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Table 1 Representative quotes for themes and subthemes

From: Assessing experts’ perspectives on challenges in substance misuse prevention, harm reduction, and treatment to shape funding priorities in New York State

1. Siloed and fragmented systems (87.5%)

1.1. Need for continuum of services with no artificial distinctions (81.3%)

• “Transitions in care is an old problem in the system, and none of this is unique to New York and people have talked about hot handoffs, warm handoffs for years, and I’ve tried to throw case management at it. We haven’t really solved the problem.”

• “The mental health world and the addiction world came more together versus separate silos…now there are treatment programs that address both at the same time but we’re still antiquated, around who funds what part. You go to an agency here, and they have the mental health side, and they have the addiction side, and they talk. But your primary diagnosis is addiction, or your primary is the mental health diagnosis.”

• “I was on a call and so I just found it funny that someone actually said ‘Well, as a counselor, do you treat the mental health issue or the substance use issue first’? And I was like, ‘Yeah, treat it all.’ You first of all make sure that patient is safe, and you don’t care if it’s a mental health or substance.”

• “Artificial, but for me, useful distinctions along the continuum of care into prevention, treatment, and recovery. Acknowledging upfront that there’s a lot of overlap and that a lot happens, and transitions and people come into treatment and then go into recovery, go back to treatment, and then you’re preventing things.”

1.2. Need for no wrong door approach for entry into services (81.3%)

• “We have to create a system in which whatever door you touch lets you in.”

• “I think hopefully, we’re creating a no wrong door trajectory”

• “We could do a better job … starting people on medications in the hospital setting and linking them to care afterwards”;

• “But people don’t really see, don’t understand, if a patient gets admitted and they treat the endocarditis but don’t treat the addiction. This happens all the time in our hospital system.”;

1.3. Need for unified policies and progress metrics (62.5%)

• “If you look at New York State, things are so segmented, so you’ll have OASAS saying one thing and [?] saying a different thing and doing things differently and requiring different things”

• “It’s super difficult to be in alignment with all the three strategies that should be in alignment, I shouldn’t have to find ways for them to align, and I often feel like that’s what I’m doing, or our partners are doing, it just causes more paperwork, less efficiency. It causes issues in terms of over burdening their staff…. There needs to be more cohesiveness with approaches from the higher levels.”

• “One of the biggest barriers has been the variety of different systems that are used to collect data and the different data that is collected”

2. Need for a skilled workforce (75.0%)

2.1. General shortage of highly skilled health professionals (68.8%)

• “The workforce is another big challenge. There are just not enough people to do the work. Providers, counselors, nurses.”

• “Right now, we’ve got a crisis with the workforce. We’ve had a shrinking workforce for a long time…There’s low pay, high levels of stress, and people are either removing themselves or not entering those professions.”

• “So these younger, hopefuls, when they are doing a good job, might get put in a position that they might not feel qualified for. And there’s not enough time to train them, because there’s such a workforce shortage.”

• “Our workforce is not equipped for the requirements that we have of people being able to do this type of work in regards to the complexity of people’s mental health and addiction pieces.”

2.2. Challenges with training, including frequent staff turnover (62.5%)

• “So it’s more support for those newer counselors, and they often get thrust into large caseloads, so it can cause burnout and early exit out of the field, because the young counselors are overwhelmed”;

• “There’s no time to implement a brand-new process and make sure that they can do it with fidelity.”

• “We don’t train physicians, nurses, NPS, even social workers, or any kind of other license, marriage and family license, mental health counselors. We don’t train them in addiction. We don’t expose them to feel placements unless they kind of seek it out on their own, or it just kind of happens.”

• “You have to start looking at pre-service training being more intensive with these kinds of these kinds of evidence-based practices, we have to start learning them, earlier on in their training and their schooling and their education.”

2.3. Competition from other sectors with higher wages and better working conditions (25.0%)

• “There’s competition with Starbucks, Tim Hortons, like just entry level jobs in the community, get paid more than perhaps people who have, you know, Master’s degrees in counseling or education, and are doing prevention or recovery work.”

• “They were burning out, they left for other things”

• “There’s just a horrible crisis, not enough people to hire to do all the work, not even just in human services, there’s not enough people for all the jobs”

3. Attitudes towards addiction/stigma (68.8%)

3.1. Negative attitudes (stigma) and misconceptions across stakeholders and populations (50.0%)

• “I struggle on a daily basis with the programs that I oversee and the community that I work in, dealing with stigma.”

• “Prevention is the first step of education prevention and breaking down barriers of stigma. It’s almost obvious, I think we have to figure that out, but that’s got to run, I think, as an undercurrent, anything else we do in the treatment and recovery worlds.”

• “I think that there’s still quite a bit of stigma and morality around substance use and the reasons each person thinks that they might be using”

• “How do you get the stigma out of Methadone? I worked in a Methadone clinic. It’s really an effective treatment for a lot of people. But there’s so much stigma related to it that people who need it won’t even try it… medication for substance use disorder needs to be addressed and utilized more.”

3.2. Lack of understanding that a substance use disorder is a chronic disease requiring long-term care (50.0%)

• “An addiction is a chronic, relapsing, remaining brain disease. And so, people in addiction care should be treated at the primary care level, and if primary care is unable to manage their use disorder, in this case opioids, then they should be referred to…an opioid treatment program.”

• “It’s a lack of understanding that this is an illness similar to diabetes or cardiovascular disorders, or anything else.”

• “There’s still this is a correlator with opiates, a fundamental misunderstanding of the chronicity. A fundamental misunderstanding of the chronicity of addiction in general. These are patients who should be thought of as long-term care patients.”

• “I think that it’s still a big barrier to try and get folks to look at it as a medical kind of condition, or that they are our brain changes, or like the chemistry of addiction in the treatment community, in the community at large.”

3.3. Stigma can have a racial element and differentially impact minority communities (25.0%)

• “We saw that with regard to prescribing opiates for pain, [someone] who was African American was more likely just drug seeking, and besides, they should be able to withstand that pain because they’re black.”

• “[There is a perception that] our black and brown brothers and sisters don’t have the same tolerance of pain at a doctor’s office that you and I would. And I think that’s a huge issue. If I walk in and I tell my doc I’m in pain, I’m gonna get something. But a black patient with the same level of pain walks in, they’re not going to be taken seriously.”

4. Limitations in treatment access (62.5%)

4.1. Access to treatment (56.3%)

• “The greatest challenge, it’s a couple of things, I think. Definitely access to care.”

• “Yes, everybody is going to say that stigma and access are [the greatest challenges]. But how do we change those 2 pieces?”

• “Limited access to services, especially in areas with few harm reduction or treatment providers.”

• “There was a guy in the cemetery yesterday, 27 years old, that was not doing well. He had just taken meth about 4 h before, and he was on something else and something else. And there was, I would say, caring and direct intervention by law enforcement. I really believe that this person probably definitely doesn’t have the same type of insurance coverage as somebody else might have in terms of them being in a position to get what’s needed.”;

4.2. Disparities in access to treatment (50.0%)

• “One of the things that’s really concerning is the barriers to getting treatment, and the way and the way that disproportionately affects minorities and underserved individuals.”

• “I think that there’s not enough evidence-based practices for communities of color.”

• “So we thought, with a certain segment of our population, those that look different than you and I, in terms of those that are brown skinned, or whatever, and so there wasn’t as much quote resource and or I’ll even say aggressiveness to try to fix this, and the whole piece now around the opiate stuff.”

• “Buprenorphine is not easily accessible to, you know, based on race in the city…poor communities that are overrepresented with black and Latino individuals tend to not have as much funding or resources available to them, and available workforce, so they tend to have older models of care.”

5. Environmental factors (56.3%)

5.1. Social determinants of health (43.8%)

• “The other major piece to the puzzle is around how housing and substance use interact… a lot of our folks are unhoused. Don’t have a phone, so it’s really hard to connect with them.”

• “With chaotic use, it’s really hard for people to maintain their housing anyway, in terms of income and making sure that they get the documentation that’s needed …it’s hard for folks to stay in the same place throughout their treatment or even if they’ve completed a treatment or recovery program to land in a place that is safe for them.”

• “there’s a direct relationship to the number of outlets of whatever, and the amount of use…communities that have lower levels of outlets have lower use rates.”

• “We cannot separate what we are calling the social drivers of health. Or I personally call them the impediments, the social impediments to health.”

5.2. Current drug environment (31.3%)

• “What people were experimenting with 50 years ago didn’t kill them in the same way that the Fentanyl is killing today.”

• “I saw Director Milgram from the DEA talking about the criminal side of the fentanyl problem. The image that I had and how the materials coming from China and the cartels in Mexico make the drug, and they’re flooding our community. They’re poisoning our communities. I suddenly had the image of like we’re doing CPR on a patient, and we don’t understand that there’s someone knifing them on the side. We’re trying to save a patient that a lot of people are trying to kill.”

• “I think when you look at society today, an opioid is kind of the easy button and I don’t feel well today or I’m in pain, I could take this substance and make it go away. We have to look at prescribing patterns… because a lot of opioid addiction happens accidentally, they didn’t know that they were going to struggle.”

• “There’s other dynamics at play with supply that that our services can’t control…the biggest challenge is to mitigate all the supply issues that are impacting demand.”

  1. Note: Percentages represent the proportions of experts expressing themes and subthemes