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Table 6 Exemplar Quotations from Physician Focus Group. Detailed Table Summary: The table presents example quotes for six themes found from quantitative data analysis: 1) efficacy of medications for opioid use disorder, 2) financial barriers to medications for opioid use disorder, 3) treatment capacity, 4) processes and procedures for treatment, 5) provider competencies, and 6) stigma.

From: A mixed-method comparison of physician-reported beliefs about and barriers to treatment with medications for opioid use disorder

Theme 1: Efficacy of Medications for Opioid Use Disorder
a. “[T] he evidence base behind [extended-release naltrexone] right now is actually really limited. And it’s one of the things that makes me the most nervous when we talk about [MOUD], lumping them all together.”
b. “I actually just put my last patient … with someone who has been through — he relapsed and was recommended to him by friends and family that he should not be on Suboxone just because he relapsed, and he’s been to detox four times in the last year. He’s been through multiple 28-day stays, all … abstinence-based. And, finally, came to the realization on his own that he did the best when he was on Suboxone. He had over a year of sobriety when he was on Suboxone, so he came back.”
c. We haven’t seen — at the one-year mark, we actually haven’t seen many positive outcomes [for patients receiving extended-release naltrexone]. We haven’t seen great retention in treatment, we haven’t seen a reduction in overdose, particularly at a year, we haven’t seen reduction in opioid use. Those first couple months, often, we will see it, but again, even in those first couple of months, the retention rates are really low compared to methadone and buprenorphine maintenance. And so, I’m not saying that I don’t think it should an option, but the same that I wouldn’t recommend a hypertension medication that has much worse outcomes as a first-line treatment, like I would only recommend [extended-release naltrexone] for people who are really aware that the outcomes are not nearly as good with Vivitrol as they are for buprenorphine or methadone maintenance”.
Theme 2: Financial Barriers to Medications for Opioid Use Disorder (provider- and client-side)
a. “And speaking to your question about coverage, even when folks had Medicaid or have Medicaid here, unless folks had a dual diagnosis, those programs feel very strongly that you cannot break even on the current reimbursement schedule. So, unless there’s another diagnosis — another major psychiatric diagnosis — in addition to the substance use disorder, or you have to be subsidizing the program from other parts of the services you provide, you can’t break even; even when folks are insured — is the perception here.”
b. “For at least the State of Maine is, 40% of our folks who suffer right now from addiction, are uninsured. And so, that brings another layer of complexity of, you know, how are these people going to get care without necessarily dragging the program underground because of the lack of reimbursement with those patients. You know, where do we find that funding?”
c. “I think the second thing is reimbursement. So, you know, when I first moved back to Illinois, buprenorphine, specifically, was not on Medicaid’s formulary. Which meant that, like, literally, every single month, my nurse — I had to have a full-time nurse assigned to just me to be able to start this program, just so she could spend all of her time filling out prior authorizations.”
Theme 3: Treatment Capacity
a. “I think a lot of people go to detox and then … it might be recommended that they move on to the next level of care, but there’s not capacity. So, then they’re sent home and (clinic staff) say, ‘Okay, we’ll put you on a wait list, and somebody will call you in the next month. And then you’ll hopefully get into treatment at that point.’ By the time that month comes around, most people have already relapsed.”
Theme 4: Processes and Procedures for Treatment
a. “Detox actually puts people at more harm for overdose than it does actually help them. Particularly if they’re not linked to the next level of care. And there are way more detox beds and way more detox capacity than there is access to actual continuation — continuing treatment. So, this is a system that’s sort of designed to fail, in my mind.”
b. “We should be putting a lot more resources into recovery-oriented systems that are going to be — continuing with the long-term, and less resources into detox for opioids specifically. For alcohol, it’s obviously very necessary.”
c. “I think that the real problem comes down to sort of the way that primary care is reimbursed right now. And that, you know, the way that things have been structured, we get these very very short visits. And particularly, again, in under-served settings like, you know — you’re seeing uninsured patients as well, where you get no payment as well. So, you have to be able to balance all of that.”
Theme 5: Provider Competencies
a. “And then, I think the knowledge — feeling uncomfortable with just an eight-hour course to take to obtain the waiver. A lot of people felt that would be insufficient to actually have a good comfort. And that’s despite us expressing that there will be (inaudible 0:28:59) support with addiction. Psychiatrists. There’s still a lot of trepidation. And just trying to fit that in with their regular panel patients.”
b. “People just don’t feel that well-versed in either how to talk to people about it, or if someone is screening positive, what am I supposed to do next? And, you know, if they don’t have behavioral health support within their clinic setting, then it’s really hard because they often don’t have the skills or the knowledge to be able to provide all of that behavioral support.”
Theme 6: Stigma
a. “Definitely stigma — it’s shocking to hear some providers say, “Well, I don’t want that patient withdrawing in the waiting room beside my two-year-old, you know, toddler that I’m going to see, you know, in the afternoon,” or whatever. There were just different excuses for — but a big part of it was there was this undercurrent of stigma.”
b. “And I think there’s a lot of stigma against methadone sort of everywhere. There’s some stigma against Suboxone or buprenorphine in Baltimore, but people, when I came back to Chicago, just never even really heard of it as a treatment option unless they were people who had lived in other states.”
c. “I think physicians have big practices, and they don’t want 200 opioid addicts to be in their waiting room a lot, I think.”