Let’s say you’re a counselor in an opioid treatment program (OTP), and your methadone maintenance treatment (MMT) program suddenly launches an open-access initiative. Within days eligible patients are enrolled—whether they can pay or not—and allowed access, whenever they want, to their choice of counseling and medical and vocational services.
Good idea? Bad idea? What will it mean to your OTP, and to you, as a counselor?
An interdisciplinary team affiliated with Yale School of Medicine and other institutions decided to find out. Anticipating possible reluctance from MMT managers to scale up treatment capacity for open access unless they could see solid evidence of benefits, the team designed a study to yield data from evidence-based models.
Participants in the study (OTP counselors) expressed their views of the advantages and disadvantages of open access, along with their perceptions and experiences. The results were coded using grounded theory (see below), then analyzed. The study was published online November 2020 in the Journal of Substance Abuse Treatment.
Below is a summary of the study.
Participants: 31 addiction counselors from MMT programs operated by The APT Foundation.
Organizers: The APT Foundation is a not-for-profit organization affiliated with Yale School of Medicine. APT began developing an open-access model in 2006 with 1,431 patients; by 2020, the foundation was operating four outpatient MMT programs enrolling 4,500 patients.
Tools and Methods: An investigator conducted, audiotaped, and transcribed semi-structured interviews of the counselors who took part in the study. (The investigator had no relationship with any of the counselors.) Each interview lasted about 45 minutes. The interviews took place between August 2015 and July 2016. Results were coded using grounded theory.
What Is Grounded Theory?
In grounded theory, data from a sample of people are analyzed to yield a theory—an explanation of the data. Researchers use the theory in studies involving the original population sample. Because the theory is developed after data collection, thus embedded in the data, the theory is said to be “grounded’ in data; thus, a “grounded theory.”
This contrasts with studies in which researchers assume a theory at the start of a study.
Conclusions: Within the open-access framework, MMT counselors reported multiple benefits to counselors, patients, and the public. They suggested research that would address the few disadvantages they found, facilitating ramping up MMT programs.
Implementing Open Access
(To avoid confusion we’ll call study participants counselors and clients patients instead of using the study terms.)
Counselors faced two major changes in their practice when implementing open access:
- “Drop-in open group sessions,” without appointments, replaced primarily individual counseling
- Teams of counselors replaced individual counselors who were assigned to specific patients and carried individual caseloads
The investigators had already published papers on various aspects of open access, and in this study they zeroed in on counselors’ perceptions of open access at APT—the treatment facility that developed and first used the open-access model.
The APT model identified unnecessary intake procedures, such as proof of previous treatment failure, that interfered with rapid entry. Deleting unnecessary procedures and prioritizing steps allowed staff to perform all intake procedures on the same day. As federal guidelines required, a licensed medical provider confirmed each patient’s eligibility for admission.
Key Aspects of Open Access
- Same-day access to treatment, regardless of ability to pay
- Team-based approach to care
- No individual caseloads
- Patient-centered focus
Advantages of the Open-Access Model
Considered “a positive experience overall,” open access required counselors to support each other. Because counselors no longer carried individual caseloads, their responsibilities were limited when they were on vacation or otherwise out of the office. The authors noted that this allowed counselors “to more effectively detach psychologically from work tasks.”
Specific comments from three counselors:
It’s great. I like it. It helps the counselors.
. . . our main goal is just to meet clients’ needs, where they’re at, and go from there . . .
Counselors said that the open-access model increased and supported patient choice in treatment, as well as patients’ autonomy and well-being.
A counselor’s comment:
If you’re here for outpatient . . . you can stay for 6 groups a day, or you can come [for] one. It’s treatment à la carte . . .
To the Community
Reducing barriers to care, serving clients with acute psychiatric conditions, a clinical setting open to all—this is how counselors viewed the community advantages of open access. They credited increased access to treatment with reducing deaths, overdoses, and crime.
We receive a lot of patients into our program… in so doing we have [brought] down the crime rates. We help people to stabilize their lives and hopefully get a job.
Our doors are open. [People are] not turned away . . .
Disadvantages of the Open-Access Model
Counselors responded to open-ended questions by discussing disadvantages to counselors and to patients, along with program-level concerns. Out of 31 counselors, 11—35%—made comments indicating there really were no disadvantages.
Some counselors mentioned possible uneven workflow and high demands resulting from perceived unpredictability of the work. Others seemed to suggest the program was almost too successful:
. . . a lot of people hanging out . . . ; We have heavy volume … it can be unpredictable… even the building [is not able] to support the amount of people coming through here.
Mentioned were a possible negative impact on the therapeutic relationship, and problems arising from lack of appointments.
It can feel chaotic . . . if someone can see a different counselor every time, they’re able to fly below the radar. That’s a concern here.
A counselor suggested that some patients might need a more structured and more intensive treatment delivery:
The only disadvantages I think . . . once they are in treatment there should be . . . a little bit more rigidity or more routine.
The counselors saw open access as a way to improve access to MMT— “regardless of resources and background.”
The authors suggest that OTP managers thinking about scaling up their methadone program will find the addiction counselors’ opinions and perceptions valuable. Especially so, they point out, because the counselors hadn’t been trained in the open-access model—meaning that their responses flowed from “their personal work experience.”
Oberleitner LMS, Madden LM, Muthulingam D, et al. A qualitative investigation of addiction counselors’ perceptions and experiences implementing an open-access model for treating opioid use disorder. J Subst Abuse Treat. 2021;121:108191. doi:10.1016/j.jsat.2020.108191