Barriers to Opioid Use Disordeer Treatment Among People who use drugs in the rural United States: A Qualitative, Multi-site study.
Abstract
Background
In 2020, 2.8 million people required substance use disorder (SUD) treatment in nonmetropolitan or ‘rural’ areas in the U.S. Among this population, only 10% received SUD treatment from a specialty facility, and 1 in 500 received medication for opioid use disorder (MOUD). We explored the context surrounding barriers to SUD treatment in the rural United States.
Methods
We conducted semi-structured, in-depth interviews from 2018 to 2019 to assess barriers to SUD treatment among people who use drugs (PWUD) across seven rural U.S. study sites. Using the social-ecological model (SEM), we examined individual, interpersonal, organizational, community, and policy factors contributing to perceived barriers to SUD treatment. We employed deductive and inductive coding and analytical approaches to identify themes. We also calculated descriptive statistics for participant characteristics and salient themes.
Results
Among 304 participants (55% male, mean age 36 years), we identified barriers to SUD treatment in rural areas across SEM levels. At the individual/interpersonal level, relevant themes included: fear of withdrawal, the need to “get things in order” before entering treatment, close-knit communities and limited confidentiality, networks and settings that perpetuated drug use, and stigma. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of gender-specific treatment programs, and concerns about jeopardizing employment. Community-level barriers included: limited availability of treatment in local rural communities, long distances and limited transportation, waitlists, and a lack of information about treatment options. Policy-level themes included insurance challenges and system-imposed barriers such as arrest and incarceration.
Conclusion
Our findings highlight multi-level barriers to SUD treatment in rural U.S. communities. Salient barriers included the need to travel long distances to treatment, challenges to confidentiality due to small, close-knit communities where people are highly familiar with one another, and high-threshold treatment program practices. Our findings point to the need to facilitate the elimination of treatment barriers at each level of the SEM in rural America.
Introduction
In 2020, 2.8 million people met the criteria for a substance use disorder (SUD) in nonmetropolitan or ‘rural’ areas in the United States (U.S.) (Substance Abuse and Mental Health Services Administration, 2022). Yet, among people with a SUD, only 10% received substance use treatment from an inpatient or outpatient program, a hospital, or mental health program, and 1 in 500 received medication for opioid use disorder (MOUD) (Substance Abuse and Mental Health Services Administration, 2022). People living with opioid use disorder (OUD) who do not access treatment face higher risks of adverse outcomes including fatal overdoses, hepatitis C virus and HIV infections, and poorer quality of life (Krawczyk et al., 2020; Platt et al., 2017; MacArthur et al., 2012; Gottlieb et al., 2022). These risks are more difficult to prevent in rural areas due to heightened barriers such as highly stigmatized perceptions of opioid use, long distances, inadequate transportation, and lower provider-to-patient ratios compared to urban settings (Meit et al., 2014; Pellowski, 2013). It is imperative to understand and address barriers to OUD treatment among rural people who use drugs (PWUD) to reduce opioid-related morbidity and mortality.
Existing high-threshold treatment program practices and government policies harm people with OUD by worsening treatment and illness burdens, compounding life demands, and straining resources, resulting in low rates of SUD treatment uptake (Englander et al., 2022). A prior study identified barriers to SUD treatment at various levels of the social-ecological model (SEM) in an urban setting (Kahn et al., 2022). Individual-level barriers include life circumstances, negative experiences with MOUD, and treatment readiness (Kahn et al., 2022; Garpenhag and Dahlman, 2021). Organizational and community-level barriers include stigma from healthcare providers and employers, long treatment waitlists, and strict program rules (Kahn et al., 2022; Garpenhag and Dahlman, 2021; Kennedy-Hendricks et al., 2017; Reisinger et al., 2009; Spithoff et al., 2019). Societal-level barriers include social norms (e.g., morality), stigma tied to substance use, system-level policies, and zoning laws against treatment centers (Bolinski et al., 2019; Haffajee and French, 2019; Bernstein and Bennett, 2013). While barriers to treatment are well-documented among the general population of PWUD, little is known about the unique barriers rural PWUD experience in accessing and remaining in OUD treatment (Carroll et al., 2011).
As part of the larger multi-site Rural Opioid Initiative (ROI), we used a multidimensional approach to better understand barriers to OUD treatment among PWUD in the rural U.S. across the following levels of the SEM framework: individual/interpersonal, organizational, community, and policy.
Study design
The U.S. Department of Health and Human Services and the Appalachian Regional Commission funded the ROI to better understand and respond to the effects of the opioid crisis in the rural U.S., specifically eight studies spanning 10 states and 65 counties across the country (Jenkins et al., 2022). The overarching goal of the ROI was to help rural communities develop comprehensive approaches to prevent and treat substance use-related outcomes.
We aimed to recruit and enroll PWUD from a diverse mix
Results
The 304 participants we interviewed from New England, Appalachia, the Midwest, and the Pacific Northwest were 55% male, 70% white, and had a mean age of 36 years. Eight in ten participants (80%) reported injecting drugs during the 30-days prior to their interview, and 18% completed less than a high school education (Table 1). We identified perceived barriers to OUD treatment in rural areas across all levels of the SEM.
While we did not note salient site-specific OUD treatment barriers in our
Motivation for treatment
At the most basic level, participants who felt they were not ready to enter treatment noted two primary reasons: The belief that they needed treatment but were not ready to initiate or that abstinence wasn’t achievable.
I’m not ready to go. I’m just not ready. I need to go and get the shit out of my system and … I’m an addict. I don’t think I’m ever going to be able to quit. (Male, 33, NC)
Need to ‘get things in order’ before entering treatment
Several participants noted their life circumstances and responsibilities as a barrier to treatment. Participants reported efforts to get their jobs, houses, finances, health issues, and family affairs ‘in order’ before being ready or able to enter treatment.
I would [get another MOUD prescription.] Now that I’m starting this new job … after my nine-day probationary period at this job, I will be given the option to be completely covered on anything. I’ll still have to pay some doctors and stuff,
Fear of withdrawal symptoms
Participants commonly cited fear and avoidance of opioid withdrawal as a barrier to OUD treatment based on their lived experience or perceptions rooted in their peers’ experiences.
I know a guy who’s on Vivitrol, and he’s been 5 years on Vivitrol … I mean I’ve thought about it, but you’ve gotta go those 7 days and about your 3rd day is when it really starts hitting you and you come into withdrawals. (Female, 42, OH)
I’ve thought about [detox/drug treatment] a couple times, but I never went. The
Interpersonal influences, settings, and triggers that perpetuate drug use
With rural areas being home to smaller, tight-knit connections, participants noted the struggles of returning to their everyday settings following treatment, which perpetuates drug use. Participants recognized the importance of changing people, places, and things to avoid triggers that might lead to re-initiation of use. Long-term residential treatment was noted as particularly appealing by participants who needed to move away from potential triggers and interpersonal relationships in their
Programs managed like correctional facilities
Participants reported that SUD treatment facilities often felt like correctional facilities due to the use of punitive approaches and inflexible rules. Participants expressed concern about losing their freedom and agency within treatment facilities. Programs generated anger among participants, which inadvertently contributed to the need to self-medicate with illicit substances:
… it kinda scared you, just the rules themself, there’s a lot of them. Some of them were more free and the environment
Lack of gender specific treatment programs
Participants reported a limited number of beds available for women seeking inpatient or residential treatment, making treatment access more challenging for women.
But if you’re a guy and need to go … I remember numerous times my brother just called and he was in that night … it’s so much easier being a guy getting into rehab. (Female, 27, IL)
Some participants felt gender-specific facilities were needed, suggesting that a lack of such facilities may be a barrier to accessing meaningful treatment,
Concerns about jeopardizing employment
PWUD found themselves in a conundrum: they wanted to remain in outpatient treatment but experienced concerns about jeopardizing employment and an inability to take time off work for treatment. Participants often reported work as a priority over treatment due to their income needs, as “you can’t make money while sitting in [treatment].” Employed participants could not take a leave of absence for treatment due to fears they would experience substance use stigma and retaliation from their
Limited treatment availability
Due to rurality, participants reported limited availability of treatment within local reach, especially for residential in-patient treatment, but also MOUD and outpatient treatment. This lack of availability created barriers to treatment access, requiring extended travel amidst a landscape with limited transportation options:
I mean, I’d like to go back, but it’s three days a week and it’s hard for my grandma to take me three days a week and sit there and wait ’cause we live all the way in
Waitlists
Participants also reported limited access due to long waitlists for treatment in local rural communities, often waiting several months for treatment slots to open, and limited walk-in treatment:
They can’t … Apparently there’s huge waiting lists to get in for beds and stuff. And the people that really want to stop are poor, just had a bad dealing of cards in their life are screwed. And it’s stupid. I think they should make it way more [accessible] … I feel personally they should make something
Negative attitudes and stigma towards MOUD
Negative attitudes and stigma related to MOUD treatment options represented additional community-level barriers to treatment in rural communities.
Unless it’s end of life, I truly feel like [methadone] should be illegal. Now that there’s a new alternative. Or not new, but newer alternatives to Suboxone, Buprenorphine, or whatever … I have gone rounds with our medical director about this one. He preaches about how methadone’s this wonderful thing. I’ve never in my life seen anybody be successful
Insurance dictates available treatment
Respondents reported a variety of insurance-related barriers. A common barrier was finding treatment programs that accepted respondents’ insurance, including Medicaid or Medicare.
I wasn’t able to go to the ones in [city] that had open beds right then because my insurance didn’t work there, even though it’s in the same state. I guess it was a different local [Medicaid managed care] provider. (Male, 29, OR)
Respondents reported difficulties with losing public insurance once they had attained a
System-imposed barriers
Respondents reported that arrest and incarceration in local jails could interfere with treatment access and continuity, noting that they had been incarcerated while on a waitlist for MOUD treatment, losing their spot when it eventually opened. They also identified challenges to communications between jails and community-based treatment providers, which were often quite distant from one another in rural counties, hindering treatment continuity post-release:
Jail is mostly the number one thing
Discussion
We identified barriers to OUD treatment across all levels within the SEM. At the individual/interpersonal level, unique rural barriers included close-knit communities and tightknit rural networks, where everyone knows one another, making it difficult to evade local substance use recurrence triggers, and stigma, networks and settings that perpetuated opioid use. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of
Conclusion
We collected and analyzed what we believe is the largest and most geographically diverse sample of PWUD living in the rural U.S. to date. Our findings highlight barriers to OUD treatment at multiple levels in rural settings. Salient findings unique to rural U.S. communities included the need to travel long distances for treatment, challenges to confidentiality in treatment due to small, close-knit communities where people are highly familiar with one another, a lack of low-threshold harm
Funding
This work was supported by the National Institute on Drug Abuse (NIDA) [UG3DA044829/UH3DA044829, UG3DA044798/UH3DA044798, UG3DA044830/UH3DA044830, UG3DA044823/UH3DA044823, UG3DA044822/UH3DA044822, UG3DA044831/UH3DA044831, UG3DA044825, UG3DA044826/UH3DA044826] with co-funding from the Centers for Disease Control and Prevention (CDC), Substance Abuse and Mental Health Services Administration(SAMHSA), and the Appalachian Regional Commission (ARC). Research presented in this manuscript is the
Ethics approval and consent to participate
All research was conducted in accordance with both the Declarations of Helsinki and Istanbul, all research was approved by the appropriate ethics and/or institutional review committee(s), and written consent was given in writing by all subjects.
Credit authorship contribution statement
T.J. Stopka: Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. A.T. Estadt: Formal analysis, Methodology, Writing – original draft, Writing – review & editing. G. Leichtling: Formal analysis, Methodology, Writing – original draft, Writing – review & editing. J.C. Schleicher: Formal analysis, Visualization, Writing – original draft, Writing – review & editing. L.S. Mixson: Data curation, Formal analysis, Writing – original draft, Writing –
Acknowledgements
This publication is based upon data collected and/or methods developed as part of the Rural Opioid Initiative (ROI), a multi-site study with a common protocol that was developed collaboratively by investigators at eight research institutions and at the National Institute of Drug Abuse (NIDA), the Appalachian Regional Commission (ARC), the Centers for Disease Control and Prevention (CDC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). The views and opinions expressed
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