The aim of this study was to examine the organizational factors that facilitate or impede the adoption of medications by publicly funded addiction treatment organizations, which are the predominant site of substance abuse treatment in the US.16
In our prior work on medication adoption within treatment settings, we largely focused on the adoption of specific medications.22, 29, 31, 33, 49
The current study extended that work by considering a typology of medication adoption in which organizations were categorized into those that had adopted at least one FDA-approved addiction treatment medication, those that had only adopted psychiatric medications (e.g. SSRIs, other antidepressants, and anti-psychotic medications), and those that had adopted neither addiction treatment nor psychiatric medications.
Findings from this study of publicly funded treatment organizations replicated some of our previous results while expanding the range of organizational characteristics included in our analysis. The multivariate model pointed to the importance of organizational resources, such as medical personnel and organizational size, in understanding the adoption of addiction treatment medications. These findings were consistent with our prior work on the adoption of buprenorphine31
and SSRIs.22, 49
As with our previous research on medication adoption,20, 22
government-owned centers were more likely than non-governmental organizations to adopt addiction treatment medications. We had not previously considered different types of public funding, so our finding that non-Medicaid public funding (e.g. federal block grant, state contracts, and criminal justice contracts) was a barrier to the adoption of addiction treatment medications was novel. Another innovative aspect of the current study was the consideration of different types of informational sources, which we had examined in a broader study of treatment innovations50
but had not included in our previous research on medication adoption. We found that contact with pharmaceutical representatives was positively associated with the adoption of addiction pharmacotherapies, even after controlling for a variety of other organizational characteristics.
Notably, these findings from the statistical model were consistent with self-reported data from administrators of organizations that had not adopted medications. In ranking the importance of different reasons for non-adoption, the most strongly endorsed reasons were related to the lack of medical staff and state regulations (which would prohibit the use of medications in centers that do not have access to medical personnel). Consistent with the finding that treatment philosophy was not associated with medication adoption, the ranking of organizational culture as a barrier (e.g. treatment philosophy and staff resistance) was considerably lower.
Our findings suggest that there are substantial barriers to further adoption of addiction treatment medications by substance abuse treatment organizations, particularly in terms of limited access to physicians and other medical personnel who can support the implementation of medication-assisted treatments. We found that the presence of staff physicians and nurses was quite low, which is consistent with other studies of addiction treatment organizations.51–53
Without increases in the employment of physicians, nurses, and other medical personnel, there are likely to be ceiling effects on the percentage of organizations that can offer medication-assisted treatments. The absence of medical personnel in these organizations also has broader implications in terms of the likelihood that programs can offer on-site primary medical care, which generally improves client outcomes.54, 55
Given the importance of medical staff for the adoption of medications, there is a need for research on why some treatment programs employ medical staff while others do not. To some extent, it may be a function of financial resources and treatment culture within organizations. The financial resource issue may reflect a lack of reimbursement for physician services by certain funding mechanisms as well as an overarching lack of available dollars to pay physician salaries.56
In addition, the absence of medical employees within these programs may also reflect shortages in physicians and nurses in the local labor market. Given projections that these shortages are likely to worsen,57, 58
addressing this barrier may be particularly challenging. Some organizations may opt to contract with physicians rather than employ them directly. It remains an empirical question as to whether contractual arrangements attain the same degree of adoption and implementation of medications when compared to direct employment of medical personnel.
It also remains unclear how federal and state-level policies may influence the adoption of evidence-based practices, such as addiction treatment medications. Some have argued that federal regulations regarding methadone have limited its spread.14
Buprenorphine, a more recently approved medication to treat opioid dependence, has less burdensome federal regulatory requirements than methadone, but still has regulations that differentiate it from medications such as naltrexone or SSRIs.10, 32
However, even if regulations are perceived by providers as a barrier to the adoption of buprenorphine, it is less clear why the adoption of medications without these requirements, such as naltrexone and acamprosate, remains low.
The statistical results point to current public funding policies as a barrier to medication adoption, while regulatory barriers were a strongly endorsed reason for non-adoption. Others have argued that state funding, regulations, and policies may influence the services offered by treatment organizations.5
A recent study found that an array of state-level regulatory and funding policies explained about 16% of facility-level variation in the adoption of naltrexone.12
Research also suggests that state policy requirements can increase the likelihood of facility-level adoption of services,17
although such policies do not achieve universal adoption. It appears that state policies of funding and regulations may need to be aligned if greater adoption of medications is to be accomplished.
These data also point to the potential role that pharmaceutical companies might play in supporting the process of medication adoption. Consistent with other reports of the low levels of marketing of addiction treatment medications,41
the average treatment center had little contact with pharmaceutical company representatives. However, this type of contact was positively associated with the adoption of medications, even after controlling for other structural, cultural, and resource characteristics. This finding was not altogether unexpected given research documenting that such detailing can result in better return on investment than direct to consumer marketing.59
The design of this study has several limitations. First, this study relies on cross-sectional data, which restricts our ability to identify causal relationships. Future research should continue to examine medication adoption through a longitudinal research design, particularly one in which data on all variables are collected at multiple time-points. Second, these data are only representative of one sector of the substance abuse treatment system. It is not known if these findings would generalize to other systems, such as the privately financed treatment sector, the Veterans Health Administration system, or programs based within correctional settings. However, these findings yield important information about the publicly funded sector of care, which serves the largest segment of treatment-seeking individuals in the US.16
Another limitation is the reliance on self-report data for all measures. While self-reports are consistent with both federal surveys (e.g. N-SSATS) and other studies of service delivery,17, 32, 60, 61
there is no way to fully eliminate the possibility that administrators may err in their descriptions of their organizations. An additional limitation is that our measures of medical personnel were restricted to those who were employed by the organization and on its payroll. We did not have a measure of the numbers of psychiatrists, other physicians, and nurses who had contracts with the organization to provide services.
Finally, it must be noted that this analysis cannot address the issue of implementation of medications, since the dependent variable is only focused on adoption. Implementation research on how routinely medications are used by treatment organizations suggests that the percentage of clients receiving these medications is very low.29, 30, 41
Understanding the factors associated with implementation within adopting centers is an important area for future research.