What’s the Question?
Opioid use disorder (OUD) remains undertreated in many parts of the United States, due to a range of barriers, including stigma, lack of treatment providers, and affordability.
One potential way to address some of these barriers is to integrate OUD treatment into primary care. Primary care clinics are much more accessible to the average patient than specialty care organizations, and primary care providers often have uniquely long-term relationships with their patients, something that can facilitate ongoing monitoring for symptoms and side effects.
The challenge? Many primary care physicians face both systems level and attitudinal barriers in treating patients with OUD.
NIDA Clinical Trials Network protocol CTN-0090 aims to develop a software-delivered measurement-based care (MBC) system to help address some of the systems-level barriers by providing digital tools for measuring symptoms and side effects at each patient visit.
Before developing the MBC system, however, CTN-0090 researchers had a question:
What kinds of barriers to OUD treatment do primary care clinicians report facing and can a software-based tool for screening, diagnosis and treatment help address those barriers?
How Was This Study Conducted?
To find answers, the study team conducted focus groups of clinicians (n=33) at 3 clinics in a north Texas community. Group facilitators asked questions about perceptions of opioid use and OUD treatment and whether a computerized MBC model could help with diagnosis and management of patients with OUD in primary care. The providers included in the focus groups (n=33) were from family medicine, internal medicine, and infectious disease practice.
What Did Researchers Find Out?
Six major themes emerged from the focus groups:
- Distinguishing between chronic pain and OUD
- Primary care clinicians reported that their patients with chronic pain usually didn’t see long-term prescribed opioid use as a problem and were hesitant to taper and discontinue their medication. The clinicians also reported a desire for training and tools for managing patients with chronic pain who have been on prescribed opioids for a long time, especially techniques for tapering and discontinuing those medications. They did not perceive OUD, which they often thought of as heroin use disorder specifically, as a significant problem in their clinical practice.
- Current practices with patients using prescribed or illicit opioids or other drugs
- Most of the clinicians reported that they did not have effective screening tools or processes in place for OUD diagnosis. They also felt they didn’t have adequate referral resources for patients with chronic opioid use and expressed frustration regarding the systems-level barriers experienced by those seeking treatment for OUD.
- Attitudes and mindsets about providing screening or treatment for OUD in your practice
- Clinicians expressed a number of false beliefs about buprenorphine treatment for OUD, including that it’s “substitution of one addiction for another,” that buprenorphine is likely to be misused or diverted by patients with OUD, and that prescribing buprenorphine without in-clinic services for psychotherapy would not be effective. They also reported low comfort level with diagnosing and treating OUD, expressing a desire for more training for themselves and their clinical staff before starting a buprenorphine program.
- Perceived resources needed for treating OUD
- Clinicians identified the need for additional, concrete resources to support prescribing buprenorphine for patients with OUD, including longer clinic visits, nursing staff familiar with buprenorphine, direct support from a pharmacist and behavioral health specialist, communication training (due to concern typical clinical language would increase shame and stigma), and training in regulatory aspects of buprenorphine prescribing.
- Primary care physician role in patient care not specific to OUD
- Providers shared thoughts on their role as primary care clinicians and their relationships with their patients. Many expressed both feeling an overwhelming responsibility to their patients and a desire to provide high-quality care. They also reported feeling burdened by increasing demands and expectations placed on them by the healthcare system. Many were hesitant to add diagnosis and management of OUD care to the list of diagnoses they were already managing.
- Reactions to implementation of proposed clinical decision support tool
- Focus group participants thought the new software-based tools could be helpful but expressed concerns about the difficulty of integrating them into clinic workflow, as well as the additional burden on patients of screenings at every visit. They were also concerned about universally screening for OUD when they felt there weren’t sufficient resources in place to treat those who screened positive.
What Are the Implications for the Workforce?
This study revealed that systemic and attitudinal barriers to screening, diagnosing, and treating OUD still exist in primary care. Many of both types of barriers appeared to be rooted in stigma against patients with OUD and misconceptions about evidence-based medication therapy for this disorder.
Continued education and training for physicians surrounding the medical, rather than moral, basis of OUD is needed. Though this study found that clinicians are interested in MBC, and it could help reduce some systemic barriers to OUD treatment in primary care, it also shows that significant work remains to combat the stigma against opioid use (both medical and non-medical), which appears to drive many of the clinicians’ concerns about integration of OUD care into their practice.
