Literature Collection

INTRODUCTION: Opioid overdose deaths are increasing rapidly in the United States. Medications for opioid use disorder (MOUD) are effective and can be delivered in primary care, but uptake has been limited in rural communities. Referral to and coordination with an external telemedicine (TM) vendor by rural primary care clinics for MOUD (TM-MOUD) may increase MOUD access for rural patients, but we know little about perspectives on this model among key stakeholders. As part of a TM-MOUD feasibility study, we explored TM-MOUD acceptability and feasibility among personnel and patients from seven rural primary care clinics and a TM-MOUD vendor. METHODS: We conducted virtual interviews or focus groups with clinic administrators (n = 7 interviews), clinic primary care and behavioral health providers (8 groups, n = 30), other clinic staff (9 groups, n = 37), patients receiving MOUD (n = 16 interviews), TM-MOUD vendor staff (n = 4 interviews), and vendor-affiliated behavioral health and prescribing providers (n = 17 interviews). We asked about experiences with and acceptability of MOUD (primarily buprenorphine) and telemedicine (TM) and a TM-MOUD referral and coordination model. We conducted content analysis to identify themes and participants quantitatively rated acceptability of TM-MOUD elements on a 4-item scale. RESULTS: Perceived benefits of vendor-based TM-MOUD included reduced logistical barriers, more privacy and less stigma, and access to services not available locally (e.g., counseling, pain management). Barriers included lack of internet or poor connectivity in patients' homes, limited communication and trust between TM-MOUD and clinic providers, and questions about the value to the clinic of TM-MOUD referral to external vendor. Acceptability ratings for TM-MOUD were generally high; they were lowest among frontline staff. CONCLUSIONS: Rural primary care clinic personnel, TM-MOUD vendor personnel, and patients generally perceived referral from primary care to a TM-MOUD vendor to hold potential for increasing access to MOUD in rural communities. Increasing TM-MOUD uptake requires buy-in and understanding among staff of the TM-MOUD workflow, TM services offered, requirements for patients, advantages over clinic-based or TM services from clinic providers, and identification of appropriate patients. Poverty, along with patient hesitation to initiate treatment, creates substantial barriers to MOUD treatment generally; insufficient internet availability creates a substantial barrier to TM-MOUD.

The nature and origins of addictions and of their adjunctive behaviors, as well as their chronicity, call for treatments that conceptualize and treat them as the long-term and complex processes that they are. Addictions are often comorbid with personality problems and with trauma histories. Patients suffering from these disorders often show poor engagement with treatment and high rates of relapse, possibly because available treatments have yet to address the patient suffering from addiction in a more integrated or holistic manner. In particular, comprehensive treatment models for addictive disorders - like treatments for personality disorders or trauma - are likely to require the integration of behavioral, cognitive, and emotion-focused interventions within a facilitative therapeutic relationship. However, most current treatment models, including ones which are highly effective in stabilization or behavioral change, lack one or more components of treatment that could sustain longer term recovery, wellness, and health for a higher percentage of patients. In this article, I propose approaching addictions and their treatment from the perspective of schema therapy, an integrative, developmental model with a strong track record of positive outcomes in addressing personality disorder symptoms and long-standing trauma histories, commonly comorbid with addictive disorders. In advancing this proposal, I begin by providing some background tying together addictions, attachment, and personality, suggesting they be treated simultaneously to achieve improved outcomes. Then, after briefly reviewing the leading approaches to the treatment of addictions, I introduce the idea that schema therapy is well-situated - both theoretically and practically - to address many of the shortcomings of existing treatment options. In particular, I note how addictive and co-occurring colluding behaviors are deeply intertwined with both early and continued frustration of core developmental needs. I illustrate how the addictive cycle is perpetuated through the process of schema reinforcement and through the operation of schema modes. I then demonstrate how these key terms (i.e., needs, schemas, and modes) inform the patient's assessment and case formulation, guiding treatment interventions from a strong therapeutic relationship that focuses on integrating recovery behavior change, healing dysfunctional schemas and modes, and preventing relapse.