Opportunities to enhance retention on medication for opioid use disorder for adolescents and young adults: results from a qualitative study with medical providers in Philadelphia, PA

Abstract

Background

Medications for opioid use disorder (MOUD) are under-prescribed to adolescents and young adults (AYA). Few published studies have explored challenges to and opportunities to enhance continuous provision of MOUD for AYA. Our report focuses on this emergent theme that was identified as part of a larger qualitative study.

Methods

We purposively sampled and enrolled medical providers who prescribed MOUD to AYA. Semi-structured individual interviews using chart-stimulated recall explored barriers and facilitators to MOUD retention. We used modified grounded theory in our qualitative analysis, with double coding of interviews.

Results

Barriers to retention on MOUD included patient-level (i.e., return to substance use) and system-level factors (i.e., cost, delayed receipt, pharmacy challenges, and in-person visit requirements). Facilitators included patient-level (i.e., motivation, support networks) and system-level factors (i.e., telehealth access, availability of certified recovery specialists).

Conclusions

Our study is the first to look at retention for this key age group, setting it apart from the existing body of literature that looks at medication initiation. Our findings confirm that significant systemic barriers exist to AYA patients’ retention on MOUD. Further research is needed to develop interventions that facilitate continuous delivery of high-quality care among this key population.

Introduction

Opioid overdoses are a leading cause of death in adolescents and young adults (AYA) internationally [1]. For AYA with an opioid use disorder (OUD), the Society for Adolescent Health and Medicine and other major medical organizations recommend timely treatment with medications for opioid use disorder (MOUD) [2,3,4]. However, in a recent analysis of national addiction treatment program data, younger age (18–29 years) was one of the strongest risk factors for MOUD discontinuation by 6 months [5]. Yet no studies have investigated specific barriers and facilitators to MOUD retention for adolescents with OUD. OUD is a chronic medical condition benefitting from longitudinal treatment, including use of MOUD for at least 2–3 months and in many cases, extending over several years [6]. Extant work describes the lack of access to treatment initiation resources for young people with OUD [7,8,9]. However, no studies have focused on contextualizing the barriers and facilitators to MOUD retention for this age group. Understanding these barriers and facilitators will be critical to increase MOUD retention for this population at high risk of death by overdose, which can be exacerbated when the healthcare system fails to meet their unique needs. To address this gap, we conducted a qualitative study with providers examining the barriers and facilitators to MOUD retention in patients with history of MOUD receipt.

Methods

We conducted semi-structured individual interviews in Philadelphia from December 2021 to April 2022 as part of a study about integrating addiction treatment and HIV prevention among AYA [10]. The theoretical framework used to develop the interview guide was the Practical Robust Implementation Sustainability Model (PRISM) [11]. Participation was limited to physicians, physician assistants (PAs), or nurse practitioners (NPs) who had prescribed either MOUD or HIV pre-exposure prophylaxis (PrEP) to patients aged 16 to 29 years. All participants completed a verbal informed consent process with study staff that detailed the study purpose, protocol, and potential risks and benefits. Recruitment ended after reaching thematic saturation as determined by the primary investigator (M.C.H) and research assistant (K.D). All transcripts were coded independently by a team of 2 experienced qualitative investigators. Consistent with the methods of the parent study, the 2 coders met to discuss and reconcile their individually assigned codes using a κ coefficient threshold of 0.8 to ensure the rigor of interrater reliability. Exemplary quotes were identified. Interviews were analyzed using grounded theory as well as iterative, inductive techniques reliant on content analysis to identify key themes. While the interview guide primarily explored barriers and facilitators to MOUD and PrEP integration, this brief communication focuses on results related to retention in MOUD care, which was an emergent theme identified in interviews after completion of data collection. Key study findings are presented following the Standards for Reporting Qualitative Research [12]. This study was approved by the Children’s Hospital of Philadelphia Institutional Review Board.

Results

Participants (n = 19) were comprised of physicians (63%), nurse practitioners (21%) and physician assistants (16%), and 90% had prescribed MOUD to AYA. Over half the sample (63%) identified as cis-gender female with the remainder identifying as cis-gender male. The majority of our sample reported either less than 5 or 5–10 years since completion of their professional training (47% and 32% respectively). Key barriers included system-level and patient-level factors (Table 1). At the system-level, cost was reported to be a barrier to retention in MOUD care given out-of-pocket expenses associated with certain MOUD options depending on insurance coverage (Participant #5). The need to switch young people to different formulations was also discussed by providers as decisions they made jointly with patients for cost-savings (Participant #10). One participant, who informed patients ahead of time how changes in insurance could impact the cost of MOUD, discussed the impact of public versus private insurance status on cost of MOUD and how private insurance would be associated with greater costs to the patient (Participant #15). In addition to cost, providers also reported delays in patient receipt of MOUD depending on requirement of insurance prior authorizations and timely arrival of long-acting injectable forms of MOUD in clinic for administration during monthly scheduled visits.

Table 1 Barriers to MOUD retention and exemplar quotes from medical providers for AYA with OUD

Participants also discussed system-level barriers at the pharmacy, noting that patients faced a wide array of challenges such as refusal of a pharmacist to dispense the prescribed dose if perceived as too high or if the pharmacist harbored stigma against suspected continued substance use (Participant #8). Some participants could not receive their MOUD prescription at their preferred pharmacy because of “caps” wherein the pharmacist reported being “capped by the pharmaceutical companies on how many patients they can have that are filling suboxone or generic formulations” or because the patient lived “outside the town limits” (Participant #11). Additionally, some patients in need of an emergency bridge prescription due to MOUD being lost/stolen were turned away by pharmacies that refused to fill MOUD prescriptions early even when covered by insurance (Participant #16). Lastly, the need to present physically for in-person office visits posed a burden for some patients due to lack of transportation or conflicting employment obligations which interfered with their ability to continue MOUD (Participant #10). At the patient-level, history of return to substance use influenced MOUD retention for AYA, including return to use of both opioids and other substances such as benzodiazepines (Participant #3).

With respect to facilitators (Table 2), at the system-level, the ability to offer telehealth was cited as a factor that enabled MOUD retention (Participant #18), as well as the linkage of patients to certified recovery specialists (CRS) (Participant #5). At the patient-level, participants emphasized the support of a patient’s social network as an integral facilitator to MOUD retention. Patients who had parental or other familial involvement, who were parents themselves or had supportive partners were noted to be more likely to continue on MOUD. Motivation as it relates to employment attainment was also a facilitator to being retained in MOUD care (Participant #7).

Table 2 Facilitators to MOUD retention and exemplar quotes from medical for AYA with OUD

Discussion

Increasing access to MOUD for AYA is a critical means toward preventing the ongoing loss of young lives to fatal opioid overdose [13].Among medical providers caring for AYA with OUD there were multiple barriers identified to retaining patients in care and ensuring that they can receive life-saving, recommended medications to treat OUD on a continuous basis [14, 15]. Our findings provide key insights into the daily experience of providers and their patients who are fighting to access MOUD and areas for future intervention development. As our findings show, young people face stigma when trying to obtain their prescriptions, which has been described as a barrier among older adults as well [16]. We recommend collaboration with pharmacy colleagues to ensure universal, comprehensive substance use disorder treatment and harm reduction education. Since this study was conducted the Consolidated Appropriations Act of 2023 [17] was introduced to repeal the special waiver and mandatory training hours for prescribing buprenorphine to patients with OUD. While this law holds immense potential to expand MOUD access, we cannot lose sight of the infrastructure needed to support MOUD retention. For example, advocacy to overcome insurance barriers is critical for this population, who are often facing transitions from parental to personal insurance and navigating employer-based insurance plans for the first time [18]. Medical providers should discuss common insurance-level barriers with AYA and offer contingency planning if their prescriptions are not dispensed.

With the limited geographic capture of our study, a future extension of this study could explore facilitators and barriers among young people living in more rural parts of the country. Another important limitation is that this study does not include the patient perspective, which we hope to elicit in future studies. Although this study focused on a single regional community of medical providers who treat AYA with OUD where potential biases may exist, there are widely applicable findings. Confidential, accessible services will be critical for young people who use drugs so they may remain engaged in their other life priorities. Given the importance of remaining on MOUD for long periods of time to achieve remission (i.e., months to years), our work is impactful in that it is the first to look at retention for this key age group, setting it apart from the existing body of literature that looks at medication initiation. Conceptualizing care models that include key supporters such as family, social network members, and CRS will also be important to leverage strengths noted by providers in this study that are pivotal for youth retention on MOUD.