The report is a product of the VA/HSR Evidence Synthesis Program.

Evidence Brief: Barriers and Facilitators to Use of Medications for Opioid Use Disorder

As a component of VA’s overall response to the crisis of opioid-related morbidity and mortality, VA provides treatment for those with opioid use disorder (OUD; i.e. ICD-10 opioid dependence), a diagnosis made based on symptoms (i.e., drug cravings) and behaviors (i.e., inability to cut down or control substance use despite knowledge of clear negative substance-related consequences). Methadone, buprenorphine, and extended-release naltrexone are approved by the Federal Drug Administration (FDA) for treatment of OUD. However, these medications are underutilized within the VA healthcare system and the general community despite evidence of their effectiveness – and guidelines from VA/DoD recommending them as an option for first-line treatment for OUD. Reasons for underutilization of OUD medications are likely due to multiple interconnected factors at the patient, provider, and systems levels. The aim of this rapid review was to synthesize the evidence on barriers and facilitators at each of these levels to help inform VA stakeholders engaged in policy development, program planning, and OUD research.

Investigators with VA’s Evidence Synthesis Program in Portland, OR searched MEDLINE, PsycINFO, CENTRAL, Cochrane Database of Systematic Reviews, and EMBASE from inception through March 2019; additional citations were identified from hand-searching reference lists and consultation with content experts. The review focused on buprenorphine and extended-release naltrexone, which can be prescribed in office-based settings (rather than methadone which is only prescribed in specialized treatment programs) and have the most potential for widespread use. The review also was limited to articles published since 2014 in order to focus on evidence in the context of recent VA and federal policy changes. Among nearly 3,000 potentially relevant citations, investigators included 26 studies published since 2014; of these, they prioritized evidence synthesis of 16 studies that were most applicable to VA. All studies discussed buprenorphine/naloxone, while only one discussed extended-release naltrexone.

Summary of Findings
Most studies in this review met investigators’ pre-specified minimum quality criteria, and findings were consistent across studies. Those findings show:

• The four most commonly cited categories of both patient-identified and provider-identified barriers to primarily buprenorphine use include: 1) stigma, 2) logistics, 3) treatment experiences and beliefs, and 4) knowledge gaps. Of these, social stigma associated with OUD and high out-of-pocket costs were the most commonly described patient-identified barriers. Among providers, logistical concerns, particularly time constraints, were the most commonly cited barriers.
• Support from peers, family, and treatment providers was the most common facilitator for patients. Among providers, limited information regarding facilitators of OUD prescribing are available – and no single factor stood out as being most important.

Further, no studies of systems-level barriers with applicability to VA settings were identified, and no studies directly evaluated whether barriers and facilitators vary by patient or provider characteristics or setting.

Limitations
Of the included studies, none assessed Veterans, VA providers, or VA administrators; therefore, there is only indirect evidence about what are likely barriers and/or facilitators within VA. Additionally, patient studies included those who had a history or were currently receiving OUD treatment and/or participating in syringe exchange programs. Barriers and facilitators to the use of OUD medications may be different for patients who are not linked into medical care or community services. Most studies also were of patients with a history of injection drug use, rather than prescription drug use, and OUD medication barriers and facilitators may be different in these two patient populations. Moreover, several survey studies had low or unclear response rates.

Implications for Current Practice and Policy
Findings from this review were used to inform prioritization of questions for an invitation-only state-of-the-art (SOTA) conference titled “Effective Management of Pain and Addiction: Strategies to Improve Opioid Safety” that was held September 11-12, 2019 in Washington, DC.

Future Research
While investigators do not expect that future studies in VA settings would uncover additional barriers and facilitators that do not relate to one of those highlighted in this report – stigma, logistics, beliefs and attitudes related to OUD, and knowledge gaps  – studies in VA populations would increase certainty about which barriers and facilitators are most significant for VA patient populations and relevant to VA systems of care.

Reference
Mackey K, Veazie S, Anderson J, Bourne D, and Peterson K. Evidence Brief: Barriers and Facilitators to Use of Medications for Opioid Use Disorder. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-009; 2019.

Related HSR&D Research Topics:

• Opioids
• Pain

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This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

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