Article Figures & Data
Tables
Characteristic N (%) Location* Rural 6 (23.1) Urban 20 (76.9) Number of medical providers 1 9 (34.6) 2 to 5 11 (42.3) >5 6 (23.1) Number of behavioral health clinicians 1 2 (7.7) 2–5 13 (50.0) >5 11 (42.3) Organization type Community service board† 13 (50.0) Private practice 8 (30.7) Health System-owned practice 5 (19.2) ↵* The Rural Urban Continuum Code (RUCC) was used to categorize each clinic as rural or urban. Urban was defined as having a RUCC of 1–3 and rural as having a RUCC of 4–9.
↵† Community service boards are county- or city-run clinics mandated by Virginia code that provide behavioral health, developmental disability, and primary care services.
Theme 1: Mixed implementation experiences Findings:
Clinics that already had BH infrastructure, such as FQHCs, and CSBs had an easier time with implementation.
Clinicians credited the ARTS benefit for empowering them to address the opioid epidemic in their communities.
Practices struggled to recruit buprenorphine-waivered prescribers and BH clinicians willing and/or credentialed to work in a P-OBOT clinic, especially in rural areas.Example quotes:
“When I started learning about the ARTS initiative, I educated the administration on the changes that were coming down the pike. I knew I would want to leverage the ARTS initiative to expand services.”
“Our doctor […] actually lives in Maryland. She does it via telehealth.”Theme 2: Stigma from local communities and other health care providers Findings:
Stigma towards MAT in local communities impacted sites' implementation experiences and clinical decision making, especially in rural areas.
Health care provider stigma, which was articulated about the addictive potential and relative harm of buprenorphine resulted in barriers to expanding MAT.Community engagement efforts helped alleviate community opposition.Example quotes:
“We had to really try to define how we can provide the service without it becoming something the community says, ‘we don't want this here anymore.’”
“A lot of them will never understand…why I'm not just trading one drug for another. Addiction is ending up in jail and not buying food for your kids, and injecting drugs into your penis and getting endocarditis in your heart valves. These people aren't doing that with Suboxone.”Theme 3: High prevalence of co-occurring medical, psychological, and social challenges. Findings:
Comorbid mental health diagnoses and polysubstance use extremely common.
Housing and employment issues were common, especially in rural areas. Poor social stability resulted in challenges with outpatient OUD treatment.Example quotes:
“One of our patients was essentially homeless when she started with us, but wasn't really considered homeless by our local DHS standards because she was sleeping on her friend's couches, but she might sleep on three different couches a week.”Theme 4: Various approaches to induction and stabilization Findings:
At-home inductions primarily were used to accommodate staff schedules rather than for medical needs.
Although most clinics responded to relapses and polysubstance use initially with increasing intensity of care, clinics have different thresholds for dismissal and/or referral to higher levels of care.Example quotes:
“Our doctor works for us a day a week, so we have to do inductions offsite. I don't have any options for doing them onsite.”
“If we have a patient relapse, our model of care is, you need to have additional services.”Theme 5: Behavioral health as “key to success” Findings:
Group counseling the most widely used behavioral health intervention. Group therapy believed to provide necessary social support and reinforce change in socialization patterns. Many sites offered multiple session times and treatment modalities to promote patient engagement in group therapy.Example quotes:
“Medication assists the therapy rather than the other way around.”
“You watch this dynamic where they develop true genuine feelings for each other, like real concern. They'll talk about, ‘you know what keeps me sober, is I don't want to let this group down.’”
“[Group therapy] is where the healing happens.”Theme 6: Large variation in care coordination structure and intensity Findings:
Large variation in the goals and intensity of care coordination efforts, as well as primary means of identifying patients' co-occurring needs.
The majority of clinics used a team approach to care coordination rather than having dedicated care coordinators.
Enhanced care coordination was facilitated by weekly or biweekly meetings to facilitate communication, information sharing and strategic planning.Example quotes:
“When you're drowning in a sea of addiction, we're going to be the life boat you want to hold onto.”“We always make Monday lunchtime meetings, all of us, the whole treatment team, and we review every patient that's in need of review.”Theme 7: Peer support services highly viewed but inconsistently implemented Findings:
Peers described as better able to provide personal support to patients, help patients manage cravings or stress, and connect patients to social support networks in the community.
Only one-third of the sites used peer support services.Example quotes:
“We, unfortunately, are bumping up against [barriers] trying to add peer recovery coaches. You have to present your business plan and how you're going to cover expenses.”
“We've found with the peer recovery coach that patients feel a connection because this person has kind of been there, done that.”Theme 8: Treatment success ambiguous to define and difficult to measure Findings:
Successful/stable patient largely defined in functional terms, as a change in physical appearance, social relationships, and ability to hold a job.
Sites expressed desire for measures through which to assess and compare themselves to other sites.
Tapering off buprenorphine not seen as necessary for “successful treatment.”
Attrition at some sites may be due to treatment models requiring 3 or more weekly appointments, especially for sites operating in rural, outlying areas.Example quotes:
“Success is always functional…somebody whose disease (including psychiatric comorbidities) is managed.”
“You can see it in their eyes, in their face, in their demeanor.”
“… not necessarily coming off of [buprenorphine] because I know very few people who have. Some of them try to come off and it doesn't work. They find themselves right back where they started. So, that's what we want to avoid.”Theme 9: Complexity best met with collaboration, compassion, and consistency Findings:
Strong collaborative relationships between medical, BH, and care coordination team members emphasized as the most important factor in effectively addressing patients' complexly interconnected medical and social needs.
Maintaining compassionate, consistent and adaptive approach seen as the key to creating therapeutic relationships with patients.Example quotes:
“It's kind of like it's all hands on deck kind of thing. Where we all kind of take it, but one of the benefits has been that we do have a lot of dual diagnosed clients who are seeing another therapist and who are seeing a support coordinator or seeing a psychiatrist so a lot of their issues are being taken care of in house, which provides the stability, but we collaborate.”BH, behavioral health; FQHC, federally qualified health center; CSB, community service board; MAT, medication-assisted treatment; P-OBOT, Preferred Office-Based Opioid Treatment; ARTS, Addiction and Recovery Treatment Services; DHS, Department of Homeland Security; OUD, Opioid Use Disorder.
