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. Author manuscript; available in PMC: 2022 Oct 1.
Published in final edited form as: J Subst Abuse Treat. 2021 Mar 4;129:108353. doi: 10.1016/j.jsat.2021.108353

Strategies to improve implementation of medications for opioid use disorder reported by veterans involved in the legal system: A qualitative study

Erica Morse a, Ingrid A Binswanger a,b,c, Emmeline Taylor d,e, Caroline Gray d, Matthew Stimmel f, Christine Timko d,g, Alex H S Harris d,h, David Smelson i, Andrea K Finlay d,j
PMCID: PMC8380634  NIHMSID: NIHMS1680046  PMID: 34080564

Abstract

Background:

Veterans involved in the legal system have a high risk of overdose mortality but limited utilization of medications for opioid use disorder (MOUD). To increase the use of MOUD in Veterans Health Administration (VHA) facilities and reduce overdose mortality, the VHA should incorporate strategies identified by legal-involved veterans to improve quality of care and ensure that their patients’ experiences are integrated into care delivery. This study aims to determine strategies to increase use of MOUD from the perspective of legal-involved veterans with a history of opioid use or opioid use disorder (OUD).

Methods:

Between February 2018 and March 2019, we conducted semistructured interviews with 18 veterans with a history of opioid use or OUD and legal involvement (15 men and 3 women; mean age 41, standard deviation 13, range 28–61). Veterans were from 9 geographically dispersed United States VHA facilities. The study analyzed verbatim transcripts using the framework method. The primary focus was themes that represented legal-involved veteran-identified strategies to improve the use of MOUD.

Results:

The 18 veterans interviewed had legal involvement directly related to their opioid use and most (n=15; 83%) had previously used MOUD. Veteran-identified strategies to improve access to and use of MOUD included: (1) VHA should provide transportation or telehealth services; (2) legal agencies should increase access to MOUD during incarceration; (3) the VHA should reduce physician turnover; (4) the VHA should improve physician education to deliver compassionate, patient-centered treatment; (5) the VHA should improve veteran education about MOUD; and (6) the VHA should provide social support opportunities to veterans.

Conclusions:

Legal-involved veterans provided strategies that can inform and expand MOUD to better meet their needs and the treatment needs of all patients with OUD. The VHA should consider incorporating these strategies into care, and should evaluate their impact on patients’ experience, initiation of and retention on medications, and overdose rates.

Keywords: Opioid-related disorders, Pharmacotherapy, Veterans, Criminal justice

1. Introduction

Despite an increased risk of overdose death upon release from prison (Wortzel, Blatchford, Conner, Adler, & Binswanger, 2012), legal-involved veterans with opioid use disorder (OUD) have lower odds of receiving medications for opioid use disorder (MOUD)—methadone, buprenorphine, and naltrexone—than veterans who are not involved in the legal system (Finlay, Harris, et al., 2020). Legal-involved veterans are U.S. military veterans detained by or under the supervision of the legal system, such as incarcerated in prisons or jails, under probation or parole supervision, or involved in court proceedings. MOUD is effective in treating OUD and reducing overdose deaths and legal involvement (Evans, Zhu, Yoo, Huang, & Hser, 2019; Larochelle et al., 2018; Sordo et al., 2017). However, veteran and nonveteran patients report barriers that inhibit MOUD use, including a preference for counseling instead of MOUD, a lack of available medications in criminal justice settings, and a desire to rely on willpower instead of medications (Finlay, Morse, et al., 2020; Fox, Maradiaga, et al., 2015; Tofighi et al., 2019). Some patients are involuntarily withdrawn from MOUD and experience withdrawal symptoms when incarcerated, making them fearful of using methadone as a treatment option (Fox, Maradiaga, et al., 2015). Negative attitudes and beliefs about MOUD are documented among legal-involved veterans and Veterans Health Administration (VHA) and criminal justice staff who work with these veterans (Finlay, Morse, et al., 2020). This study examines strategies to increase MOUD access and use from the perspective of legal-involved veterans with OUD (Howell, 2020).

Patient-, provider-, and system-level factors are barriers to MOUD for legal-involved, veteran, and other patient, populations (Grella, Ostile, Scott, Dennis, & Carnavale, 2020; Mackey, Veazie, Anderson, Bourne, & Peterson, 2020; Oliva, Maisel, Gordon, & Harris, 2011). Patient-level barriers include a lack of knowledge about MOUD, negative experiences with MOUD, stigma because of MOUD use, and logistical barriers such as cost and transportation (Finlay, Morse, et al., 2020; Mackey, Anderson, Bourne, & Peterson, 2019; Oliva et al., 2011; Tofighi et al., 2019). Patients with OUD and legal involvement describe a fear of forming a dependency on another drug, homelessness, unstable economic conditions, and drug-using peers as barriers to MOUD treatment retention (Fox, Maradiaga, et al., 2015; Fu, Zaller, Yokell, Bazazi, & Rich, 2013; Velasquez et al., 2019). Provider-level barriers include stigma toward patients with OUD, a lack of training and knowledge of MOUD effectiveness, provider perceptions that patients are disinterested in MOUD, and a dearth of prescribing providers with buprenorphine waivers (Andrilla, Moore, Patterson, & Larson, 2019; Finlay, Wong, et al., 2018; Mackey et al., 2019; Oliva et al., 2011). System-level barriers include requirements for additional training to prescribe office-based buprenorphine; requirements to co-deliver psychosocial treatment; a lack of coordination among correctional, community, and health care systems; and a lack of treatment capacity in various settings (Grella et al., 2020; Mackey et al., 2020; Oliva et al., 2011).

Intervention strategies to improve receipt of MOUD primarily focus on providers and legal staff (Finlay, Wong, et al., 2018; Friedmann et al., 2015; Oliva et al., 2011). Effective strategies include improving knowledge of MOUD safety and efficacy for patients, providers, and legal system personnel, and providing access to all medications during incarceration and after release (Finlay, Morse, et al., 2020; Fox, Maradiaga, et al., 2015). The most common patient-level facilitator identified to improve MOUD use is peer, family, and provider support (Mackey et al., 2019). Research has recommended providing more training and mentoring support for providers, access to MOUD experts, and institutional support, and educating providers that MOUD can be prescribed without additional psychosocial supports to improve MOUD prescribing (Mackey et al., 2019).

One of the VHA’s priorities is to increase access to MOUD for veterans, but uptake of this mandate is inconsistent (Finlay, Harris, et al., 2020; Wyse et al., 2018). With the VHA’s recent focus on patient-centered care models (Agha et al., 2018), understanding the veterans’ perspectives is an important step to developing interventions. Legal-involved veterans have unique experiences and requirements, such as incarceration and court mandates, that need to be incorporated into programmatic efforts to increase MOUD access and use. Strategies to improve MOUD use that these patients identify may be more effective and are sensitive to the treatment needs of this population than strategies that providers or other stakeholders generate. This study examined strategies to improve access and use of MOUD based on the perspectives of legal-involved veterans with a history of OUD.

2. Material and methods

2.1. Overall study design

This study was part of a larger project that examined receipt of MOUD among legal-involved veterans who received treatment at VHA facilities (Finlay, Harris, et al., 2020; Finlay, Morse, et al., 2020). In the first phase of the study, we used data drawn from the VHA Corporate Data Warehouse, a repository of the electronic health records of veterans who receive care provided by or paid for by VHA. Using fiscal year (FY)2017 data, we calculated the rate of receipt of MOUD for legal-involved and non-legal-involved veterans at each facility separately and then ranked facilities. In high performing facilities (n = 76 out of 129), legal-involved veterans had a higher rate of receipt of MOUD (+1% or better) compared to their non-legal-involved counterparts. Conversely, in low performing facilities (n = 41), legal-involved veterans had a lower rate of receipt of MOUD (−1% or worse) compared to non-legal-involved veterans. We then limited the population to legal-involved veterans and examined the change in receipt of MOUD from FY2016 to FY2017. Increasing facilities (n= 78) had more legal-involved veterans receiving MOUD (+1% or better) in FY2017 compared to FY2016, whereas in decreasing facilities (n = 28) the change from FY2016 to FY2017 was negative (−1% or worse).

From the top 15 in each group, we then selected 3 high performing, 3 low performing, 3 increasing, and 3 decreasing facilities. Although there was overlap among facilities with 13 facilities appearing in two of the top 15 groups, we purposively selected 12 unique facilities. We aimed to recruit two legal-involved veterans per facility and three staff members per facility who worked with this population, including one VHA’s Veterans Justice Programs staff, one VHA and community substance use disorder treatment provider, and one community criminal justice system staff. The goal of 12 participants for each staff group was based on the rationale that thematic saturation is generally achieved within 6–12 interviews (Guest, Bunce, & Johnson, 2006), with a goal of 24 participants for the legal-involved veterans group to prioritize and give more attention to the veteran patient experience. The study subsequently added two additional decreasing facilities in response to low recruiting rates at the initially selected facilities. We strategically selected facilities from urban and rural areas and from the four regions of the United States (Northeast, South, Midwest, and West).

2.2. Sample

The study recruited eighteen veterans from 14 pre-identified VHA facilities across the United States that were high or low performing or increasing or decreasing facilities. The final sample represented 9 facilities. Recruitment and interviews occurred between February 2018 to March 2019. VHA outreach staff at selected facilities who participated in the larger study were asked to assist with snowball sampling to recruit veterans (Finlay, Morse, et al., 2020). They distributed recruitment fliers in-person and asked veterans if they could share their contact information with the research team. We were unable to determine the response rate because we did not know how many veterans received a flier or were asked to share their contact information.

Veterans were eligible to participate if they were 18 years or older, English speaking, had a history of opioid use or OUD within the last 10 years, and a history of legal involvement, defined as having been arrested, in jail, prison, or criminal court within the last 10 years but not incarcerated at the time of the interview. The study chose the 10-year timeframe because of the long-term course of opioid use and legal involvement (Hser, Evans, Grella, Ling, & Anglin, 2015; Russolillo, Moniruzzaman, McCandless, Patterson, & Somers, 2018). The study used a brief telephone screening prior to the interview to confirm veterans had a history of opioid use or OUD and a history of legal involvement. The research team was unable to reach eight veterans for whom contact information was provided. The study excluded three veterans because they did not meet inclusion criteria (one had no history of opioid use or OUD, one had a history of OUD more than 10 years ago, and one had a history of legal involvement more than 10 years ago).

Research staff conducted interviews in one session lasting 15–60 minutes, either over the phone or in-person at a conference room in a VHA research office building. Informed consent was obtained at the interview start. Only participants and interviewers were present during the interviews. Three research assistants, who had no prior relationships with the interviewees, conducted the interviews. Participants received a $30 check for compensation. The Stanford University Institutional Review Board and the VA Palo Alto Research & Development committee approved the study.

2.3. Interview guide

The authors developed an interview guide informed by the Consolidated Framework for Implementation Research (CFIR), specifically, domains of Intervention Characteristics, Outer Setting, and Characteristics of Individuals (Damschroder et al., 2009). The interview asked participants about their general experiences with OUD treatment, their philosophy of addiction treatment, and their legal system involvement. The research team pilot tested the interview guide with one legal-involved veteran prior to conducting the interviews.

2.4. Analysis

The main outcome of the analyses focused on strategies to overcome barriers to MOUD access and use that participants identified. We digitally audio recorded the interviews with participant consent, and transcribed and deidentified them prior to uploading into ATLAS.ti version 8 (Atlas.ti Scientific Software Development GmbH, 2019). The principal investigator (PI) read through each transcript as they were returned from the transcription company. The study did not return transcripts to participants for comment and/or correction. The PI, a co-investigator, the project manager, and three research assistants conducted the analyses. All these team members, except two of the research assistants, had prior experience with qualitative research. Core research team members met regularly throughout the interview process. Thematic saturation had been reached during the data collection process, but we were unable to recruit additional legal-involved veterans to participate prior to closing the recruitment phase.

The core qualitative team developed an a priori code list using the interview guide and subsequently revised the guide to include emerging codes. We created code groups to combine similar codes to assist with the data organization and development of the analytical framework. Four study team members (the project manager and three research assistants) applied codes to the transcripts and the PI checked one randomly selected transcript from each team member to ensure consistency in applying the code list.

We used the framework method to guide analyses (Gale, Heath, Cameron, Rashid, & Redwood, 2013). The project manager charted coded interview transcripts into a framework matrix in a spreadsheet. The matrix included four code groups that the core analysis team had pre-selected: (1) barriers to MOUD treatment; (2) facilitators to MOUD treatment; (3) participant needs, preferences, and experiences; and (4) strategies to improve MOUD treatment. For each participant, the project manager added salient quotations and summarized content into the matrix. Coders and other team members (four co-investigators; one qualitative expert) not involved in coding used the matrix to discuss themes and explore connections between individual participants and cross-interview concepts. The study did not ask participants to provide feedback on the findings.

3. Results

3.1. Participant characteristics

Eighteen veterans from nine VHA facilities completed interviews. Most veterans interviewed were male (n=15; 83%), white (n=16; 89%), and non-Hispanic (n=16; 89%). The majority of veterans indicated that they struggled with OUD for most of their lives (n=11; 61%) and almost all had tried MOUD at some point (n=15; 83%; Table 1). The majority (n=12; 67%) were most recently involved in the legal system in the past year, such as being arrested, being involved in court, or being incarcerated. For all veterans, legal involvement was directly related to their opioid use.

Table 1.

Veteran interview participant characteristics.

Characteristics N = 18
Mean (SD, Range)
Age 41 (13, 28–61)
N (%)
Women 3 (17%)
Race
Black 2 (11%)
White 16 (89%)
Hispanic 2 (11%)
Highest education level
High school diploma 8 (44%)
Some college 7 (39%)
Bachelor’s degree 3 (17%)
Self-reported OUD history
OUD a problem most of their life 11 (61%)
Currently using medications for OUD 5 (28%)
Used medications for OUD in the past 10 (55%)
Never used medications for OUD 3 (17%)
Self-reported legal history
Involved in legal system most of their life 9 (50%)
Legal involvement directly related to OUD 18 (100%)
OUD treatment philosophy
Harm reduction 10 (56%)
Abstinence 8 (44%)
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SD = standard deviation. OUD = opioid use disorder.

3.2. Themes

Six themes represented legal-involved veteran-identified strategies to improve access to and use of MOUD: (1) the VHA should provide transportation or telehealth services; (2) legal agencies should increase access to MOUD during incarceration; (3) the VHA should reduce physician turnover; (4) the VHA should improve physician education to deliver patient-centered treatment; (5) the VHA should improve veteran education about MOUD; and (6) the VHA should provide social support opportunities. Although used to create the interview guide, the study did not use CFIR to analyze or interpret the interviews as it did not map well to veterans’ experiences.

3.2.1. The VHA should provide transportation or telehealth services.

Veterans noted the need for consistent and reliable transportation to VHA and community treatment facilities, particularly for those using methadone treatment. One veteran explained,

If you’re going to be on methadone or suboxone, you need transportation. If you can’t get to the VA […] you can’t be on those medications. (ID 148)

Veterans suggested telehealth services as an alternative for unavailable or inconsistent transportation to in-person treatment.

3.2.2. Legal agencies should increase access to MOUD during incarceration.

Some veterans reported reluctance to seek MOUD due to concerns about withdrawal if incarcerated. Some had experiences of forced withdrawal without medication upon incarceration. One veteran said he was not given ibuprofen though other veterans reported that they received acetaminophen or diphenhydramine while incarcerated. Veterans suggested increasing access to medicated withdrawal management while incarcerated to facilitate MOUD treatment and lower the likelihood of recurrent opioid use. One veteran explained,

Without getting the necessary treatment [in jail], all it did was make me focus on the drug even more. [If I] would have had the treatment necessary, some methadone or what not, then I probably wouldn’t have had such a high rate of relapse. (ID 147)

3.2.3. The VHA should reduce physician turnover.

Veterans spoke about the need to reduce physician turnover. One veteran described that switching physicians resulted in a change in his MOUD dosage, which caused him frustration and uncertainty around treatment. Some veterans complained that physician changes led to delays in treatment and exacerbated legal issues.

At times you get pushed from one provider to the next. Almost every other month. […] So then when I go back to court, it looked like I’m not doing as much as I should be sometimes, even though it’s completely out of my hands. (ID 146)

Veterans also felt that having a consistent physician would help keep them moving toward remission of their OUD.

There should be some kind of attempt to make that a policy where you’re not seeing somebody new every other month. Because it’s very discouraging as a recovering addict because […] you never […] get to that point where you feel like you’re moving in a forward direction because you have to start over every single time you see a new doctor. (ID 152)

3.2.4. The VHA should improve physician education to deliver patient-centered treatment.

Veterans noted the need to improve physician knowledge on all MOUD treatment options and on how to provide compassionate, patient-centered care. One veteran described, “[h]alf the doctors I see don’t even know what Suboxone is” (ID 152). Some veterans wanted more discussion with their physician about the long-term plan for their health, including the possibility of tapering off MOUD:

I think that if they were more involved in helping you get off [MOUD] instead of maintaining […] that would be more helpful. There’s all this information on how you can stay on methadone the rest of your life, but there’s like none on the proper way to get off of it. (ID 146)

Others wanted a MOUD tapering plan because they felt pressure from their physician to discontinue MOUD.

Overall, the majority believed that compassionate, patient-centered treatment incorporating individual circumstances and preferences was the most effective way to help veterans. MOUD treatment that veterans preferred varied and was dependent upon previous medication experiences. Methadone was described as helpful by one veteran because of the strict daily regimen to prevent a return to opioid use. Some veterans preferred one medication over another because of particular side effects or fears about using certain medications. For instance, one veteran preferred injectable naltrexone because he said it was not addictive. Veterans wanted clinical staff to listen to their treatment preferences and show greater compassion about the challenges of overcoming OUD, including recurrent opioid use during treatment.

3.2.5. The VHA should improve veteran education about MOUD.

Veterans noted that increased education around OUD and available treatment options were necessary to improve MOUD treatment use.

If you take somebody off a[n opiate pain] medication that is going to live with pain the rest of their lives, you know that they’ll go get something else. So why not tell them there’s a program that can help them? I’d have never went to the street and been on heroin if I knew that this [Suboxone] program was available. I’d have been in it years ago. (ID 118)

Veterans expressed the need for increased MOUD awareness by posting advertisements and fliers at clinics and creating online OUD videos on the VHA website.

Veterans also expressed the importance of being educated about how a person becomes addicted to opioids, in particular through pain management of military-related injuries. One veteran described,

I’ve had nine surgeries on my left knee. That’s how I started getting [opioid analgesics] prescribed. I didn’t have to take a pain pill until I had my surgery. […] Before I knew it, I didn’t feel well one day and my buddy said, “You’re probably dope sick.” I went, “What are you talking about?” He gave me a pill and I felt fine. I was addicted before I even knew what was going on. (ID 141)

3.2.6. The VHA should provide social support opportunities.

Veterans expressed a strong preference for peer support strategies for treating OUD, including group therapy in conjunction with MOUD.

Maybe other veterans [could help veterans with OUD]. I think personal experiences have a lot more impact than what you read on a pamphlet, or medications. (ID 120)

Veterans described having someone to talk to who understands the veteran’s military experience as helpful.

4. Discussion

Some veterans with a history of opioid use and legal involvement experience difficulties accessing and using MOUD. Veterans described six strategies to overcome barriers to access and all strategies are novel to legal-involved veterans. However, prior studies have identified the barriers or facilitators related to all six strategies with other populations. A scoping review of MOUD implementation among legal-involved nonveteran populations identified implementation barriers and facilitators that map to legal-involved veteran strategies that this study identified (Grella et al., 2020): a lack of MOUD availability in correctional settings (barrier), which maps to the strategy that legal agencies should increase access to MOUD during incarceration; high staff turnover (barrier), which maps to the strategy that the VHA should improve physician turnover; training for criminal justice staff on MOUD (facilitator), which maps to the strategy that the VHA should improve physician education to deliver compassionate, patient-centered treatment; and negative patient beliefs about MOUD (barrier), which maps to the strategy that the VHA should improve veteran education about MOUD. A rapid review of veteran and nonveteran populations, most of which were not legal-involved, also found barriers and facilitators to MOUD that map to the strategies identified in this study (Mackey et al., 2020): transportation difficulties (barrier) and delivering MOUD treatment via telehealth (facilitator), which maps to the strategy that the VHA should provide transportation or telehealth services; negative patient experiences with providers and lack of trust in physicians, which maps to the strategy that the VHA should improve physician education to deliver compassionate, patient-centered treatment; a lack of knowledge about MOUD among patients, which maps to the strategy that the VHA should improve veteran education about MOUD; and the value of positive social support from peers and family, which maps to the strategy that the VHA should provide social support opportunities to veterans. We discuss each strategy and unique aspects of legal involvement that veterans experience and may influence implementation of MOUD. Most of these strategies would benefit veterans treated for OUD and improving MOUD in incarcerated settings would benefit legal-involved populations.

4.1. The VHA should provide transportation or telehealth services

Consistent with prior studies (Brunet, Moore, Lendvai Wischik, Mattocks, & Rosen, 2020; Fox, Chamberlain, Sohler, Frost, & Cunningham, 2015; Godersky et al., 2019), veterans in this study reported transportation difficulties as a barrier to MOUD. VHA could offer transportation options, such as free shuttles and reduced or free bus passes, though the benefits of subsidized transportation services are mixed (Solomon, Wing, Steiner, & Gottlieb, 2020). For veterans exiting incarceration, transportation is particularly important from jail or prison settings where releases frequently occur late at night or in the early morning hours. VHA-arranged services that pick up veterans upon release and immediately bring them to health care and other services may improve engagement in MOUD and reduce the high risk of overdose death observed among people exiting incarceration (Binswanger, Blatchford, Mueller, & Stern, 2013).

Veterans suggested telehealth as an alternative to improve access to MOUD. However, an in-person visit is required for buprenorphine induction, though emergency changes in regulations because of the COVID-19 pandemic may result in more induction and maintenance via telehealth (M. Harris et al., 2020; Nunes, Levin, Reilly, & El-Bassel, 2020). Pilot testing suggests that MOUD induction is feasible via telehealth (Castillo et al., 2020). Many legal-involved veterans also experience homelessness (Finlay et al., 2017) and do not have stable addresses where prescriptions can be mailed. Mobile agonist units (Hall et al., 2014; Iheanacho, Payne, & Tsai, 2020) may help to overcome this barrier. Outreach through telephone and video services to incarcerated and other legal-involved veterans expanded during the COVID-19 pandemic. Screening veterans for OUD and educating them about MOUD during their outreach visit will improve identification and linkage of veterans to needed OUD treatment.

4.2. Legal agencies should improve access to MOUD during incarceration

Veterans recommended increasing access to MOUD in correctional settings, which may be particularly important because of links between offering these medications and improved treatment retention and reduced mortality after transitioning from correctional settings to the community (Macmadu et al., 2020; Moore et al., 2019). The VHA cannot directly improve MOUD availability in these settings because it is currently prohibited from providing health care to incarcerated veterans (Title 38 CFR 17.38(c)(5)). However, training VHA staff who conduct outreach in jails and prisons on the benefits of MOUD and various resources at their local VHA facilities and in their local communities may increase discussions about these medications with legal-involved veterans during outreach visits. These staff can also educate veterans and their partners in criminal justice agencies on the benefits of MOUD and prepare veterans to talk with waivered providers (prescribers) about MOUD at their next VHA or community health care visit.

The VHA’s Veterans Justice Programs aim to link legal-involved veterans from legal settings to VHA and community health care. The VHA can ensure that all three medications (methadone, buprenorphine, and naltrexone) are available at each VHA facility so that veterans with different experiences and preferences (Saunders et al., 2020; Velasquez et al., 2019) receive their chosen medications. Unfortunately, although medications are mandated to be available for all indicated veterans (Department of Veterans Affairs, 2008), uptake varies widely (Finlay, Binswanger, et al., 2018) and methadone is available in only 32 opioid treatment programs at VHA facilities nationally (Wyse et al., 2018). Initiatives are underway to improve access to MOUD in primary care, pain management, and mental health clinics (Gordon et al., 2020), but we do not yet know whether there will be an impact on medication use among legal-involved veterans. Forced withdrawal from MOUD if incarcerated is a concern among legal-involved populations (Fox, Maradiaga, et al., 2015; Fu et al., 2013) and currently no clear guidelines exist for how VHA or health care systems can address this issue.

4.3. The VHA should reduce physician turnover

Veterans described reducing physician turnover as a strategy to promote MOUD use because veterans felt frustrated with changing dosage and providers. Providers with waivers to prescribe buprenorphine show no difference in job satisfaction, compared to providers without waivers (Knudsen et al., 2019), which is important because job dissatisfaction is linked with provider turnover and may negatively affect patient care and patient-provider relationship (Williams & Skinner, 2003). Waivered providers did report lower overall satisfaction with buprenorphine elements of their practice compared to general practice elements, though, suggesting that research should aim to understand and address physician challenges to buprenorphine prescribing (Knudsen et al., 2019). Care teams may provide more stability for legal-involved veterans receiving MOUD (O’Toole, Johnson, Aiello, Kane, & Pape, 2016). Even if team members change, veterans may have more consistent treatment over time, which could result in fewer prescription changes and less need for veterans to repeat their treatment history to new physicians. Training physicians and care teams who work with legal-involved veterans on some of the unique aspects of these veterans’ treatment, such as court mandates for care or concerns about incarceration, may help to address issues in the patient-provider relationship that may be due to veterans’ legal experiences.

4.4. The VHA should improve education for physicians

Veterans with legal involvement recommended educating physicians on MOUD and patient-centered care. Academic detailing, which the VHA already uses to increase receipt of medications for alcohol use disorder (A. H. S. Harris et al., 2016), and provider-directed marketing (Nguyen, Andraka-Christou, Simon, & Bradford, 2019) are effective tools to improve MOUD prescribing. Offering academic detailing to VHA physicians and those outside the VHA system, particularly health care staff in legal settings, may help to improve use of these medications for legal-involved veterans and other people with OUD. VHA staff who conduct outreach in legal settings may also benefit from training to improve their MOUD knowledge and reduce stigma toward these medications (Finlay, Morse, et al., 2020). A training intervention with correctional staff found improved attitudes and intention to refer clients to MOUD (Friedmann et al., 2015).

Patient-centered care—focusing on the health and wellness of a patient rather than a disease or illness perspective—is a priority for the VHA. Results are yet unkown of efforts to improve patient-centered care, such as incorporating patient-generated data with clinical care (Woods, Evans, & Frisbee, 2016) and using a team-based approach to enhance continuity of care and better engage patients (Agha et al., 2018). Although veterans expressed a desire to have their preferences included in treatment decisions, the value of shared decision-making approaches in reducing substance use is mixed (Friedrichs, Spies, Harter, & Buchholz, 2016). Incongruent treatment goals between patients and physicians pose challenges in delivering patient-centered care (Yarborough et al., 2016), especially when patient goals, such as tapering off long-term MOUD use, may result in a return to opioid use (Fiellin et al., 2014; Tofighi et al., 2019). Patient-centered care for legal-involved veterans is further complicated by legal system requirements, such as court mandated treatments. Future research should help to develop and test trainings for physicians that help physicians to deliver patient-centered care for this population while still improving patient health.

4.5. The VHA should improve education for veterans

Veterans with legal involvement described concrete educational efforts that would help to improve veterans’ use of MOUD, including posting advertisements and fliers at clinics and creating online OUD videos on the VHA website and social media sites. Peer networks and internet searches are valuable tools for locating treatment programs, but misinformation may be distributed via these mechanisms as well (Tofighi et al., 2019). For veterans who had previously used MOUD, knowing that different treatment options were available was critical to their engagement. Direct-to-patient promotion of MOUD may be effective at improving veterans’ knowledge and use of these medications. However, a review of patient educational interventions for prescription opioids was mixed (Kadakia, Rogers, Reed, Dark, & Plake, 2020). Veterans also explained the importance of understanding different options for treating military-related injuries and how MOUD could help them to transition off pain medications. Patients who received a preoperative educational intervention used fewer opioid pills postoperatively than patients who received treatment as usual (Andelman et al., 2020). Implementation of educational programs and health literacy recommendations (Hersh, Salzman, & Snyderman, 2015) in primary care, substance use disorder clinics, and other relevant treatment settings may help to address gaps in patient knowledge and will have value to legal-involved and non-legal-involved patients. Research has also shown the link between educational interventions in correctional settings and improved knowledge of and attitudes toward MOUD (Lam et al., 2019).

4.6. The VHA should provide peer support

Legal-involved veterans in our study indicated a need for social support connections with other veterans, whether through individual peers or groups, to increase use of MOUD. Overall, peer recovery support programs that focused on substance use positively impact participants, including increasing their treatment retention, reducing their substance use, and decreasing their legal involvement (Bassuk, Hanson, Greene, Richard, & Laudet, 2016; Reif et al., 2014). Studies with people who had previously used MOUD (Randall-Kosich, Andraka-Christou, Totaram, Alamo, & Nadig, 2020) and veterans receiving medications for alcohol use disorder in group settings (Robinson, Bowe, & Harris, 2013) found that hearing peers’ positive experiences with the medications motivated their own treatment engagement. Mutual self-help groups historically held negative attitudes toward MOUD, but programs are in development to address this stigma and create respectful MOUD-educated peer groups (Krawczyk, Negron, Nieto, Agus, & Fingerhood, 2018). Emotional support, such as empathy, offered through peer recovery support groups may be especially important for veterans who face additional stigma because of their legal history (Schnittker & John, 2007). Online social media, though mentioned as a place to disseminate information on MOUD, may also be an effective forum to connect peers and offer referrals to resources and recovery groups and activities, which may be particularly important during the COVID-19 pandemic.

4.7. Limitations

This study had a few limitations. First, although we interviewed 18 veterans, we did not achieve our original goal of 24 participants, only 3 participants were women, and there was limited racial and ethnic diversity in the sample. Generally, saturation is achieved within 6–12 interviews (Guest et al., 2006), but we may have found more themes if we had achieved our intended sample size. In addition, more interviews would be required to achieve saturation for women and nonwhite veterans (Hagaman & Wutich, 2017; Hennink, Kaiser, & Marconi, 2017). Second, we did not find contradictory comments among the themes in this study, possibly due to a sample that was made up of primarily white males. However, another study derived from the same sample found contradictory remarks among themes (Finlay, Morse, et al., 2020). Third, legal-involved veterans who did not or cannot use VHA health care may not express the same strategies to overcome barriers that the veterans in this study described. We did not restrict our sampling to veterans who were eligible and used VHA care, but we were unable to recruit veterans not actively using the VHA health care system.

4.8. Conclusion

The study identified strategies to overcome barriers to using MOUD from the unique perspectives of veterans with a history of opioid use or OUD and legal involvement, though prior studies with different populations have identified these strategies. Suggested strategies ranged from patient-level changes, such as improving veterans’ education about MOUD, provider-level changes, such as reducing turnover and improving physician education, to system-level changes, such as offering telehealth services and offering MOUD in incarcerated settings. A variety of existing programs address these strategies and could be tested to determine if they improve receipt of MOUD, reduce overdose rates, and improve patient satisfaction with care.

Highlights.

  • Identified strategies to improve use of medications for opioid use disorder.

  • Legal-involved veterans recommended more compassionate care and social support.

  • Strategies should be evaluated for improvement in patient experience and outcomes.

Acknowledgments:

Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number R21 DA041489. Dr. Timko was supported by a Department of Veterans Affairs Health Services Research & Development (VA HSR&D) Senior Research Career Scientist award (RCS 00-001). Dr. Harris was funded as a VA HSR&D Research Career Scientist (RCS 14-232). Dr. Finlay was supported by a VA HSR&D Career Development Award (CDA 13-279). The National Institutes of Health and VA had no role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The views expressed in this article are those of the authors and do not necessarily reflect the position nor policy of the Department of Veterans Affairs (VA) or the United States government.

Footnotes

Declarations of Interest: None.

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