Barriers and facilitators to pharmacotherapy for alcohol use disorders in primary care: results of a qualitative study in 4 va primary care clinics

Abstract

Objective: While several medications are effective for treating alcohol use disorders (AUD), most patients with AUD are not offered them. Primary care may be an optimal setting in which to increase access to AUD medications, but multiple barriers may exist to prescribing AUD medications in primary care. This qualitative study sought to understand barriers and facilitators to use of AUD medications in primary care. Methods: Key contacts and snowball sampling were used to recruit 20 primary care providers (16 Attending MDs, 3 NPs, and 1 Resident NP) from 4 clinics of a single VA facility. Participants completed semi-structured interviews in person, which were recorded, transcribed, and qualitatively analyzed using rapid team-based methods. Analyses were guided by a social marketing theoretical framework to explicitly identify barriers related to participants' emotions, as distinct from knowledge and awareness. Results: Participants reflected a spectrum of readiness and willingness to prescribe AUD medications. Some viewed it as part of their role as a primary care provider, others were open to but not comfortable prescribing without specific support and/or training, and some stated explicitly that they were not willing to prescribe AUD medications as it was outside the scope of primary care. Those willing to prescribe described possible facilitators: training in AUD medications and side-effect profiles, and on-site staff to provide monitoring and behavioral support. Participants expressed a range of beliefs and attitudes. Some reflected a lack of optimism regarding their ability to help patients with AUD, expressing beliefs that medications were ineffective in the absence of behavioral treatments, that patients needed to be ready to change in order to be treated, that most patients with AUD were not interested in change and that abstinence was the only goal of treatment. Others reflected a desire to help patients with AUD with any option available and viewed treatment in primary care as a way of catalyzing change and addressing stigma and barriers to specialty treatment. Attitudes and beliefs were often informed by personal experiences unless interrupted by formal training, such as an addiction medicine rotation or fellowship. Conclusion: With the provision of training and staff support, it may be possible to capitalize on some providers' willingness and optimismin order to encourage provision of medications as part of care for AUD in primary care.