Clinician identified barriers to treatment for individuals in Appalachia with opioid use disorder following release from prison: A social ecological approach

Background: The non-medical use of opioids has reached epidemic levels nationwide, and rural areas have been particularly affected by increasing rates of overdose mortality as well as increases in the prison population. Individuals with opioid use disorder (OUD) are at increased risk for relapse and overdose upon reentry to the community due to decreased tolerance during incarceration. It is crucial to identify barriers to substance use disorder treatment post-release from prison because treatment can be particularly difficult to access in resource-limited rural Appalachia. Methods: A social ecological framework was utilized to examine barriers to community-based substance use treatment among individuals with OUD in Appalachian Kentucky following release from prison. Semi-structured qualitative interviews with 15 social service clinicians (SSCs) employed by the Department of Corrections were conducted to identify barriers at the individual, interpersonal, organizational/institutional level, community, and systems levels. Two independent coders conducted line-by-line coding to identify key themes. Results: Treatment barriers were identified across the social ecological spectrum. At the individual-level, SSCs highlighted high-risk drug use and a lack of motivation. At the interpersonal level, homogenous social networks (i.e., homophilious drug-using networks) and networks with limited treatment knowledge inhibited treatment. SSC's high case load and probation/parole officer's limited understanding of treatment were organizational/institutional barriers. Easy access to opioids, few treatment resources, and a lack of community support for treatment were barriers at the community level. SSC's noted system-level barriers such as lack of transportation options, cost, and uncertainty about the implementation of the Affordable Care Act. Conclusions: More rural infrastructure resources as well as additional education for family networks, corrections staff, and the community at large in Appalachia are needed to address barriers to OUD treatment. Future research should examine barriers from the perspective of other key stakeholders (e.g., clients, families of clients) and test interventions to increase access to OUD treatment.