Sample Characteristics
A total of 271 counselors completed the survey from 29 (59.1% response rate) distinct agencies who serve Medicaid recipients in Philadelphia. Five counselors could not be linked to an agency. Respondents were mostly female, White, and had completed a bachelor’s degree (Table 1). The typical respondent had over a decade of professional experience and close to five years of experience at their current agency. Most respondents worked for agencies that dispensed or prescribed buprenorphine and naltrexone whereas only about half worked for agencies prescribe or dispensed methadone.
Table 1
Characteristics of participating counselors
Characteristic | M (SD) |
Age | 43.5 (13.5) |
Number of years of working experience | 10.7 (9.7) |
Number of years in current position | 4.6 (5.7) |
Gender: | % (N) |
Female | 192 (70.8%) |
Male | 73 (26.9%) |
Not Reported | 6 (2.2%) |
Non-binary | 0 (0%) |
Education: | |
Bachelor’s degree or above | 238 (87.8%) |
Master’s degree or above | 165 (60.8%) |
Race: | |
Asian/Pacific Islander | 7 (2.6%) |
Black | 100 (36.9%) |
Native American | 1 (0.4%) |
White | 139 (51.2%) |
Other | 18 (6.6%) |
Not Reported | 6 (2.2%) |
Ethnicity | |
Hispanic | 19 (7.0%) |
Not Hispanic | 249 (91.9%) |
Not Reported | 3 (1.1%) |
Agency dispenses or prescribes medication onsite | |
Buprenorphine | 197 (72.7%) |
Methadone | 128 (47.2%) |
Naltrexone Unknown | 222 (82.0%) 5 (1.8%) |
Advantages.
There was a total of 1,055 reported advantages across the three types of MOUD from 250 respondents. Twenty-one counselors submitted blank responses and could not be coded for an advantage. There were 375 reported advantages from 245 respondents about buprenorphine, 335 advantages from 238 respondents about methadone, and 345 advantages from 234 respondents about naltrexone. Each advantage was coded into one of 28 themes (see Supplemental File 1).
Table 2 shows most the five most commonly reported advantages across the three types of MOUD: (1) reduces urges to use (42%), (2) reduces use of illegal opioids (37%), (3) flexibility (25%), (4) supports recovery lifestyle (20%), (5) reduces withdrawal symptoms (17%). Overall, the ability to reduce opioid cravings and use were the most frequently mentioned clinical benefits for all three types of MOUD. Other clinical effects mentioned include buprenorphine and methadone’s ability to reduce overdose risk and withdrawal symptoms, and naltrexone’s ability to block opioid receptors and prevent the sedative and euphoric effects associated of opioid use.
Table 2
Most prevalent advantages and illustrative excerpts
Advantages | Buprenorphine (245 responses) | n (%) | Methadone (238 responses) | n (%) | Naltrexone (234 responses) | n (%) | Total (250 responses) |
“No advantages” | - | 1 (0%) | - | 7 (3%) | - | 0 (0%) | 7 (3%) |
Reduces urges to use | “Curbs cravings while preserving general functioning.” | 76 (31%) | “Helps reduce cravings” | 60 (25%) | “Helping with triggers and cravings.” | 57 (24%) | 104 (42%) |
Reduce use of illicit opioids/substances | “The advantages are the patient will decrease their craving for their particular substance, and then possibly stop using their substance of choice.” | 53 (22%) | “[Helps] stay away from illegal usage” | 52 (22%) | “Can help to reduce likelihood of use after treatment… No withdrawal to come off medication.” | 38 (16%) | 92 (37%) |
Flexible/convenient | “Not having to go to a clinic every day to get dosed and also being able to travel out of town for a period of time because you have your doses with you.” | 11 (4%) | - | 0 (0%) | “It is a once-a-month injection allowing members to have more freedom.” | 57 (24%) | 62 (25%) |
Supports recovery lifestyle | “The chance to chemically trick your body enabling you the time to change habits, though processes and obtain clean time from the substance you are desperately trying to avoid.” | 26 (11%) | “This form of [medication assisted treatment] could support their efforts to manage their recovery management and stay away from negative people, places, and illicit activities.” | 37 (16%) | “Of course this can offer many patients an ability to function and live a productive life.” | 14 (6%) | 51 (20%) |
Reduces withdrawal symptoms | “It reduces severe opiate withdrawal symptoms, such as perspiration, nausea, anxiety, difficulty sleeping, chills, sensitivity to the light, and stomach pain.” | 28 (11%) | “Clients can manage their cravings and withdrawal symptoms with methadone use, been used for a long time as a substitute treatment.” | 28 (12%) | "Activat[es] to relieve craving and withdrawal it acts as a blocker, preventing other opioids from having any effect.” | 9 (4%) | 42 (17%) |
Approximately a third of respondents mention the ability for buprenorphine and methadone to reduce the use of illicit substances, jumpstart treatment readiness, and support of a recovery lifestyle. A smaller share of counselors (20%) associated these qualities with naltrexone. Instead, counselors described the advantages of naltrexone’s monthly dosing cycle: flexibility, convenience, and less interference with daily life.
Disadvantages
There was a total of 940 reported disadvantages across the three types of MOUD from 245 respondents. Twenty-six counselors submitted blank responses and could not be coded for an advantage. There were 329 reported disadvantages from 239 respondents about buprenorphine, 353 disadvantages from 237 respondents about methadone, and 258 disadvantages from 218 respondents about naltrexone. Each disadvantage was coded into one of 26 themes (see Supplemental File 1).
Table 3 shows most the five most commonly reported disadvantages across the three types of MOUD: (1) it creates a long-term dependency (30%), (2) has harmful side effects (28%), (3) it is inconvenient (27%), (4) misuse potential (17%), (5) and difficult medication adherence (15%). Responses related to side effects frequently appeared for all three medications, including reports of cognitive and physical mal effects after taking buprenorphine or methadone and nausea or allergic reactions after a naltrexone administration. Notably, many counselors reported the tendency for buprenorphine and methadone to cause withdrawal symptoms which make it difficult for some clients to taper off.
Table 3
Most prevalent disadvantages and illustrative excerpts
Disadvantages | Buprenorphine (226 responses) | n (%) | Methadone (223 responses) | n (%) | Naltrexone (202 responses) | n (%) | Total (245 responses) |
“No disadvantages” | - | 10 (4%) | - | 4 (2%) | - | 19 (9%) | 24 (10%) |
Creates a long-term dependency | “If you stay on it for years, it never gets them off the dependence.” | 45 (19%) | “Methadone is often referred to as ‘liquid handcuffs’ because clients must travel to and from the clinic daily to receive it and ‘take home doses’ are difficult to earn…” | 47 (20%) | “A person can become dependent upon it.” | 12 (6%) | 74 (30%) |
Side effects | “Sedation, nausea, vomiting, itching.” | 35 (15%) | “Long-term side-effects; damages teeth” | 42 (18%) | “Nausea, headache, dizziness”; “stomach pain”, “fever”, “allergic reactions”. | 38 (17%) | 70 (28%) |
Inconvenient | “Having to see the doctor so much because it is so regulated” | 13 (5%) | “It’s a daily commitment to go to the clinic.” | 68 (29%) | “You CAN'T [sic] miss that appointment.” | 4 (2%) | 68 (27%) |
Specific misuse | “[Buprenorphine] is a divertible medication and is frequently diverted as we are learning from our clients. This means they may not use it properly and instead use it to support their ongoing addiction to fentanyl.” | 20 (9%) | “Patient would use other substances to intensify the effects of the medication to continue use drugs or sell their medication.” | 24 (11%) | “You can overdose if you try to get high when using it” | 9 (4%) | 42 (17%) |
Medication adherence or maintenance difficult | “The most important part is keeping up with the prescription and keeping the re-fills.” | 24 (11%) | “Must be dosed every day and if a dose is missed, then the patient can withdrawal and have a lot of issues. Many patients cannot keep up with it because it does have to be dosed daily.” | 14 (6%) | “Once [on a] starting regimen many patients don't keep up with their monthly appointments.” | 16 (8%) | 39 (16%) |
The main disadvantages that counselors communicated about buprenorphine and methadone related their “addictive” properties. The words “reliance”, “dependence”, “habit”, or “crutch” frequently appeared in counselor responses when describing buprenorphine and methadone. Many counselors expressed concerns about buprenorphine or methadone developing physical dependencies and the difficulty involved with weaning off the medications. In addition, counselors often described the inconvenience, stigma, and psychological attachment involved with daily dosing at a methadone clinic. Responses which mention the methadone clinic often included phrases like, “time consuming”, “schedule”, and “commitment”.
Counselors mentioned misuse potential (incl. “abuse potential”, “selling”, “mixing with other substances”, “use to get high”) in 24% of buprenorphine responses, 18% of methadone responses, and 7% of naltrexone responses. Counselors characterized MOUD misuse as selling or diverting buprenorphine and mixing methadone with other substances to achieve euphoric effects. The disadvantages counselors offered for naltrexone were primarily related to its unique properties, including the requirement of abstinence before being induced and the possibility the blocker will fail or wear off before the next dose could be administered.
Stigma directed at the concept of using MOUD as an intervention for OUD were uncommon among respondents, but not absent. Phrases like “it’s substituting one drug for another” or “it’s still a drug” appeared in 18 (8%) responses for buprenorphine, 12 (5%) responses for methadone, and two (1%) responses for naltrexone.