mendoza, & Hansen, 2018; Mendoza, Rivera-Cabrero, & Hansen, 2016)	53 participants total; buprenorphine prescribers at 9 hospitals and 3 Veterans’ Affairs Medical Centers in NYC that offered outpatient methadone and/or buprenorphine treatment; private prescribers in NYC	Interview	67% of physicians felt that 8 hours of training required for buprenorphine certification worked against providers becoming buprenorphine certified because it could not easily be attended with providers’ busy schedules More than half of participants felt that the DEA was a deterrent from offering buprenorphine treatment Prescribers expressed that other physicians were hesitant about providing buprenorphine because of the stigmatized nature of opioid dependent patients
Buprenorphine maintenance treatment of opiate dependence: correlations between prescriber beliefs and practices	(MacDonald, Lamb, Thomas, & Khentigan, 2016)	30 buprenorphine qualified prescribers in the San Diego County area	Internet questionnaire	Most participants believed that patients on BMT were functioning well and are in recovery 67% believed that some prescriber’s practices increase diversion 47% believed that there is negative stigma for BMT in the community Endorsement of the 12-step model was positively correlated with the belief that a patient on BMT is “in recovery” Most maintenance research studies are one year or less - yet 40% of the sample reported treating patients over one year, demonstrating the need for long-term data for community-based treatment
Why aren’t physicians prescribing more buprenorphine?	(Huhn & Dunn, 2017)	558 physicians with and without the waiver to prescribe buprenorphine	Survey	Reasons for minimal BUP prescribing: not enough time for additional patients, not knowing how to get the waiver, insufficient reimbursement, concerns about diversion Resources that may help physicians prescribe BUP more were information about local counseling resources and being paired with an experienced provider 55% of waivered providers that were not prescribing to their capacity and 34% of nonwaivered physicians reported that nothing would increase their willingness to prescribe buprenorphine
Medication-assisted treatment should be part of every family physician’s practice: Yes	(Loxterkamp, 2017)	Opinion Piece	Opinion	Suboxone helped patients “turn life around”
Knowledge and stigma regarding methadone maintenance treatment and non-methadone maintenance treatment addiction facilities in Israel	(Shidlansik, Adelson, & Peles, 2017)	Staff at buprenorphine and MMT clinics in Israel; 63 total staff from 11 MMT clinics, 46 staff from SSD (social service department) facilities	Questionnaire	SSD staff had more negative beliefs about MMT than MMT staff, stating that “[MMT] encourages drug use”, “is bad for health.” SSD group stigmatized MMT more than the MMT group; correlation between knowledge and acceptance of MMT
Commune health workers’ methadone maintenance treatment (MMT) knowledge and perceived difficulties providing decentralized MMT services in Vietnam	(C. Lin, Tuan, & Li, 2018)	300 commune health workers from 60 communes in Vietnam	Survey	55.7% felt they needed more training in order to treat PWID Perceived difficulties in treating PWID were associated with higher education level and less MMT-related knowledge
Perceptions and practices addressing diversion among US buprenorphine prescribers	(L. A. Lin, Lofwall, Walsh, Gordon, & Knudsen, 2018)	1,174 buprenorphine prescribers currently treating at least one OUD patient with buprenorphine	Mail survey	Majority of prescribers report assessing all patients for buprenorphine diversion. Providers assess for diversion through frequent visits early in treatment, urine screens for buprenorphine, and using medication counts when diversion is suspected Over 50% were willing to terminate patients for diversion Physicians who perceived greater diversion reported seeing patients more frequently
Primary care physicians’ views about prescribing methadone to treat opioid use disorder	(Livingston, Adams, Jordan, MacMillan, & Hering, 2018)	20 primary care physicians in various sized communities throughout Nova Scotia, Canada	Interviews	Physicians noted patients expressed access to methadone expertise from a provider who has experience prescribing this medication as a factor Help from allied professionals needed Patient-related factors include physician’s reporting people with substance use disorders as a difficult patient group with complex needs, which can be disruptive to family practices
A nurse practitioner’s perspective on prescribing suboxone for opioid use disorder	(Moore, 2018)	Nurse practitioner treating patients in clinic setting	Opinion	Allowing Nurse Practitioners (NP) and Physician Assistants to prescribe buprenorphine/naloxone has filled a treatment gap for patients with OUD In states where NP practice is limited, NPs must be supervised by a buprenorphine/naloxone waivered physician, which can be difficult to find 90% of waivered practitioners are in urban cities 44% of rural providers who treat OUD are not accepting new patients “When you require personal authorizations, you double the workload per patient.”
Caring for Ms. L -- overcoming my fear of treating opioid use disorder	(Provenzano, 2018)	Opinion piece by a physician about treating a woman with OUD	Opinion	Patient (Ms. L) wanted buprenorphine but Dr. Provenzano would not prescribe it: Cited not having the right kind of license Referred to colleague Cited reasons for physician disinterest in buprenorphine waiver: Too tired to do extra training / work Didn’t want to deal with the type of patients who would need buprenorphine Didn’t want to take on patients with needs that she did not know how to meet Ms. L stopped showing up to this doctor after she was referred to another provider to get Buprenorphine “A space had opened between us” Ms. L overdoses and dies Dr. describes feeling shame regarding the “what if s” about if she had treated instead of referring? She and Ms. L had a relationship and trust, but she referred Ms. L to a stranger
				Dr. then decided to get certified and trained, however it has not been simple to incorporate into practice “I could not provide this care without the support of colleagues with expertise in addiction and social work” “Learning how to manage other aspects of addiction care… has been formidable” “We must advocate for team-based behavioral health and social work resources in every primary care setting to support patients and providers in managing all aspects of OUD”
Treating patients with opioid use disorder	(Lopes, 2019)	Opinion	Opinion	PAs and NPs gaining the ability to write a buprenorphine prescription does not address the problem of limited access to care for patients Reasons for providers not prescribing buprenorphine to capacity include: lack of psychosocial support, time constraints, lack of confidence, resistance from practice partners, lack of patient need, and lack of institutional support
Attitudes of primary care physicians toward prescribing buprenorphine: a narrative review	(Louie, Assefa, & McGovern, 2019)	Narrative review	Not Applicable	Providers were sometimes worried about the effectiveness of buprenorphine Providers were concerned about the cost of buprenorphine, since many insurance plans do not cover the medication Providers were worried about the “type” of patient buprenorphine treatment would attract Providers who did not prescribe buprenorphine were more likely to estimate lower efficacy of medication Providers mentioned how MOUD treatment was not taught in medical school

Providers feel inadequately trained to provide methadone services:

Eight articles discussed providers’ lack of training and lack of experience with methadone as significant barriers to care (Aletraris, Edmond, Paino, Fields, & Roman, 2016; Fischer, Cape, Daniel, & Gliksman, 2002; Fraeyman, Symons, Van Royen, Van Hal, & Peremans, 2016; Klingemann, 2017; Lin, Tuan, & Li, 2018; J. D. Livingston, Adams, Jordan, MacMillan, & Hering, 2018; Moradi et al., 2015; Pelet, Besson, Pecoud, & Favrat, 2005). A qualitative study of 20 primary care physicians in Nova Scotia, Canada, showed that few participants learned about treating substance use disorders in medical school, but those who pursued continuing medical education (CME) for addiction, “found it beneficial to their clinical practices” (J. D. Livingston et al., 2018). In most of the studies that we included, providers noted that resources, including education and a qualified interdisciplinary team, are vital in treating patients with methadone.

Methadone patients are difficult to treat in clinical practice:

Physicians in 13 articles expressed that individuals with OUD have complex medical needs and can be difficult, argumentative, manipulative, and undesirable in clinical settings (Table 3). In 7 studies, physicians expressed concerns that patients on MMT would be disruptive in the primary care setting because of their untidy appearance, unusual behavior, inappropriate language, and general “street culture” (Table 3). In fact, a study of physicians in Dublin reported that 41% of providers felt above average stress levels when working with methadone patients (Langton et al., 2000). Because providers perceived this patient population as challenging and the stress they felt when caring for those with addiction, many providers expressed that interdisciplinary, well-resourced teams, along with psychological and social support, were required to effectively care for patients on MMT, and that these teams were not often present in outpatient settings (Becker & Fiellin, 2005; Coffin et al., 2006; Fischer, Cape, et al., 2002; Guarino et al., 2009; Moradi et al., 2015; Newman, 1976).

Methadone is associated with negative social stigma:

In 8 papers, providers expressed a negative stigma about people who used methadone (Table 2). In interviews with 26 directors of clinics in New York and Philadelphia, more than 90% held negative opinions of methadone-treated people (McMurphy, Shea, Switzer, & Turner, 2006). Physicians and staff in 6 studies reported either observing and/or themselves holding stigmatized beliefs about those on methadone maintenance (Table 2). One article referenced the idea that physicians perceived “[an] addict abstinent from all drugs [is]… more effective and capable… than is the addict using methadone” (B. S. Brown et al., 1972). A common theme that emerged in the papers was that providers believed in abstinence-oriented recovery, which corresponded with providers being less likely to understand or appreciate the benefits and efficacy of methadone maintenance (Benton, 2001; B. S. Brown, Jansen, & Bass, 1974; J. R. Caplehorn, Irwig, & Saunders, 1996; Gjersing, Butler, Caplehorn, Belcher, & Matthews, 2007). A cross-sectional analysis of surveys from Switzerland, which found that providers in outpatient clinical settings were less likely to promote methadone treatment to their patients (Besson et al., 2014), exemplifies how these opinions have practical implications for patients.

Providers’ other beliefs and attitudes about methadone:

Despite providers’ lack of clinical experience, perceived challenges of treating methadone patients, and stigma, providers in many studies expressed that methadone provided significant benefit for those with OUD and contributed significantly to harm reduction (B. S. Brown et al., 1972; R. M. Caplehorn, Lumley, Irwig, & Saunders, 1998; Loxterkamp, 2017; McNeely, Drucker, Hartel, & Tuchman, 2000; Newman, 1976; Zamani et al., 2010). A survey from the early 2000s of inner-city practitioners in New York found that 72% of providers were convinced methadone was effective and supported its use (McNeely et al., 2000). In an opinion piece, David Benton wrote that, despite the stigma, challenges, and concerns of methadone maintenance treatment, “Substance dependence treatment is not an issue of „weakness of will’… [as such] treatment approaches and opioid dependent people must be approached from this perspective” (Benton, 2001).

3.5. Patients’ attitudes toward buprenorphine

As referenced in Tables 2 and 4, 37 articles discussed patients’ attitudes toward buprenorphine.

Buprenorphine treatment is a decision against methadone:

Most notably, patients in 16 articles expressed their opinions about buprenorphine in direct comparison to their perceptions of methadone (Table 2). In 10 of these articles, patients being treated with buprenorphine held negative views of methadone, and thus framed their “choice of buprenorphine treatment as a decision against methadone” (Table 2). In 8 interview and/or focus group–based studies, patients expressed preference for buprenorphine because of its relative lack of stigma compared to methadone (Table 2). Specifically, patients found that buprenorphine was less stigmatizing due to the relative anonymity of receiving treatment at a primary care office, and the perception that buprenorphine is not simply “replacing one addiction for another” (Fox, Masyukova, & Cunningham, 2016; Hatcher et al., 2018; Kosten & Fiellin, 2004; Larney, Zador, Sindicich, & Dolan, 2017; Yarborough et al., 2016). These qualities were seen as significant benefits of buprenorphine treatment among patients. Patients in many qualitative studies said that buprenorphine was lower maintenance, safer, or had fewer side effects compared to methadone (Gryczynski et al., 2013; Pinto et al., 2010; Schwartz et al., 2008; Uebelacker, Bailey, Herman, Anderson, & Stein, 2016).

Buprenorphine allows for a sense of normalcy and stability:

Patients in 6 studies felt that buprenorphine allowed them a sense of normalcy and stability in their lives (Table 2). One patient described buprenorphine as being “the first time you don’t have to chase anything” (Notley et al., 2015). Other patients described buprenorphine as allowing them to feel, “better”, “driven”, “motivated”, “level headed”, and “normal” (Bentzley, Barth, Back, Aronson, & Book, 2015). Patients also noted that the ability to receive buprenorphine in a private, primary care setting was desirable and allowed a return to anonymous normalcy (Fox et al., 2016; Hatcher et al., 2018; Kosten & Fiellin, 2004; Yarborough et al., 2016).

Other patient beliefs and attitudes about buprenorphine:

Though most patients had positive perspectives of buprenorphine, not all did. Some patients commented on the challenge of finding access to prescription buprenorphine (Johnson & Richert, 2015; Shah, Sohler, Lopez, Fox, & Cunningham, 2013; Sohler et al., 2013). Patients cited limited access to buprenorphine as playing a significant role in its diversion (Johnson & Richert, 2015; Sohler et al., 2013). A number of patients reported that previous experience with diverted/“street” buprenorphine played a large role in their positive feelings toward and pursuit of buprenorphine treatment (Bentzley, Barth, Back, & Book, 2015; Fox et al., 2016; Gryczynski et al., 2013; Monico et al., 2015; Moore, 2018). Patients referenced other negative perspectives of buprenorphine such as its bitter taste and its long dissolution time (Awgu, Magura, & Rosenblum, 2010; Daulouede et al., 2010).

Patients in 4 studies expressed that buprenorphine treatment does not offer sufficient structural support or accountability for patients (Fox et al., 2015; Fox et al., 2016; Sohler et al., 2013; Yarborough et al., 2016). For example, one patient stated that they, “feel that the service tends to treat the symptoms, not the cause hugely” (Notley et al., 2015).

3.6. Provider attitudes toward buprenorphine

Thirty-five articles, as shown in Tables 2 and 3, focused on providers’ attitudes toward buprenorphine, and focused primarily on interest in or barriers to prescribing buprenorphine.

Lack of resources is a barrier to care for prescribing buprenorphine:

Respondents noted a lack of knowledge or training, lack of time, and the belief that treating OUD is not a primary care issue in 17 studies (Table 3). In a cross-sectional survey of 511 health care providers, nurse practitioners and physician assistants in metropolitan areas showed the most interest in prescribing buprenorphine (Roose et al., 2008). A cross-sectional study with qualitative interviews of attending physicians and residents (from specialties including internal medicine, family medicine, pediatrics, and OB/GYN) from a hospital in an urban setting found that 83% of respondents cared for patients with OUD yet only 52% of physicians were comfortable talking about substance use treatment with patients. They also noted the lack of available supportive structures or services as additional barriers to the use of buprenorphine (C. O. Cunningham, Sohler, McCoy, & Kunins, 2006). Physicians noted a lack of institutional support as a barrier to their prescribing buprenorphine. Specifically, physicians indicated that a scarcity of behavioral health services, a lack of buprenorphine training, and limited access to addiction specialist consults were deterrents to their prescribing buprenorphine to opioid dependent patients (C. O. Cunningham et al., 2006; Hutchinson, Catlin, Andrilla, Baldwin, & Rosenblatt, 2014; Suzuki, Connery, Ellison, & Renner, 2014). In a study of 53 buprenorphine prescribers, 67% of participating physicians felt that the 8-hour buprenorphine training course worked against providers because they felt it was either an insufficient amount of time or it was too burdensome to fit into their busy schedules. Additionally, more than half of the participants cited the DEA as a barrier to offering buprenorphine treatment, and felt that buprenorphine prescribers were subject to more scrutiny from the DEA and felt “harassed” by the agency (Mendoza, Rivera-Cabrero, & Hansen, 2016).

Education is a necessary tool for increasing use of buprenorphine:

Fourteen papers cited buprenorphine education as a necessary tool for increasing the acceptability of the medication (see Table 3). In a cross-sectional analysis, psychiatrists who had completed buprenorphine training were less likely to report barriers to prescribing buprenorphine than those who had not completed buprenorphine training (Suzuki et al., 2014)(Suzuki et al., 2014). Another questionnaire-based study of community-based counselors stated that “continued efforts to disseminate information about buprenorphine are needed” to maximize the potential of this medication (Knudsen, Ducharme, Roman, & Link, 2005).

Other provider beliefs and attitudes about buprenorphine:

A study of 23 practicing physicians in New England explored the positive aspects of buprenorphine treatment and found that these providers were satisfied with buprenorphine in the primary care setting. Some physicians noted that buprenorphine treatment gave them the opportunity to provide continuity of care for their patents. Physicians who already prescribed buprenorphine noted an enhanced sense of control in the treatment of their opioid-dependent patients (Barry et al., 2009). In a systematic review of provider satisfaction with MOUD in the office setting, a study by Bouchez et al. found that most general practitioners felt their relationships with opioid-dependent patients improved after they prescribed buprenorphine (Becker & Fiellin, 2005; Bouchez & Vignau, 1998).

3.7. Patient attitudes toward buprenorphine/naloxone

Nineteen articles focused on patients’ preference for buprenorphine/naloxone (Table 2).

Buprenorphine/naloxone tastes bad:

In a study examining discussion board posts of buprenorphine/naloxone users, a frequently cited complaint was that it was a “bad tasting medicine” (S. E. Brown & Altice, 2014; Marchand et al., 2015; Montesano, Zaccone, Battaglia, Genco, & Mellace, 2010). In a study of 53 opioid-dependent patients, favorable opinions about buprenorphine/naloxone included that the tablet size and taste were favored over buprenorphine alone, and that it had a shorter dissolution time compared to buprenorphine, and 71% of wished to continue treatment with buprenorphine/naloxone (Daulouede et al., 2010). Despite this preference, satisfaction rates were similar between patients receiving buprenorphine and buprenorphine/naloxone.

Buprenorphine/naloxone increases the quality of life for patients:

Another study demonstrated that patients had fewer side effects associated with buprenorphine/naloxone when compared to other MOUDs, but that patients were still dissatisfied with their medication choice because it did not meet their expectations (Muller et al., 2018). A qualitative study examined the use of buprenorphine/naloxone in patients with HIV. Patients were generally satisfied with the effects of buprenorphine/naloxone, as it led to increases in quality of life, and they were better able to focus on managing their HIV through more consistent adherence to medication regimens (Egan et al., 2011). Other studies have also demonstrated a similar increase in the quality of life for patients (Bentzley, Barth, Back, Aronson, et al., 2015; Daulouede et al., 2010; Egan et al., 2011; Hatcher et al., 2018; Montesano et al., 2010; Prakash & Balhara, 2016; Uebelacker et al., 2016). One patient stated, “Actually, I don’t feel like I’m on any drug when I take the Suboxone [compared to methadone]. I don’t nod. I’m not speedy. I’m not sleeping. I feel good when I’m on the Suboxone.”

3.8. Provider attitudes toward buprenorphine/naloxone

Fourteen studies/articles addressed providers’ opinions about buprenorphine/naloxone (see Tables 3 and 4). One opinion piece from a nurse practitioner (NP) noted that allowing NPs and PAs to prescribe buprenorphine/naloxone gave patients greater access to care. The biggest obstacle noted for NPs and PAs was finding a waivered physician to work under in states with limited NP practice (Moore, 2018). A study of buprenorphine/naloxone “waivered” and “nonwaivered” physicians found that 55% of waivered providers were not prescribing to their capacity and 34% of nonwaivered physicians reported that nothing would increase their willingness to prescribe buprenorphine (Huhn & Dunn, 2017).

Diversion is a problem associated with prescribing buprenorphine/naloxone:

Five studies examined providers’ beliefs and attitudes toward buprenorphine/naloxone diversion (Johnson & Richert, 2014; Larance et al., 2011; Lofwall et al., 2014; Louie et al., 2019; Schuman-Olivier et al., 2013). Beliefs about buprenorphine/naloxone among these providers included that diversion leads to more accidental overdoses and that when buprenorphine/naloxone is used legally it helps those in recovery and is less likely to be diverted (Schuman-Olivier et al., 2013). In a study of 23 practicing New England physicians, one doctor noted, “given its low abuse potential, I don’t think that diversion is going to be a big problem” (Barry et al., 2009).

3.9. Patient attitudes toward naltrexone

A total of 12 papers focused on patients’ views of naltrexone. Seven studies examined oral naltrexone and two examined once monthly extended-release naltrexone (see Table 2). Patients who engaged in daily heroin injection were more likely to be interested in using naltrexone as an MOUD, and patients who were unwilling to stop use of opioids were least likely to be interested in naltrexone as an MOUD (Schecter, 1975). One study examined the barriers that patients faced with using extended release naltrexone, including difficulty ordering the medication, cost of the medication, insurance companies’ coverage of the medication, and cultural resistance (Alanis-Hirsch et al., 2016).

Patient desire to remain “drug-free” was a motivating factor for naltrexone use:

We identified the theme of living “drug-free” as important in a patient’s choice to use naltrexone (Fram, Marmo, & Holden, 1989; Haas, Ling, Holmes, Blakis, & Litaker, 1976; Prakash & Balhara, 2016; Uebelacker et al., 2016). Some studies found that patients preferred oral or XR-NTX over methadone and buprenorphine (Prakash & Balhara, 2016; Singleton, Sherman, & Bigelow, 1984; Uebelacker et al., 2016). However, patients who did not intend to stop the use of opioids or who were unable to remove themselves from social situations that encouraged opioid use found oral naltrexone to be ineffective (Fram et al., 1989). In a qualitative Ukrainian study, participants’ attitudes toward XR-NTX were positive, and patients who held negative attitudes about treating OUD with opioid agonists or those with no exposure to MOUD favored XR-NTX. Patients referred to the “ideal candidate” for XR-NTX as someone who was young, without a long history of injecting heroin. Some patients feared XR NTX’s use as an MOUD because of it injectable administration (Marcus et al., 2018).

3.10. Provider attitudes toward naltrexone

Five papers examined providers’ attitudes toward naltrexone. One study examined the barriers to routine use with XR-NTX (Alanis-Hirsch et al., 2016). Providers noted that some state Medicaid-managed plans now require “failures” with other medications before patients can transition to XR-NTX. This requirement has reduced the number of patients to whom providers are able to prescribe XR-NTX (Alanis-Hirsch et al., 2016). XR-NTX must be refrigerated and have temperature data loggers, creating more tasks and requirements for treatment center staff to manage (Alanis-Hirsch et al., 2016). In a study of Australian prison staff, many staff members were uncertain of oral naltrexone, its properties, and how it compares to other agonist forms of MOUD (Gjersing et al., 2007).

Patients needing to be substance-free prior to administering naltrexone is a barrier to care:

The most common barrier that providers mentioned was the need for patients to be opioid-free for 7–10 days to avoid precipitating withdrawal prior to administering XR-NTX. Providers noted the difficulty in keeping their patients substance-free in the days leading up to the initiation of XR-NTX. One provider noted, “Many patients are lost during those seven days,” a problem that is further magnified when insurance companies discharge patients before they are 7 days opioid-free and can receive an injection (Alanis-Hirsch et al., 2016; Gjersing et al., 2007; Resnick & Schuyten-Resnick, 1976).

4. Discussion

4.1. Relevance of overall findings

Providers’ incorporating patients’ preferences into treatment is linked to beneficial health outcomes in addiction treatment (Friedrichs, Spies, Harter, & Buchholz, 2016)(Friedrichs, Spies, Harter, & Buchholz, 2016). Medication treatments for OUD are the most effective treatment for OUD. The attitudes and beliefs that surround these medications are important to understand because of their effects on patients’ retention, adherence, and the recovery process. Providers’ and patients’ beliefs can affect the type of medication chosen, how the medication is taken, and the stigma associated with a medication (Akoul, 1998; Eshete et al., 2019). Based on their experiences, patients had both negative and positive views surrounding each of the medications that we reviewed.

In addiction service centers, the continuum of care includes the patient, and a mix of different health care professionals, including doctors, counselors, nurses, and PAs. Due to the interprofessional nature of addiction treatment, the preferences and attitudes of each member of the health care team has the power to influence the patient’s view of medications. For instance, people who use methadone have been historically discouraged from speaking in some Narcotics Anonymous meetings, which recommend abstinence-based and where opioid medications are considered “trading one addiction for another” (W. L. White, 2011). Similarly, some providers avoid initiating buprenorphine treatment with patients because of the belief that it can be laborious and time consuming (Gryczynski et al., 2013). Each form of MOUD has varying stigmas and beliefs associated with it, and it is important to understand how this may affect patient care. Research has found that extended-release naltrexone is a good option for people with OUD who have negative perceptions of opioid agonist therapies, such as methadone (Marcus et al., 2017). Since the decision to pursue MOUD is made between the patient and provider, it is essential to assess the opinions and beliefs of both and investigate how these factors are associated with patients’ outcomes.

4.2. Methadone treatment

Of the articles included in this systematic review, the majority focused on providers’ and patients’ perceptions of methadone. Methadone was first available in the U.S. in the 1960s and has been used across the globe for decades, which contributes to the volume of research available on this medication (Defalque & Wright, 2007). Despite this, there remain many myths about methadone, including the prevalent myth that methadone is bad for your health. For example, people have a misconception that it “rots bones and teeth” and can contribute to infertility (Stancliff et al., 2002). Incorrect beliefs such as these may deter patients from choosing methadone, even when they may otherwise be suitable candidates for the medication. Papers written as early as the 1970s, which were some of the first studies examining perceptions of methadone, documented belief about the negative health impacts of methadone (B. S. Brown et al., 1972; B. S. Brown et al., 1975; Davidson, 1977; Dole & Nyswander, 1976; Sutker & Allain, 1974). Providers may find it nearly impossible to change this belief among participants and should focus instead on the positive aspects of methadone treatment.

Considerable social stigma continues toward patients who are prescribed methadone. Patients and providers in the studies that we reviewed recognized the stigmatization of methadone users as undesirable liars and thieves, who are difficult, manipulative, and challenging members of society (Fraeyman et al., 2016; J. D. Livingston et al., 2018; McMurphy et al., 2006; Polonsky et al., 2016; Rozanova et al., 2017). To combat the negative stigma surrounding methadone treatment, providers should be trained on and patients should be educated about the positive aspects and efficacy of MOUD. In one study, a patient suggested that education would be the most effective way to target the public’s fear of methadone (Woo et al., 2017). Further, 44% of participants endorsed education for healthcare workers as a means to mitigate stigma associated with participants’ treatment (Woo et al., 2017). Healthcare providers should be trained to be empathic and mindful of patients using methadone and other forms of MOUD for patients to feel less judged and stigmatized (Woo et al., 2017). Education can be structured, or can be provided as factsheets, leaflets, or patient stories. Interpersonal contact between those who are learning about and those who are struggling with addiction can enhance these educational interventions (James D Livingston, Milne, Fang, & Amari, 2012).

4.3. Buprenorphine treatment

Papers that discussed buprenorphine as an MOUD indicated that many patients chose buprenorphine as a decision against methadone. Patients who chose buprenorphine for this reason perceived it as a helpful alternative to methadone, which they saw as a harmful narcotic (Gryczynski et al., 2013). Patients frequently observed that buprenorphine and buprenorphine/naloxone had a bitter or bad taste, which may deter some from taking it (Pinto et al., 2010). We do not yet know whether generic forms of buprenorphine taste different than brand name versions; however, patients did rate a newer sublingual tablet of buprenorphine/naloxone, Zubsolv®, as having a better taste compared to both Suboxone® tablets and films (Lyseng-Williamson, 2013). These factors often influence patients’ beliefs about MOUDs, and patients must feel that they have a role in deciding what medication to take to treat their OUD. The SUMMIT Trial presented both methadone and buprenorphine as treatment options to patients, and 10% of participants stated that they would not have pursued treatment if there were only methadone available (Pinto et al., 2010). This finding shows that patients should be given a choice of medications, especially to increase the number of persons treated and retained on MOUD (Pinto et al., 2010). And research recommended that patients are offered all 3 forms of treatment (Comer et al., 2015; Connery, 2015). If clinics or physicians are unable to provide different forms of MOUD, they should provide referrals to clinics or physicians who are able to do so.

Buprenorphine prescriptions can include a month of medication, which allows more flexibility with scheduling (Sohler et al., 2013). This flexibility can reinforce a sense of normalcy in patients’ lives and help patients to keep up with their responsibilities. In an analysis of factors associated with patients’ choice of buprenorphine or methadone, patients’ choosing buprenorphine was influenced by their wanting shorter treatment (less than a year) (Ridge, Gossop, Lintzeris, Witton, & Strang, 2009). With long-acting formulations of buprenorphine FDA approved (e.g. Probuphine® and Sublocade®), adherence and retention in treatment may be improved; however, more research is needed to compare these treatments to the oral daily formulations to assess how patients’ attitudes and beliefs may affect outcomes such as treatment retention and reduction in opioid use. If a client is unsure of what MOUD to use, client decision tools can be a useful guide. For example, SAMHSA’s “Decisions in Recovery: Treatment for Opioid Use Disorder” is a helpful interactive website that disseminates vital information about MOUD to help patients choose the medication that is right for them (Adminstration, 2016).

Family medicine has the greatest number of physicians with waivers to prescribe buprenorphine. Yet in one study, only 58% of addiction specialist physicians waivered to prescribe buprenorphine actually reported prescribing it (Huhn & Dunn, 2017). Providers have cited lack of nursing and institutional support, inadequate Medicaid financial reimbursement, office staff stigma, and insufficient training as barriers to their offering buprenorphine treatment (Haffajee, Bohnert, & Lagisetty, 2018). In New Mexico, Project Extension for Community Healthcare Outcomes (ECHO) uses an internet network and teleconferencing to connect primary care providers in rural settings with specialists at an academic center to provide support and education through case-based learning for rural providers (Komaromy et al., 2016). The ECHO model has increased the per capita numbes of providers with buprenorphine waivers, making New Mexico one of the states with the highest number of per capita waivered buprenorphine physicians (Pupillo, 2016). Using teleconferencing to connect rural patients to specialists can increase the number of MOUD providers and ultimately improve access to care for patients with OUD.

NPs and PAs have also reported high levels of interest in prescribing buprenorphine in metropolitan areas (Roose et al., 2008). The Massachusetts Nurse Care Manager Model reimburses nurse care managers through Medicaid who are supporting physicians who are prescribing naltrexone or buprenorphine for OUD. The nurse manager performs essential duties, such as patient screening, intake, patient education, and scheduling (Korthuis et al., 2017). The overseeing physician confirms OUD diagnoses and feasibility of MOUD and co-manages the care of the patient with the nurse manager. Through this model, the physician’s workload is appropriately managed and offloaded by a Medicaid-reimbursed provider. With this model, the number of buprenorphine waivered physicians in Massachusetts increased by 375% in 3 years (LaBelle, Han, Bergeron, & Samet, 2016). Given that the waiver is often cited as a barrier to providing treatment among providers, removing the waiver may increase provider interest in prescribing buprenorphine (Chinazo O Cunningham, Kunins, Roose, Elam, & Sohler, 2007; Fiscella, Wakeman, & Beletsky, 2019). Even when providers receive MOUD education and waivers, some still do not prescribe MOUD (Hutchinson et al., 2014; Kissin, McLeod, Sonnefeld, & Stanton, 2006). More research is needed to assess what factors, if any, can increase prescribing practices after providers receive MOUD education.

Educating future physicians is one area that can be targeted for implementing change in MOUD prescription patterns. Research has shown that providers’ empathy for patients who have SUDs decreases during residency (Avery et al., 2017). Some medical schools have taken steps to integrate SUD education into their curriculum, and, thus, new medical school graduates have been able to be waivered upon graduation (McCance-Katz et al., 2017). Research has shown that introducing DATA 2000 buprenorphine waiver training into medical school curriculum increases students’ confidence in treating SUDs, and increases rates of buprenorphine waiver applications (Zerbo et al., 2020). Integrating MOUD into medical school curriculums can help to improve physicians’ confidence in prescribing MOUD, while simultaneously normalizing treatment of individuals with SUDs.

The studies that we reviewed found that concern about diversion of buprenorphine/naloxone to be a widely held belief among providers. Buprenorphine/naloxone can produce mild euphoric effects in opioid-tolerant patients and can be used on the street as a means of detoxification. The significant affinity for the mu-receptor displaces opioids for the receptor producing withdrawal in opioid-dependent individuals (A Yokell, D Zaller, C Green, & D Rich, 2011). In contrast, the slow dissociation rate of the medication allows the individual to lessen physical withdrawal symptoms by titrating to lower doses of opioids gradually (Furst, 2014; Lofwall et al., 2014; Walsh & Eissenberg, 2003). For this reason, buprenorphine/naloxone possesses a “street value” in that it can help individuals safely withdraw from opioids (Lavonas et al., 2014). One study found that 64% of diverted buprenorphine/naloxone users reported using buprenorphine/naloxone because they were unable to access treatment while 74% reported using the medication to manage withdrawal symptoms (Bazazi, Yokell, Fu, Rich, & Zaller, 2011). There are also methods for physicians to address diversion of buprenorphine/naloxone by checking urinary buprenorphine levels or doing film checks (Velander, 2018). Diversion is often tied to the lack of availability of the medication, and for various reasons. First, there are not enough providers to prescribe buprenorphine, so patients are unable to access prescribed buprenorphine, and further, in some clinics patients must overcome wait times and other rules that may prohibit them from starting buprenorphine when they are ready (Cicero, Ellis, Surratt, & Kurtz, 2014).

4.4. Extended release naltrexone treatment

In contrast to the wide adoption of and beliefs about methadone and buprenorphine, we found few studies about attitudes and beliefs associated with XR-NTX for OUD. This is a limitation of this review. The FDA approved XR-NTX in 2011 for treatment of OUD so it has not been available to patients for as long as buprenorphine and methadone, which also contributes to fewer studies for that medication. Despite the research proving the effectiveness of treating OUD with XR-NTX, few patients are taking this medication. The National Drug Abuse Treatment System Survey (NDATSS) in 2017 showed that less than 12% of patients received XR-NTX in SUD treatment programs (Abraham, Andrews, Harris, & Friedmann, 2020); and in a survey of primary care physicians, only 4% reported prescribing XR-NTX (McGinty, Stone, Kennedy-Hendricks, Bachhuber, & Barry, 2020). The cost, hesitancy of some clinicians to prescribe an opioid antagonist, apprehension about receiving an injection, and overdose potential if drug use escalates as this medication wears off are all factors that could potentially contribute to practitioners’ stunted adoption of XR-NTX and limited research on attitudes and beliefs related to it. There is a need for more research on the biases, attitudes, and beliefs associated with XR-NTX for treatment of OUD. Treating addiction with a long acting antagonist or extended-release MOUDs may be the best option for some patients, particularly those who may be unstably housed or unable to reliably take a daily medication.

4.5. Limitations

One of the goals of this reviews was to broadly assess attitudes and beliefs over time; therefore, we included all articles that mentioned attitudes or beliefs about MOUD. We did not do any formal assessment of sampling methods, sample size, or risk of bias since we chose to include all articles regardless of study quality. We noted that some of the papers from the earlier time period would not meet current standards of publication regarding sample selection, minimization of bias, methods, and data analysis. However, we did find views in early papers that persisted in current papers, such as the stigmatization of methadone use. Readers should interpret with caution earlier views that we did not find in more recent and rigorous research.

4.6. Conclusion

Any member of a health care team, along with their beliefs, may influence patient OUD treatment and its success. Whether consciously or subconsciously, providers influence patients with their own biases, opinions, and beliefs. Yet providers have the responsibility to provide patients with accurate and unbiased information about each medication. If providers hold a negative view about a certain medication, they may not educate patients or present that medication as a viable treatment option. In the midst of the opioid epidemic, treatment providers must both increase access to treatment and increase personalized treatment for each patient. To ensure patients’ investment in their recovery process and high retention in treatment, physicians and other health care professionals need to debunk myths about medications, educate patients about medications without biases, and work with patients to make a mutual decision about the best MOUD for the patients, which may involve thoroughly discussing patients’ attitudes and beliefs about different MOUDs. Understanding patients’ and providers’ beliefs about MOUDs can help to focus education efforts to combat the growing opioid epidemic.

Table 1.

Common Attitudes and Beliefs of MOUD

Belief	Perspective	Number of Papers	Referenced Papers
Methadone is associated with negative social stigma	Patient and Provider	Total Papers: 38 Patient papers: 24 Provider: 14	Patient: (Zweben & Payte, 1990; Zweben & Sorensen, 1988) (Zule & Desmond, 1998) (Gourlay, Ricciardelli, & Ridge, 2005) (Nyamathi et al., 2007) (Madden, Lea, Bath, & Winstock, 2008) (Anstice, Strike, & Brands, 2009) (Reisinger et al., 2009) (Zaller, Bazazi, Velazquez, & Rich, 2009) (Peterson et al., 2010) (Zamani et al., 2010) (De Maeyer et al., 2011) (C. Lin, Wu, & Detels, 2011) (Liu et al., 2013) (Sanders, Roose, Lubrano, & Lucan, 2013) (Wu et al., 2013) (Notley, Blyth, Maskrey, Pinto, & Holland, 2015) (Mukherjee et al., 2016) (Polonsky et al., 2016) (Yarborough et al., 2016) (Hewell, Vasquez, & Rivkin, 2017) (Larney, Zador, Sindicich, & Dolan, 2017) (Rozanova et al., 2017) (Hatcher, Mendoza, & Hansen, 2018) (Khazaee-Pool et al., 2018) Provider: (B. S. Brown, Bass, Gauvey, & Kozel, 1972) (Jansen, Brown, & Bass, 1973) (Zweben & Payte, 1990) (Caplehorn, Irwig, & Saunders, 1996) (Benton, 2001) (McMurphy, Shea, Switzer, & Turner, 2006) (Gjersing, Butler, Caplehorn, Belcher, & Matthews, 2007) (Barry et al., 2009) (Zamani et al., 2010) (Wu et al., 2013) (Lofwall et al., 2014) (Aletraris, Edmond, Paino, Fields, & Roman, 2016) (Fraeyman, Symons, Van Royen, Van Hal, & Peremans, 2016) (Shidlansik, Adelson, & Peles, 2017)
Methadone is bad for your health	Patient	28	(Sutker & Allain, 1974) (B. S. Brown, Benn, & Jansen, 1975) (Hunt, Lipton, Goldsmith, Strug, & Spunt, 1985) (Rosenblum, Magura, & Joseph, 1991) (Koester, Anderson, & Hoffer, 1999) (Porter, 1999) (Fischer, Chin, Kuo, Kirst, & Vlahov, 2002) (Montagne, 2002) (Stancliff, Myers, Steiner, & Drucker, 2002) (Gourlay et al., 2005) (Schwartz et al., 2008) (Ridge, Gossop, Lintzeris, Witton, & Strang, 2009) (Zaller et al., 2009) (Peterson et al., 2010) (Wu et al., 2013;Zamani et al., 2010) (Xu et al., 2012) (Gryczynski et al., 2013) (Liu et al., 2013) (Sanders et al., 2013) (Wu et al., 2013) (Marchand et al., 2015) (Notley et al., 2015) (Liu et al., 2013; Makarenko et al., 2016) (Uebelacker, Bailey, Herman, Anderson, & Stein, 2016) (S. E. Brown et al., 2017) (Hatcher et al., 2018) (Khazaee-Pool et al., 2018) (Muller, Bjornestad, & Clausen, 2018)
Methadone is challenging to stop using due to fear of withdrawal	Patient	19	(Gold, Sorensen, McCanlies, Trier, & Dlugosch, 1988) (Milby et al., 1990) (Rosenblum et al., 1991) (Lenne et al., 2001) (Fischer, Chin, et al., 2002) (Stancliff et al., 2002) (Schwartz et al., 2008) (Mitchell et al., 2009) (Reisinger et al., 2009) (Winstock, Lintzeris, & Lea, 2009) (Peterson et al., 2010) (Pinto et al., 2010) (C. Lin et al., 2011) (Kelly et al., 2012) (Sohler et al., 2013) (Wu et al., 2013) (Maradiaga, Nahvi, Cunningham, Sanchez, & Fox, 2016) (Yarborough et al., 2016) (Hatcher et al., 2018)
A lack of resources (institutional, educational, financial) as a barrier to care for prescribing buprenorphine	Provider	17	(Kosten & Fiellin, 2004) (Knudsen, Ducharme, Roman, & Link, 2005) (Cunningham, Sohler, McCoy, & Kunins, 2006) (Rieckmann, Daley, Fuller, Thomas, & McCarty, 2007) (Roose, Kunins, Sohler, Elam, & Cunningham, 2008) (Thomas et al., 2008) (Springer & Bruce, 2008) (Barry et al., 2009) (Golovanevskaya, Vlasenko, & Saucier, 2012) (Besson et al., 2014) (Hutchinson, Catlin, Andrilla, Baldwin, & Rosenblatt, 2014) (Suzuki, Connery, Ellison, & Renner, 2014) (DeFlavio, Rolin, Nordstrom, & Kazal, 2015) (Molfenter et al., 2015) (Mendoza, Rivera-Cabrero, & Hansen, 2016) (Provenzano, 2018) (Louie, Assefa, & McGovern, 2019)
Buprenorphine treatment as a decision against methadone	Patient	16	(Kosten & Fiellin, 2004) (Madden et al., 2008) (Schwartz et al., 2008) (Ridge et al., 2009) (Winstock et al., 2009) (Awgu, Magura, & Rosenblum, 2010) (Pinto et al., 2010) (Gryczynski et al., 2013) (Sohler et al., 2013) (Fox, Masyukova, & Cunningham, 2016) (Uebelacker et al., 2016) (Yarborough et al., 2016) (Hewell et al., 2017) (Larney et al., 2017) (Hatcher et al., 2018) (Moore, 2018)
Methadone maintenance is inconvenient and uncomfortable due to required daily attendance at a clinic	Patient	16	(Hunt et al., 1985) (Gold et al., 1988) (Porter, 1999) (Fischer, Cape, Daniel, & Gliksman, 2002) (Stone & Fletcher, 2003) (Madden et al., 2008) (Reisinger et al., 2009) (Peterson et al., 2010) (Golovanevskaya et al., 2012) (Wu et al., 2013) (Johnson & Richert, 2015) (Yarborough et al., 2016) (Klingemann, 2017) (Rozanova et al., 2017) (Frank, 2018) (Hatcher et al., 2018)
Education as a necessary tool for increasing use of buprenorphine	Provider	14	(Moatti, Souville, Escaffre, & Obadia, 1998) (Kosten & Fiellin, 2004) (Knudsen et al., 2005) (Cunningham et al., 2006) (Rieckmann et al., 2007) (Roose et al., 2008) (Thomas et al., 2008) (Barry et al., 2009) (Suzuki et al., 2014) (DeFlavio et al., 2015) (Molfenter et al., 2015) (Mendoza et al., 2016) (Provenzano, 2018) (Louie et al., 2019)
Methadone patients are difficult patients to treat in a clinical practice	Provider	13	(Newman, 1976) (Fischer, Cape, et al., 2002) (Langton et al., 2000) (Becker & Fiellin, 2005) (Coffin et al., 2006) (McMurphy et al., 2006) (Guarino et al., 2009) (Besson et al., 2014) (Moradi et al., 2015) (Fraeyman et al., 2016) (Klingemann, 2017) (L. A. Lin, Lofwall, Walsh, Gordon, & Knudsen, 2018) (Livingston, Adams, Jordan, MacMillan, & Hering, 2018)
Methadone helps patients make positive changes in their lives	Patient	10	(Sutker & Allain, 1974) (Zule & Desmond, 1998) (Koester et al., 1999) (Porter, 1999) (Fischer, Chin, et al., 2002) (Stancliff et al., 2002) (Schwartz et al., 2008) (Al-Tayyib & Koester, 2011) (De Maeyer et al., 2011) (Liu et al., 2013)
Buprenorphine/naloxone increases the quality of life for patients	Patient	9	(Daulouede et al., 2010) (Montesano, Zaccone, Battaglia, Genco, & Mellace, 2010) (Egan et al., 2011) (Teruya et al., 2014) (Bentzley, Barth, Back, & Book, 2015) (Fox et al., 2016) (Prakash & Balhara, 2016) (Uebelacker et al., 2016) (Hatcher et al., 2018)
Providers feel inadequately trained to provide methadone services	Provider	8	(Aletraris et al., 2016) (Fischer, Cape, et al., 2002) (Pelet, Besson, Pecoud, & Favrat, 2005) (Moradi et al., 2015) (Fraeyman et al., 2016) (Klingemann, 2017) (C. Lin, Tuan, & Li, 2018) (Livingston et al., 2018)
Buprenorphine allows for a sense of normalcy and stability	Patient	6	(Kosten & Fiellin, 2004) (Bentzley, Barth, Back, Aronson, & Book, 2015) (Notley et al., 2015) (Fox et al., 2016) (Yarborough et al., 2016) (Hatcher et al., 2018)
Diversion is a problem associated with prescribing buprenorphine/naloxone	Provider	5	(Larance et al., 2011) (Schuman-Olivier et al., 2013) (Johnson & Richert, 2014) (Lofwall et al., 2014) (Louie et al., 2019)
Patient desire to remain “drug-free” was a motivating factor for naltrexone use	Patient	5	(Haas, Ling, Holmes, Blakis, & Litaker, 1976) (Lewis, Hersch, Black, & Mayer, 1976) (Fram, Marmo, & Holden, 1989) (Prakash & Balhara, 2016) (Uebelacker et al., 2016)
Buprenorphine/naloxone tastes bad	Patient	3	(Montesano et al., 2010) (S. E. Brown & Altice, 2014) (Marchand et al., 2015)
Patients needing to be substance-free prior to administering naltrexone is a barrier to care	Provider	3	(Resnick & Schuyten-Resnick, 1976) (Gjersing et al., 2007) (Alanis-Hirsch et al., 2016)

Highlights.

• Myths about methadone’s negative health impact may deter patients from choosing it

• Patients choose buprenorphine over methadone because it is less stigmatizing

• Lack of training, time, and support prevent providers from prescribing buprenorphine

• Few studies were found regarding attitudes about use of XR-naltrexone for OUD

• Providers must educate patients/themselves about MOUD

• Patients and providers must make mutual decisions in the choice of MOUD