Transcript Russian Addiction

Barriers to opioid agonist therapy among
persons with high-risk opioid use
AMERSA 2015
Washington, DC
Judith I. Tsui, MD, MPH
Acting Assistant Professor
Division of General Internal Medicine
University of Washington
Seattle, WA
Co-Authors
• Caleb Banta-Green (PI)
• Anthony Floyd
• Joseph Merrill
Conflicts of Interest
• The authors do not have financial conflicts
of interest to declare
Background
• Opioid use disorders (prescription opioids and heroin)
have emerged as a major public health concern in the past
decade.1,2
• Opioid agonist therapy (OAT) with methadone and/or
buprenorphine have been shown to decrease illicit opiate
use.3
• Yet treatments for substance use disorders in general, and
OAT specifically, are underutilized.4,5
1 Warner M, Chen LH, Makuc DM, et al. National Center for Health Statistics. 2011.
2 Paulozzi L, Jones C, Mack K, et al. MMWR Morb Mortal Wkly Rep. 2011
3 Mattick RP, Kimber J, Breen C, Davoli M. Cochrane Database Syst Rev. 2008
4 Volkow ND, Frieden TR, Hyde PS et a. NEJM 2014
5 National Survey of Drug Use and Health 2013
Background
• Barriers to OAT occur at many levels (systems,
providers, patients).
• Much current research has focused on provider and
system level barriers to OAT.1-4
• Given efforts to expand OAT, it is important to
recognize patient level barriers, and how individual
attitudes toward OAT contribute to lack of engagement
treatment.
1 Walley AY, Alperen JK, Cheng DM, et al. JGIM 2008.
2 Becker WC, Fiellin DA, Merrill JO, et al. Drug Alcohol Depend. 2008
3 Ducharme LJ, Abraham AJ. Subst Abuse Treat Prev Policy 2008
4 Knudsen HK, Ducharme LJ, Roman PM. Drug Alcohol Depend. 2007
Study Aim and Design
• Objective: To understand access and barriers to
OAT in a sample of persons high-risk opioid use
(heroin and/or prescription opioids).
• Secondary analysis of data from an RCT.
• Descriptive and qualitative analyses of baseline
questionnaire data.
Parent Study: Project OOPEN
• “Opioid Overdose Prevention, Education and
Intervention” (R01DA030351); PI: Banta-Green
• RCT of an intervention to prevent overdose among high
risk patients using opioids
• Intervention includes risk assessment, feedback,
education, and take-home intranasal naloxone.
• Recruitment occurred 2013-2015 from Emergency
Department and post hospitalization respite setting of
Harborview Medical Center, Seattle WA.
Eligibility Criteria
• Current heroin or prescription opioid users with one of
the following:
– Opioid overdose is reason for hospital encounter
– Concurrent use of other opioids, alcohol, benzodiazepines or
stimulants
– Average daily dose of prescribed opioids >10 mg MEQ
• Age 18-70, living in WA state, speaks English
• No active SI, psychiatric or cognitive impairment
• No current naloxone
Research Questions
• What proportion sought treatment with OAT in
the past 3 months but were unsuccessful?
• What proportion did not seek treatment with
OAT?
• Of those who sought OAT but were
unsuccessful, what were the barriers?
• Of those who did not seek OAT, what were the
barriers?
Questions
• “Have you been in opioid drug treatment that
include buprenorphine or methadone?”
– Never
– More than a year since treatment
– In treatment in the past year, but not currently
– Currently in treatment
Questions
• “Have you tried to get opioid drug treatment that
include buprenorphine or methadone in the past
3 months?”
– Yes, I got into treatment
– Yes, but I didn’t get into treatment
– No
Questions
• (Tried but did not get treatment) “Why didn’t you
go into treatment?”
– Changed my mind Patient (readiness)
– Don’t know how to find treatment Patient (education)
– Worried someone would find out Patient (stigma)
– Was on waitlist, but did not get in System (access)
– Could not find a buprenorphine provider Provider
– Could not afford treatment System (coverage/cost)
– No insurance System (coverage/cost)
– Transportation problems System (access)
Questions
• (Did not try get into treatment) “Why didn’t you
try to go into treatment?”
– I don’t need treatment
– I don’t like buprenorphine
– I don’t like methadone
– I don’t like the rules/requirements of buprenorphine
– I don’t like the rules/requirements of methadone
– Treatment didn’t work previously
Baseline Demographic Characteristics of
Sample (n=256)
Characteristic
Overall (%)
Median age (range)
40 (19-65)
Female
74 (29%)
Nonwhite
90 (35%)
Employed
22 (9%)
Homeless
129 (50%)
Ever heroin use
232 (91%)
Ever prescription opioid use
243 (95%)
Current (90 day) heroin use
227 (88%)
Current (90 day) prescription opioids use
212 (82%)
Results
• 74/256 (29%) reported current treatment with
buprenorphine or methadone for opioid use
disorders.
• 182 were not currently on OAT.
Results: OAT Seeking Behaviors
Among Participants
“Have you tried to get opioid drug
treatment that include buprenorphine
or methadone in the past 3 months?”
n = 182 (%)
Yes, I got into treatment
5 (2.75%)
Yes, but I did NOT get into treatment
51 (28%)
No, I didn’t try to get into treatment
126 (69%)
Reasons Why Participants Tried
But Did NOT Get OAT
n = 51 (%)
Changed my mind
Don’t know how to find
Was on waitlist
Couldn’t find buprenorphine
provider
3 (6%)
0
14 (28%)
0
Transportation problems
3 (6%)
Couldn’t afford
5 (10%)
No insurance
5 (10%)
Worried someone would find out
Other
*multiple responses allowed
0
36 (71%)
Reasons Why Participants Did
Not Seek OAT
n = 126 (%)
Don’t need treatment
Don’t like buprenorphine
29 (23%)
3 (2%)
Don’t like methadone
18 (14%)
Don’t like rules of buprenorphine
2 (1.5%)
Don’t like rules of methadone
11 (9%)
Treatment didn’t work before
4 (3%)
Other
*multiple responses allowed
94 (75%)
Analysis of “Other” Responses
• “Other” responses transcribed verbatim by research
assistants
• Responses coded for emergent themes
• Reviewed for most common themes
OAT is Another “Addiction”
• “It's just switching one addiction for another.”
• “Methadone is just as bad as heroin.”
• “Methadone creates more problems and is harder to
stop than heroin.”
• “I don’t want to trade one drug for another drug.”
OAT Constitutes Loss of
Control
• “I didn't want to be in treatment, I don't like someone
having that kind of power over me.”
• “It's liquid handcuffs.”
• “I don't want to be a slave to methadone.”
Complex or Unstable
Co-Morbidities
• “I got in but never went due to my hospitalization.”
• “My surgeries got in the way.”
• “I was going to start suboxone on (date), but I was in the
hospital.”
• “Can’t give a benzo-free urine due to my seizure
disorder.”
Interference with Pain
Management
• “It doesn’t meet my needs for pain.”
• “I don’t want to. I’m already on methadone for pain.”
• “I don’t need treatment, I need pain management.”
• “I don't really know how, and I just want pain treatment.
I don't know that they would help me.”
Conclusions
• In a sample of patients using heroin and/or prescription
opioids, more than one quarter had attempted to get
treatment with OAT in the past 3 months, but were not
successful.
• Among those who sought but did not get OAT, the most
common response category selected was the existence
of a waitlist.
• Of those who did not seek treatment with OAT, the most
common reason selected was belief of not needing
treatment.
Conclusions
• However, most participants identified “other” reasons for
not receiving OAT.
• Open ended responses identified themes that have been
previously reported in the literature1,2 such as fear of loss
of control and equating OAT with “addiction”.
• Competing co-morbidities and concerns about need for
treatment for pain emerged as additional reasons why
participants did not seek out OAT.
• Results adds to literature demonstrating that pain plays
an important role in substance use treatment outcomes.3
1 Brown BS, Benn GJ, Jansen DR. Am J Psychiatry 1975
2 Schwartz RP, Kelly SM, O’Grady KE. Am J Addict 2008
3Larson MJ, Paasche-Orlow M, Cheng DM Addiction 2007
Limitations
• Recruitment from single healthcare setting.
• No clinical assessment for diagnosis of opioid use
disorders.
• Limited qualitative data on barriers (single open
ended question).
Next Steps/Future Research
• Immediate access to OAT is still an issue for patients
with opioid use disorders: alternatives to waitlist needed.
• Pain and co-morbidities are barriers—interventions
needed to address pain and addiction for complex
medical patients.
• Research needed to understand why negative beliefs
about OAT persist among patients, and whether these
beliefs are fixed or can be changed.
Thank you!