How do patients and prescribers define “success”?
The Recovery Research Institute recently posted a review of a study examining patient and physician definitions of success for opioid treatment beyond treatment retention.
The Study
The researchers conducted semi-structured qualitative interviews with prescribers and patients from 2 family medicine clinics. Interviews were conducted by phone and lasted 20-30 minutes.
Physicians
14 physicians
- All waivered to prescribe buprenorphine.
- Half were faculty and half were residents.
- The faculty had been waivered for an average of 5.7 years and the residents for an average of 1 year.
- All white, 8 female & 6 male.
- They were asked 2 questions in a semi-structured interview about treatment success:
- What do you consider success in your patients receiving MAT?
- In addition to retention in treatment, what else reflects patients doing well?
Patients
18 patients
- Average age was 38 years old.
- 14 white, 2 black, 1 American Indian, 3 Hispanic.
- 8 female, 10 male.
- All were long-term MAT patients, averaging 2.5 years at this clinic (range 1.5–4 years).
- They were asked 2 questions in a semi-structured interview about treatment success:
- What progress have you made in your recovery by being part of our medication-assisted treatment program?
- What does success mean to you with respect to your recovery?
Findings
7 themes
Seven themes emerged from the interviews:
- Staying sober
- Tapering off Buprenorphine
- Taking Steps to Improve Physical and Mental Health
- Improved Psychological Well-being
- Improved Relationships
- Improved Role Functioning (Setting and Meeting Goals)
- Shift in Identity (Decreased Stigma and Shame)
Patient / Prescriber Misalignment?
Of the 7 themes identified, the physician and patient groups shared 5 of the 7 themes, but there were 2 that were only identified by the patient group. Those were themes 2 (tapering off buprenorphine) and 7 (shift in identity).
Regarding tapering off buprenorphine, the paper noted that “Only one physician noted that he hears this goal from many patients”. They did not quantify the number of patients identifying this theme but characterized it as “several”. Interestingly, their desire to taper off buprenorphine was not characterized in a way that communicated ambivalence about using the medication to stabilize and initiate their recovery. Comments included mention that it should happen “eventually” and after stabilization.
I find a couple of things striking here.
First, only one of these physicians (who have been waivered for an average of 5.7 years) reported hearing this goal from many patients. It’s easy to imagine physicians not seeing tapering as an indicator of success, but it’s striking that they report not hearing it from many patients, when the researchers found this sentiment to be prevalent among them. Over that average of 5.7 years, how many patients have these physicians treated? Are patients not communicating this to physicians? If not, why? Are physicians not hearing this from patients? If not, why?
Second, these were patients who’d been in the MAT program for an average of 2.5 years and their comments imply positive feelings about their treatment. I imagine a lot of people would frame this theme as a manifestation of stigma. That is possible, but it isn’t intimated in their responses. In fact, one of the comments in theme 7 (Shift in Identity) describes their treatment helping them feel more like a normal person and changing how they feel about their medication.
It’s interesting that I’m familiar with models of care that don’t involve agonist medications like buprenorphine, and there are millions of American receiving treatment with buprenorphine. What I haven’t seen are pathways for tapering stabilized patients off buprenorphine. One wonders if buprenorphine retention would improve if these patients’ preferences were integrated into treatment models. You could frame retention rates as patients voting with their feet about this preference and it’s important to note that these patient comments indicate that they are in no rush to taper, but would like to eventually. Of course, we also need to keep in mind that these are patients who have been retained for 1.5 to 4 years.
As the X waiver is eliminated, addressing this misalignment seems particularly important.
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