Table 1 describes the 17 participants in this study. Of these, 6 were REACH staff (labeled “S” in quote attributions), 4 were leadership (labeled “L”), and 7 were external stakeholders (labeled “E”). Of the 10 REACH leadership and staff, 7 were clinical providers and 5 of these were buprenorphine prescribers. We first describe the clinical activities as reported in the interview data. We then report 3 major themes: (1) an organizational mission to provide equitable and low-stigma healthcare, (2) low-threshold buprenorphine treatment, and (3) the creation and retention of a harm reduction workforce. These themes, with representative quotes, are summarized in Table 2.
Description of REACH Clinical Activities
Figure 1 shows clinical and social services that REACH offered at the time of our interviews. The practice relied on a nurse-led model: patients were first evaluated by registered nurses (RNs) who performed history and vital signs, and then conducted a “bio-psychosocial assessment” (S1) which elicited information about treatment goals, current substance use behaviors, and socioeconomic factors. Patients were asked to provide urine for drug screening. Both home and office induction were available. Most prescribers were contracted on an hourly basis, whereas most nurses were employees.
Part-time family medicine and internal medicine providers at REACH offered primary care, including for a small number of patients not on buprenorphine. The initial visit for primary care patients involved a less extensive intake and no urine drug screen. One participant estimated that “40% of our unique patients get primary care here” (L3). At the time of our study, REACH was in the process of developing quality assessment protocols for primary care.
REACH employed one psychiatric nurse practitioner for medication management of people with mental health conditions. Because of high demand, the individual practitioner was “having to see people for quite short visits” (S4). This limited the ability to provide therapeutic counseling as it related to substance use disorder, or to manage more severe mental health conditions. Since the time of the interviews, REACH added additional mental health providers to address this need.
Theme 1: Organizational Mission to Provide Equitable and Low-Stigma Healthcare
Participants were aware of the harm reduction–oriented mission of REACH, and felt that the mission was unique when compared to other substance use treatment providers in the region.
Theme 1.1: Mission of Reducing Stigma as the Key to Organizational Identity
REACH employees and external stakeholders both identified an organizational mission of reducing stigma and advancing health equity: “We knew from day one that …we would provide stigma free, compassionate care at all times. That’s really the foundation of our organization and has always been part of our mission” (L2). Participants emphasized established principles of harm reduction, such as “meeting people where they’re at” to offer individualized support based on a patient’s readiness to change and their current medical and social situation. Staff were motivated to meet patients’ complex social needs without judgment: “REACH is a place that just has the reputation where you will get help. You will get accepted. It’s really remarkable [how] the philosophy—there was always a philosophy—translates through the staff” (E5).
Theme 1.2: Contrast Between REACH and Other Healthcare Providers
Stigma was linked to the inability to access medical care in the area: “We struggle with local primary care providers [not] wanting those with substance use disorders to be there. It’s the stigma of ‘I don’t want these people in my lobby with my other clients’” (E1). Participants were also aware of the contrast between REACH’s approach and the “traditional” substance use disorder treatment model:
They’re mainstream [state-licensed] substance use treatment providers, but I think that those models or those organizations are stuck in a place of using older technology. …There’s really a focus on kind of a 12-step foundation that has a lot to do with group therapy experiences, individual talk therapy experiences, but is very short on some of the things that we can prove work, like medication assisted treatment. (E2)
This was partly attributed to the “traditional abstinence only perspective” (E2) that had been a norm in substance use treatment. Several participants noted that state-licensed substance use treatment providers practice in “a very rigid system” (E2) due to regulation from the state licensing agency. REACH, in contrast “[intentionally] opened as a freestanding medical practice” to be more “nimble” and have the “liberty to [provide care] as the organization chooses, and not be subject to state approval” (L2). Since the time of the interviews, REACH did obtain state-licensing, due to new state policies that allowed them to continue their model of practice.
Theme 2: Low-Threshold Buprenorphine Treatments and Other Clinical and Social Services
The “low-threshold” model of REACH aimed to reduce barriers to initiating patients on buprenorphine and retaining them in treatment. There were differing perspectives among stakeholders and challenges in integrating this treatment into primary care. The hallmarks of this low-threshold model, according to participants, were “being willing to give anybody a shot” (E4), and to “never discharge [patients] if they miss too many appointments” (L2).
Theme 2.1: Differences with Community Buprenorphine Dosing and Treatment Norms
External stakeholders observed tension in the community around prescribing practices at REACH:
[REACH] has received a lot of…public shaming about the doses of Suboxone that [they are] using because…a certain amount of people are on 16 [mg], or 24 [mg]…and the local treatment providers tend to be fairly reluctant to put people on 16 and rarely would ever consider a dose larger than that (E3).
One participant had been contacted by several pharmacists who “refuse to fill a REACH prescription, saying it was outside of the FDA guidelines for the prescription” (E4). The difference between the maintenance dose of buprenorphine that is recommended in medical training and the dose that patients might need to avoid withdrawal was also noted by one staff member: “You kind of do your training and they’re talking about people on 4 mg and 8 mg and…many of our patients are on 24 mg, which.. I feel comfortable going up to that, but then patients are often like ‘I need a higher dose’” (S4). One participant felt there was a philosophical barrier in the community: “there is a long history in the methadone world of, you know, get people on it, give them as little as possible, and then get them back off as quickly as possible. And that philosophy…carries on into the present and…on the face of it, it’s ridiculous” (E2).
There was disagreement around diversion of medication. Some participants, including one external stakeholder, shared a belief that diverted buprenorphine “means that somebody else doesn’t buy heroin” (L1). However, several participants commented that law enforcement agencies did not view it the same way: “Law enforcement is finding them at drug raids. They’re really upset about this. They’re feeling like it’s adding to the drugs on the street” (E4).
Theme 2.2: Logistical Challenges in Providing Low-Threshold Buprenorphine
One REACH employee commented on the need to balance a “very high no-show rate” and a “lot of walk-ins,” which made the clinical flow variable (L2). Staff performed “morning huddles” to anticipate the potential workflow in each day. Physician providers were largely part time, so walk-in visits and phone calls were often addressed by covering physicians, although nursing staff were usually present to ensure continuity of care. Sometimes this approach presented logistical challenges:
One of the… things that make it a little bit tricky…is that there are so many providers that are working short shifts, and so when these people call needing something we have to reach out to these providers…and then wait for them to get back (S2).
An added complexity was managing each provider’s buprenorphine “slots.” For newly trained providers, the maximum patient load was 30, so “in order to meet the demand, [REACH] had to bring on multiple doctors that are all just doing 30 in their first year” (E1). The practice manager took on the logistics of managing prescriber slots to ensure that all prescribers were within the limits allotted to them, which sometimes involved scheduling patients with other providers who had slots available. This was an important problem but a temporary one, as most providers were able to increase their capacity from 30 to 100 in their second year, and to increase even further after the second year up to 275. Most REACH staff agreed that lack of personnel and physical space presented larger challenges to meeting demand than physician prescribing capacity did.
Theme 2.3: Integration of Primary Care with Buprenorphine Treatment
Integration of primary care and created additional challenges to overcome. For many patients with substance use disorder, other health issues “get shuffled to the back” (S3). One provider expressed a tension between the need to quickly get patients on buprenorphine with the time commitment needed to practice longitudinal primary care:
People will call, they need to get in because they’re desperate to get on [medication assisted therapy (MAT)]…but then they also want primary care….and all of a sudden I’m now their primary care physician and they’re like, diabetic, on insulin, and we never did the groundwork that we needed to do (S4).
Some providers stated they would require additional training in skills such as abscess drainage, whereas others would need training in chronic disease management or in specific areas such as hepatitis C treatment.
Theme 3: Creation and Retention of a Harm Reduction Healthcare Workforce
Participants described the steps needed to train healthcare workers in the harm reduction culture and to maintain that culture over time.
Theme 3.1: Providers’ Previous Experiences in the Healthcare System
REACH needed to attract providers and staff who were willing to practice in a harm reduction model, train them in that model, and sustain their culture as the medical practice expanded. REACH leadership set the goal of being “low threshold for providers,” stating that “it’s under-recognized by patients…that [we] providers are being treated in a corporate medical model and...we’re not delivering the care we want to give” (L4). Providers and staff reinforced this notion: “I’m at the hospital [in my previous job], and I’m there for 12 hours just churning out visits for the sake of volume, and that’s not what I want to do” (S3). Staff also mentioned the appeal of “[working] with more underserved populations” and “doing hands-on, meaningful work in a respectful and compassionate way” (S3).
Participants acknowledged the difficulties of prescribing buprenorphine in many other office settings:
We’ve had local providers who have been waiver providers for several years and never used their licenses because they didn’t feel like they could do it in their primary care office...[REACH] is offering them an opportunity to do the right thing and making it easy (E3).
One provider recalled “so many structural barriers to providing [buprenorphine] that I didn’t even try to do it at my other jobs,” including lacking other clinical providers who could cover for related issues (L3). Another was also grateful for billing support: “if I were billing for myself, I would be overwhelmed” (S5).
Theme 3.2: “Harm-Reductionizing” New Providers
Multiple participants referred to providers as being “harm-reductionized,” meaning they were provided training and acculturation to the harm reduction environment (S1, L2, L3). REACH covered the cost for providers who needed buprenorphine waiver training. New providers shadowed the director and met with the practice manager to learn the culture of the practice. New hires also received online educational sessions related to harm reduction such as training in motivational interviewing and using stigma-free language. There was an explicit attempt to orient new hires to some of the logistical challenges of the work: “Your patients aren’t gonna show up on time. You’re not gonna get out on time. If [patients] do show up, we’re not gonna turn them away...” (S1). Staff meetings provided an opportunity for ongoing reinforcement of these principles. The importance of acculturation was considered critical for maintaining patient trust: “If any part of that chain falls apart, then we re-traumatize someone and they stop coming for help” (L3).
Theme 3.3: Maintaining a Harm Reduction Culture
There were several challenges to maintaining this culture, especially as the practice grew to include more providers and staff. Some providers were initially less attuned to harm reduction principles, being “deeply rooted in the old model” (L2) and having “one of [the] biggest learning curves [be] tipping my focus and my frame of mind in approaching the population” (S3). Working with the high-need population also came with a risk of emotional burnout:
After about the first three or four months I was definitely feeling emotionally burned out…getting everybody’s hour long story of why they started doing heroin at 13-years-old. So, it was incredibly just draining in that sense that I could just feel all of them and what they've been through... I just felt so bad because I feel helpless with this population at times (S2).
The harm reduction culture also encouraged staff to be more vulnerable and open than in traditional medical environments, which could lead to difficulty in setting professional norms:
[They] know that it’s a safe space and they wind up sharing more with you, and sharing more with the patients, and relating with everybody on this rock-bottom raw, honest level. And so it’s almost more difficult to manage because you’re like, ‘well, I don’t know if it’s appropriate in the workplace, but wait, where do I draw the line?’ (S1).