Abstract for: Dynamics of Prescribing and Accessing Medications for Opioid Use Disorder: A Community-based Systems Analysis

Background: Although medications for opioid use disorder (MOUD) are effective for treating opioid use disorder (OUD), persistent barriers still prevent patients from accessing this life-saving care. This study presents a qualitative system dynamics model that elucidates the complexities of MOUD treatment. Methods: We utilized a community-based system dynamics approach to modeling the MOUD treatment system. We engaged a cohort of nine system experts/stakeholders, including individuals with lived and living experience of OUD, treatment providers, and policymakers. These stakeholders participated in individual key informant interviews and group model-building to inform model development and refinement. Throughout the interviews and workshop, we iteratively synthesized a single causal loop diagram. Results: The causal loop diagram captures four key factors affecting treatment initiation, retention, and leaving: 1) fraught interactions between patients and healthcare providers; 2) stigma-driven regulation of MOUD creating a culture of fear and defensive medicine; 3) a punitive culture within clinics offering MOUD, including opioid treatment programs; and 4) the internalization of the 12-step narrative contributing to early termination of treatment. Conclusions: Our analysis highlights how interdependent and non-linear feedback processes diminish or counteract the effectiveness and sustainability of MOUD policy interventions. We note, in particular, system memory and obstinacy to change such that even rolling back reactionary policies may do little to curb established behavioral patterns.