Patients Identify Barriers in Transition to Outpatient Substance Use Treatment and Highlight Need for Continuity of Care

BOSTON – According to new research from Boston Medical Center, patients transitioning from short-term inpatient medically managed withdrawal programs, commonly referred to as drug detoxification (detox) centers, to outpatient treatment identified lack of continuity of care, especially care coordination, as a major barrier to substance use treatment. The findings, in Journal of Substance Abuse Treatment, show that a multimodal approach to continuity of care, low-barrier access to medications for opioid use disorder (MOUD), and support to address unstable housing are necessary to address these issues. Patients also expressed the need for care that incorporates options and respect for individualized preferences and needs.

Approximately 20 million adults in the United States have a substance use disorder (SUD) with 1.6 million having an opioid use disorder (OUD). Access to and uptake of evidence-based treatment for SUD, specifically OUD, are limited despite the high death toll from drug overdose in the United States in recent years. For individuals with OUD, detox alone, without medications for OUD such as methadone or buprenorphine, carries an increased risk for fatal drug overdose, while initiation of MOUD has been shown to decrease rates of overdose.

Little information exists on barriers faced in the transition from detox discharge to outpatient treatment for opioid use. A recent study included interviews of clinicians at a detox center, but it did not specifically gather information from detox patients themselves.

The purpose of this study was to collect patient perspectives on challenges to transition to treatment, including MOUD after detox and potential solutions. This study interviewed 24 patients with self-reported substance use to determine barriers to accessing further substance use treatment, including MOUD, after admission to detox, and to elicit patients’ input on solutions to address these gaps in care.

“Engaging those who are most affected in the design and implementation of treatment can help ensure that policies and services reflect the priorities, needs, and values of the population, and that the specific challenges they face are taken into account,” said Sabrina Assoumou, MD MPH, infectious diseases physician at Boston Medical Center and senior author of this study.

According to the patients, these were the top five barriers to definitive care after detox: 

1. The care individuals receive after detox lacks continuity with outpatient management.
2. Inpatient detox lacks the necessary support staff to help with transitions in care.
3. Time at inpatient detox is not long enough for individuals to remain in recovery after discharge.
4. There is a lack of physical beds at long-term residential treatment programs after completion of acute inpatient detox, a particular problem for patients without stable housing.
5. The lack of stable housing is an important barrier to recovery from substance use.

According to the patients, these are potential solutions to the barriers and challenges they highlighted:

1. The importance of having options to select the best treatment plan for each patient’s unique experience.
2. The need for assistance with establishing continuity of care after completion of inpatient detox.
3. Additional case managers and more time available with them could help with continuity of care.
4. Some participants thought that low-barrier access to substance use treatment, including MOUD, with same-day and walk-in clinic visits can serve as a potential solution to improve access to treatment.
5. Assistance with securing stable housing would allow individuals to focus on recovery from substance use.

To assist individuals in their recovery process, next steps should focus on providing individuals with information on the benefits of initiating treatment for opioid use disorder while at detox and the ability to initiate treatment at that time if they chose, creating more substantial pathways of access to evidence-based medications for substance use, adding a navigation component to assist with bridging from detox to sustainable treatment, likely involving case managers at inpatient detox facilities, and scheduling short interval follow-up prior to discharge.