Vermonters didn’t hesitate when recently asked to share their opinions about the state’s hub-and-spoke (H & S) medication treatment for opioid use disorder (MOUD). Instead, they responded freely to open-ended questions and queries posed during in-depth interviews.
Their perceptions and opinions are the subject of a recent study in Preventive Medicine: “Patient perceptions of treatment with medication treatment for opioid use disorder (MOUD) in the Vermont hub-and-spoke system.” Until now, the literature offered little in the way of person-centered perspectives on MOUD, and MOUD care in a primary care setting.
Study Details
The H & S system assesses patients for appropriate level of care—whether hub or spoke would be best. Hubs generally treat more complex, chronic cases.
| Hubs | Opioid treatment programs (OTPs), offering methadone or buprenorphine/ naloxone treatment |
| Spokes | Primary care settings, offering office-based opioid treatment, primarily buprenorphine/ naloxone |
Evaluation
Of 100 participants who took part in a quantitative evaluation of the H & S system in 2013, 20 were currently out of treatment. The 80 who remained, in-treatment patients, were taking methadone or buprenorphine/naloxone. Qualitative data from these 80 patients are included in this study. (Qualitative data are descriptive; quantitative data deal with numbers and measurements and things that can be counted.)
Data collection was followed by:
Structured questionnaires ▬ Lead author Richard A. Rawson, PhD, and a coauthor administered the questionnaires. (These subjects showed reductions in substance use, OD, and other drug-related behaviors. The data were reported in a separate publication, Journal of Substance Abuse Treatment; see References.).
Open-ended questions ▬ 40 hub and 40 spoke participants responded to five open-ended questions.
In-depth interview ▬ investigators carried out 24 in-depth interviews with newly drawn participants—12 each from the hub pool and the spoke pool.
Responses to Open-Ended Questions
Here again, participants freely shared helpful information. Below are some of their comments.
Helpful/valued aspects of treatment
Hub patients—More than half said they valued their treatment, and were grateful to have been able to access it. They valued the counselors and medication as well. Patients considered the treatment environment “challenging,” however.
Spoke patients—Almost all cited benefits of the medication. Most also highly valued their doctor. . . someone who I know “is going to be there for me. . . People gotta have a good doctor.” Many especially appreciated being treated in an office, “Like an everyday, normal person.”
Unhelpful/unpleasant aspects of treatment
Hub patients—More than half cited what they viewed as “a disruptive environment,” with long lines, “drug talk”; one patient coped by “wearing earphones. . . in the clinic and while waiting in line” to drown out offers to buy drugs.
Spoke patients—Almost half didn’t like mandatory counseling, felt counseling wasn’t useful; other than that, few reported any negative aspects of treatment. Some mentioned they’d had trouble finding a spoke doctor who would accept them. “Lax rules” bothered a few, referring to patients who were “allowed to use” without being kicked out.
High turnover of staff was an issue. A patient commented about having had six different counselors in eight months of treatment. Another noted, “I’ve given up talking to my counselor about anything important because he probably won’t be my counselor tomorrow.”
Other comments, in brief:
Services that helped the most
Hub patients—counseling
Spoke patients—doctor visits and medication
Additional services desired
Hub patients—mental health treatment, employment help, discharge planning, medical services, more counselor availability
Spoke patients—mental health treatment, help with employment or transportation
Obstacles to treatment
Hubs: major: transportation problems; less common: long lines, child care issues, stigma, cocaine availability, alcohol use
Spokes: transportation, co-pays
In-Depth Interviews
Hubs:
Participants at hubs complained about long lines and other participants talking, arguing, or swearing: “If they don’t need the help or don’t want the help that the hub or the spoke is offering, they need to get the hell out of there because there’s a lot of people out here dyin’ that need it.”
“ . . . It’s like, ‘Can’t you just take your dose and go?’”
Numerous comments mentioned stigma; one person said, if you’re in hub treatment, you’re “immediately associated with opioid addiction, drug addicts, or ‘junkies.’”
Staff, however, drew praise for providing support and help, and for treating participants “like an everyday, normal person.”
Spokes:
Spoke participants, as well, rated staff highly. Some mentioned little things, like a receptionist’s “friendly hello.” Others had more substantial comments. A patient who’d “slipped up” a couple of times said that instead of kicking him off the program, his doctor was arranging to see him more often for a couple of weeks—indicating “I just really wanna support you and work through this with you.”
Summary
A key finding from this study stems from the working structure of the two treatment types—hubs and spokes—from the time they were initially established. Thus, we have spoke patients, who perceive their treatment for opioid use disorder as “for a health condition requiring ongoing care.” The fact that they can receive their care from their primary care doctor seemed to “reduce their feelings of stigma, and to ‘normalize’ their view of addiction treatment.” In contrast, patients in hubs must go to “a special clinic” where, the authors pointed out, “everyone knows you are an addict.”
Here is a key statement from the article:
The view of the patients in spokes highlights the potential importance of characterizing OUD as a chronic health condition, similar to diabetes or cardiovascular disease . . .
Incorporation of OUD treatment into primary care may provide an important avenue for increasing the perception of OUD as a chronic condition treatable within a mainstream healthcare setting.
The study’s authors suggest moving OUD treatment to primary care. Of course, patients prefer to get the medication with as little hassle as possible, as this research report shows. Buprenorphine can already be given in primary care. Methadone can’t, and there is no evidence backing it.
References
Rawson RA, Rieckmann T, Cousins S, McCanna M, Pearce R. Patient perceptions of treatment with medication treatment for opioid use disorder (MOUD) in the Vermont hub-and-spoke system [Epub ahead of print July 27, 2019]. Prev Med. 2019. doi:/10.1016/j.ypmed.2019.105785.
Rawson RA, Cousins SJ, McCann M, Pearce R, Van Donsel A. Assessment of medication for opioid use disorder as delivered within the Vermont hub and spoke system [Epub ahead of print November 10, 2018]. J Subst Abus Treat. 2019;97:84–90. doi:/10.1016/j.jsat.2018.11.003