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A qualitative investigation of addiction counselors' perceptions and experiences implementing an open-access model for treating opioid use disorder

Published:October 31, 2020DOI:https://doi.org/10.1016/j.jsat.2020.108191

      Highlights

      • Counselors identify positives and negatives to scaling up opiate agonist clinics.
      • Advantages to clients include reduced barriers and greater autonomy.
      • Advantages to counselors include stimulating work environment and fewer demands.
      • Advantages to the community include less crime and treatment to vulnerable members.
      • Disadvantages include uneven counselor workloads and lack of structure for clients.

      Abstract

      Objective

      To examine addiction counselors' perceptions and experiences of implementing an open-access model for methadone maintenance treatment (MMT), in which the program rapidly enrolled prospective patients, irrespective of ability to pay, and provided real-time access to multiple voluntary treatment options. Between 2006, when the treatment program initially implemented this model, and 2020, the census of clients receiving methadone maintenance at the study site grew from 1431 to 4500.

      Methods

      Participants were 31 addiction counselors employed at a treatment organization that implemented an open-access model to scale up MMT. We examined counselors' perceptions and experiences of working in programs that employed this model, using individual semi-structured interviews, which an interdisciplinary team audiotaped, transcribed, and systematically coded using grounded theory. The team reviewed themes and reconciled disagreements (rater agreement was 98%). We describe themes that more than 10% of participants reported.

      Results

      Counselors described perceived advantages of the open-access model for clients (e.g., “individualized to client needs”), clinicians (e.g., “fewer demands”), and the community (e.g., “crime reduced”). Counselors also described perceived disadvantages of the open-access model for clinicians (e.g., “uneven workload”) and clients (e.g., “need for more intensive services for some clients”), as well as program-level concerns (e.g., “perceived lack of structure”).

      Conclusions

      Counselors who work in opioid treatment programs that use an open-access framework described multiple benefits to themselves, their clients, and the public; they also outlined disadvantages for themselves and clients, which research should further explore and address to facilitate MMT scale up.

      Keywords

      1. Introduction

      Untreated opioid use disorder (OUD) is an important contributor to the opioid crisis and is associated with increased risk of infection with HIV and hepatitis C, opioid overdose, and all-cause mortality (
      • Kolodny A.
      • Courtwright D.T.
      • Hwang C.S.
      • Kreiner P.
      • Eadie J.L.
      • Clark T.W.
      • Alexander G.C.
      The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction.
      ). The standard of care for OUD is medication for opioid use disorder (MOUD) with methadone, buprenorphine, or naltrexone (
      • Volkow N.D.
      • Frieden T.R.
      • Hyde P.S.
      • Cha S.S.
      Medication-assisted therapies—Tackling the opioid-overdose epidemic.
      ). Since a minority of individuals with OUD receive MOUD (
      • Jones C.M.
      • Campopiano M.
      • Baldwin G.
      • McCance-Katz E.
      National and state treatment need and capacity for opioid agonist medication-assisted treatment.
      ;
      • Knudsen H.K.
      • Roman P.M.
      Financial factors and the implementation of medications for treating opioid use disorders.
      ), scaling up this effective treatment is a national public health priority (
      • Association of Schools and Programs of Public Health
      Bringing science to bear on opioids.
      ;
      • National Academies of Sciences Engineering and Medicine
      Medications for opioid use disorder save lives.
      ). For scale up to occur, either new providers or programs need to begin offering MOUD or existing providers and programs need to expand their treatment capacity. However, the paucity of evidence-based implementation models and anticipated negative provider responses may deter program managers from attempting scale up (
      • Brownson R.C.
      • Fielding J.E.
      • Green L.W.
      Building capacity for evidence-based public health: Reconciling the pulls of practice and the push of research.
      ;
      • Madden L.M.
      • Farnum S.O.
      • Eggert K.F.
      • Quanbeck A.R.
      • Freeman R.M.
      • Ball S.A.
      • Schottenfeld R.S.
      • Shi J.M.
      • Savage M.E.
      • Barry D.T.
      An investigation of an open-access model for scaling up methadone maintenance treatment.
      ).
      Methadone maintenance treatment (MMT) program managers in the United States may be particularly reluctant to scale up treatment capacity without evidence-based models to assist them because federal and state regulations impose multiple restrictions to attenuate the risk of overdose and diversion. Prospective patients often incur wait times that exceed a month for MMT (i.e., time between first face-to-face appointment and treatment entry;
      • Andrews C.M.
      • Shin H.-C.
      • Marsh J.C.
      • Cao D.
      Client and program characteristics associated with wait time to substance abuse treatment entry.
      ). Admission delays for MMT are more common among persons of racial and ethnic minority descent (versus whites) and with greater (versus lower) psychiatric burden (
      • Gryczynski J.
      • Schwartz R.P.
      • Salkever D.S.
      • Mitchell S.G.
      • Jaffe J.H.
      Patterns in admission delays to outpatient methadone treatment in the United States.
      ).
      While few studies have systematically examined sustained MMT scale up (
      • Madden L.M.
      • Farnum S.O.
      • Eggert K.F.
      • Quanbeck A.R.
      • Freeman R.M.
      • Ball S.A.
      • Schottenfeld R.S.
      • Shi J.M.
      • Savage M.E.
      • Barry D.T.
      An investigation of an open-access model for scaling up methadone maintenance treatment.
      ), research has investigated the effects of changes to traditional methadone treatment practices on patients' enrollment and engagement in treatment. In a clinical trial comparing patient-centered MMT and treatment-as-usual, no significant differences emerged in illicit substance use at 12 months (
      • Schwartz R.P.
      • Kelly S.M.
      • Mitchell S.G.
      • Gryczynski J.
      • O’Grady K.E.
      • Gandhi D.
      • Jaffe J.H.
      Patient-centered methadone treatment: A randomized clinical trial.
      ). Counselors in the patient-centered MMT condition noted that changes to treatment-as-usual allowed them to enhance rapport with clients (
      • Mitchell S.G.
      • Monico L.B.
      • Lertch E.
      • Kelly S.M.
      • Gryczynski J.
      • Jaffe J.H.
      • Schwartz R.P.
      Counseling staff’s views of patient-centered methadone treatment: Changing program rules and staff roles.
      ). A literature synthesis by Jackson and colleagues identified three factors that lead to effective psychosocial treatment with MMT: client-centered focus, relationships at the treatment site, and addressing broader psychosocial needs (
      • Jackson L.A.
      • Buxton J.A.
      • Dingwell J.
      • Dykeman M.
      • Gahagan J.
      • Gallant K.
      • Karabanow J.
      • Kirkland S.
      • LeVangie D.
      • Sketris I.
      Improving psychosocial health and employment outcomes for individuals receiving methadone treatment: A realist synthesis of what makes interventions work.
      ).
      Regulations in the United States require MMT programs to provide counseling in addition to methadone medication. Addiction counselors play an important role in the delivery of counseling, but scant research has systematically examined the experiences of those who work in opioid treatment programs that have scaled up treatment capacity in response to the opioid crisis (
      • Center for Substance Abuse Treatment
      Medication-assisted treatment for opioid addiction in opioid treatment programs.
      ;
      • Oberleitner D.E.
      • Marcus R.
      • Beitel M.
      • Muthulingam D.
      • Oberleitner L.
      • Madden L.M.
      • Barry D.T.
      “Day-to-day, it’sa roller coaster. It’s frustrating. It’s rewarding. It’s maddening and it’s enjoyable”: A qualitative investigation of the lived experiences of addiction counselors.
      ). One model of MMT scale up that has been found to be effective and economically viable over a sustained time period is the “open-access model” in which prospective eligible clients are enrolled rapidly in methadone treatment, irrespective of their ability to pay, and are provided access to a variety of counseling, medical, and vocational services (
      • Madden L.M.
      • Farnum S.O.
      • Eggert K.F.
      • Quanbeck A.R.
      • Freeman R.M.
      • Ball S.A.
      • Schottenfeld R.S.
      • Shi J.M.
      • Savage M.E.
      • Barry D.T.
      An investigation of an open-access model for scaling up methadone maintenance treatment.
      ). The implementation of the open-access model involved two major changes in counselors' clinical practice: First, they switched from conducting primarily individual counseling by appointment to conducting group counseling without appointments (see description of “drop-in groups” in the Methods section). Second, counselors no longer carried individual caseloads; instead, the program assigned cases to teams of counselors.
      The current study aimed to examine the perceptions and experiences of the open-access model among addiction counselors at the treatment organization that developed the model and initially implemented it. Whereas we previously examined addiction counselors' lived experiences (
      • Oberleitner D.E.
      • Marcus R.
      • Beitel M.
      • Muthulingam D.
      • Oberleitner L.
      • Madden L.M.
      • Barry D.T.
      “Day-to-day, it’sa roller coaster. It’s frustrating. It’s rewarding. It’s maddening and it’s enjoyable”: A qualitative investigation of the lived experiences of addiction counselors.
      ) and burnout (
      • Beitel M.
      • Oberleitner L.
      • Muthulingam D.
      • Oberleitner D.
      • Madden L.M.
      • Marcus R.
      • Eller A.
      • Bono M.H.
      • Barry D.T.
      Experiences of burnout among drug counselors in a large opioid treatment program: A qualitative investigation.
      ), we did not examine their perceptions or experiences of the open-access model itself. Because of the lack of prior research examining addiction counselors' perceptions of the open-access treatment model, we used qualitative methods to facilitate in-depth examination of the counselors' experiences. We anticipated that the study findings would be useful to program managers who are interested in scaling up MMT programs by implementing an open-access or similar model. Reading counselors' lived experiences of the open-access model may be valuable for clinicians who work in settings that are considering scale up. Specifically, we anticipated prior to conducting the study that:
      • 1)
        Counselors would emphasize reduced barriers to treatment entry and the provision of multiple group counseling options when describing the open-access model. Reducing barriers to treatment entry and providing patients the opportunity to choose from a large variety of group counseling options are core aspects of the open-access model, and distinguish it from traditional models of MMT involving long wait times and the provision of appointment-based individual counseling.
      • 2)
        Counselors would describe both personal (removal of individual caseloads) and client benefits (reduced barriers to entering MMT and fostering autonomy because of choice regarding counseling group attendance) when outlining the advantages of the open-access model. Team-based rather than individual caseloads are notably different from other models of MMT; consequently, we expected this feature to also arise in clinicians' descriptions.
      • 3)
        Counselors would discuss the de-emphasizing of individual counseling and individual clinician-patient alliance when describing disadvantages of this model. Individual counseling and forging individual clinician-patient alliances may be rewarding for counselors and consistent with their professional training.

      2. Methods

      2.1 Study site and sample

      The APT Foundation, Inc. (hereafter referred to as APT) is a not-for-profit community-based organization in Connecticut, founded in 1970, which specializes in the treatment of substance-related disorders and is affiliated with Yale School of Medicine. APT operates four outpatient methadone maintenance treatment programs; with a current census of approximately 4500 clients, it is one of the largest providers of methadone maintenance treatment in southern New England.
      In 2006, APT began developing an “open-access model” for scaling up methadone maintenance treatment in which eligible persons are enrolled rapidly in treatment irrespective of their ability to pay and are provided real-time access to multiple voluntary drop-in treatment options (
      • Madden L.M.
      • Farnum S.O.
      • Eggert K.F.
      • Quanbeck A.R.
      • Freeman R.M.
      • Ball S.A.
      • Schottenfeld R.S.
      • Shi J.M.
      • Savage M.E.
      • Barry D.T.
      An investigation of an open-access model for scaling up methadone maintenance treatment.
      ). In the first 9 years of implementation (2006–2015), wait time to accessing treatment decreased from an average of 21 days to same-day, and the census increased 183% (from 1431 to 4051 clients
      In this paper, we use the terms “client” and “patient” as well as “clinician” and “counselor” interchangeably.
      ) without decrements to rates of retention, opioid-negative drug tests, or mortality (
      • Madden L.M.
      • Farnum S.O.
      • Eggert K.F.
      • Quanbeck A.R.
      • Freeman R.M.
      • Ball S.A.
      • Schottenfeld R.S.
      • Shi J.M.
      • Savage M.E.
      • Barry D.T.
      An investigation of an open-access model for scaling up methadone maintenance treatment.
      ). Currently, APT offers methadone treatment to approximately 4500 patients. By comparison, from 2003 to 2012, the methadone maintenance treatment capacity nationwide increased by only 37% (
      • Jones C.M.
      • Campopiano M.
      • Baldwin G.
      • McCance-Katz E.
      National and state treatment need and capacity for opioid agonist medication-assisted treatment.
      ). Ukraine has used key elements of this open-access model to scale up access to MOUD (
      • Madden L.
      • Bojko M.J.
      • Farnum S.
      • Mazhnaya A.
      • Fomenko T.
      • Marcus R.
      • Barry D.
      • Ivanchuk I.
      • Kolomiets V.
      • Filippovych S.
      Using nominal group technique among clinical providers to identify barriers and prioritize solutions to scaling up opioid agonist therapies in Ukraine.
      ;
      • Tan J.
      • Altice F.L.
      • Madden L.M.
      • Zelenev A.
      Effect of expanding opioid agonist therapies on the HIV epidemic and mortality in Ukraine: A modelling study.
      ).
      The open-access model identified intake procedures that regulations did not require and that impeded rapid MMT entry. For example, intake workers at the study site (similar to those at some other MMT programs) assumed incorrectly that federal guidelines required “proof of previous treatment failure.” Workers altered the procedures for verification so that they could perform them on the same day: Consistent with federal requirements, all admitted patients met with a clinician who formally evaluated the patient for DSM-5 OUD (
      • American Psychiatric Association
      Diagnostic and statistical manual for mental disorders.
      ); a licensed medical provider confirmed eligibility for admission. While the federal requirements for MMT entry recognize that certain DSM-5 OUD diagnostic criteria (
      • American Psychiatric Association
      Diagnostic and statistical manual for mental disorders.
      ) may not apply to specific categories of individuals (e.g., those who were recently incarcerated or completed a rehabilitation program), intake workers at the study site, prior to the implementation of the open-access model, required written verification of previous treatment for OUD and/or other medical information. Securing written verification can be difficult and can take time; however, information can often be verbally verified on the same day while the prospective patient waits, avoiding the need for another visit. Rapid treatment entry also entailed re-ordering the sequence of required steps so that eligible persons receive medication as quickly as possible after being determined appropriate for treatment. For example, previously the study site required a full physical exam (PE) prior to admission; following the advent of the open-access model, medical screening for contraindications to MMT are conducted prior to admission and a PE is performed on a walk-in basis within 2 weeks of admission (
      • Madden L.M.
      • Farnum S.O.
      • Eggert K.F.
      • Quanbeck A.R.
      • Freeman R.M.
      • Ball S.A.
      • Schottenfeld R.S.
      • Shi J.M.
      • Savage M.E.
      • Barry D.T.
      An investigation of an open-access model for scaling up methadone maintenance treatment.
      ).
      Participants in the current study were 31 addiction counselors who we recruited from APT's four methadone maintenance treatment programs. Counselors at the study site that developed the open-access model faced major changes following its implementation in 2006. The primary mode of counseling delivery switched from individual appointments to “drop-in” open group sessions (with individual sessions available upon request) and from individual to team caseloads, where the program no longer assigned individual clients to specific counselors. At each APT methadone program, addiction counselors provide patients a variety of drop-in group options (usually more than fifteen 50-min groups daily from 5 am to 3 pm). Patients choose the number and the topics of groups they wish to attend and are also able to access individual services as they deem needed. Per federal guidelines (
      • Center for Substance Abuse Treatment
      Medication-assisted treatment for opioid addiction in opioid treatment programs.
      ), patients must attend at least one counseling session per month.

      2.2 Procedures

      One of the authors (DTB) attended clinical staff meetings to recruit participants for a study to solicit feedback about providers' work experiences, APT's clinical programs, and suggestions for improving these programs and clinician work life. Fifty-one (out of a staff of 57) addiction counselors signed up to be interviewed. We based the order in which we conducted the interviews on counselor availability. We conducted interviews until there was saturation of qualitative themes (i.e., the point where the interviewer determined that no new themes were emerging from the interviews). The final sample consisted of 31 counselors. An investigator (DTB) with no personal or professional relationship with the counselors conducted the interviews in a private office. The investigator, a licensed clinical psychologist, had experience conducting qualitative interviews. We audiotaped, transcribed verbatim, and then coded the interviews. We did not conduct any repeat interviews. We did not contact participants to receive feedback about thematic coding. Procedures for recruitment and the interviews have been described in detail previously (
      • Beitel M.
      • Oberleitner L.
      • Muthulingam D.
      • Oberleitner D.
      • Madden L.M.
      • Marcus R.
      • Eller A.
      • Bono M.H.
      • Barry D.T.
      Experiences of burnout among drug counselors in a large opioid treatment program: A qualitative investigation.
      ).
      Interviews were confidential. We did not request or record any identifying information, and research assistants independently read each transcript, identified, and expunged possibly identifying information (e.g., unique employment or educational history) prior to dissemination of the transcripts to the coding team. One of the authors (LMM) is the CEO at APT, and is the only team member who had a professional (e.g., supervisory) or personal relationship with any of the participants. We maintained a demographic sheet separately from the interview on which participants recorded age, gender, race/ethnicity, years of counseling experience, and education. We compensated counselors for the time spent completing the interview with a $25 gift card. The APT Board of Directors approved the current study and the Human Investigation Committee at the Yale School of Medicine exempted it from review as a quality improvement project.

      2.3 Interviews

      Semi-structured interviews lasted approximately 45 min and we conducted them between August 2015 and July 2016. Three authors (DTB, MB, and LMM) created the structured interview to assess counselors' (a) experiences treating patients, (b) suggestions for optimizing work life and training, (c) views of optimal treatment, (d) attitudes on interventions, and (e) perceptions and experiences of the open-access model. Specific to the current study on counselors' perceptions and experiences of the open-access model, we prompted participants with the following: “APT uses an ‘open-access model’ of treatment. What is your understanding of what this means?” We then instructed participants: “So open-access means that APT tries to get patients into treatment as quickly as possible irrespective of their ability to pay (ideally within 24 hours) and then tries to retain patients, in part by offering patients multiple treatment options that they are free to choose from.” We then prompted participants with the following questions: 1) “What do you think of this model?” 2) “What are the advantages of this model?” and 3) “What are the disadvantages of this model?”

      2.4 Coding

      We convened a multidisciplinary team to analyze the transcripts. Team members comprised seven researchers experienced in qualitative data analysis, including clinical psychologists, a social psychologist, a medical anthropologist, a physician, and a senior administrator with a doctorate in inter-professional studies. The semi-structured nature of the interviews allowed the team to focus coding on counselor responses to specific questions. The questions coded in the current study were different from those that we coded in prior studies with participants about lived experiences (questions about roles, motivation, and perceived responses of others to their work) (
      • National Academies of Sciences Engineering and Medicine
      Medications for opioid use disorder save lives.
      ) and burnout (questions about perceived burnout, strategies used to cope with or prevent burnout) (
      • Beitel M.
      • Oberleitner L.
      • Muthulingam D.
      • Oberleitner D.
      • Madden L.M.
      • Marcus R.
      • Eller A.
      • Bono M.H.
      • Barry D.T.
      Experiences of burnout among drug counselors in a large opioid treatment program: A qualitative investigation.
      ). We used a grounded theory approach to identify themes that arose from the transcripts (
      • Belgrave L.L.
      • Seide K.
      Grounded theory methodology: Principles and practices.
      ;
      • Glaser B.G.
      • Strauss A.L.
      The discovery of grounded theory: Strategies for qualitative research.
      ). As an initial training step, all seven researchers coded responses to one question for a sample of interviews; as all team members were well versed in qualitative methods and coding, we wanted to establish an agreed-upon approach for coding. Subsequently, three researchers (LMM, DM, and LMO) reviewed responses to questions pertaining to counselors' perceptions and experience of the open-access model, and they identified themes and subthemes included in this article. Two researchers independently reviewed and coded each individual response. The mean percent agreement between the pairs of coders was 98%. We calculated percentages of participants who spontaneously reported each identified theme or subtheme in response to open-ended questions regarding the open-access model of care and we provided them in the Results section and Table 1, Table 2, Table 3. Participants could provide responses that we coded into multiple subthemes, as we coded each meaningful and responsive unit separately. However, we only counted participants once per major theme, even if they provided multiple subtheme responses within that major theme. Themes that we coded in at least 10% of the interviews are presented here. We did not use coding software for these analyses.
      Table 1Description of the open-access model.
      ThemeSubthemeN%Example
      Clinician levelPersonal evaluation positive516%Excellent; wonderful; it works
      Team approach516%Support each other; no caseloads
      New experience413%New experience; adaptation; no caseloads
      Disadvantages to clinician310%Safety concerns; lack of physical boundaries
      Total1239%
      Client levelClient autonomy/responsibility516%system/model supports autonomy and growth
      Individualized/needs met516%Flexibility in the system to meet all client needs
      Staff/system is responsive413%Clinicians and the system are eager to adapt to client needs/interests
      Total1961%
      Community levelSame day access/admission2065%Clients can walk in when ready; no wait list
      Services provided on same day as admission1032%Provide medication, medical care, mental health care same day as requested
      Ongoing care barriers reduced1858%Access to everything needed for addiction; no appointments; financial barriers reduced; reduced physical boundaries
      High acuity clients served826%“Last resort”; provide care and open door to all clients
      Total2684%
      Note: The “Total” number and percentage provided for each major theme represents the number of participants who reported any of the subthemes in that category. If a participant reported multiple subthemes within the larger thematic category, that participant would only count as one individual for the major theme total value.
      Table 2Advantages of the open-access model.
      ThemeSubthemeN%Example
      Clinician levelPositive assessment1135%“Good”, “great”
      Positive personal assessment516%“Like it”, “love it”, “enjoy it”
      Positive clinician outcome413%Clients choose you; less demands; clients more engaged
      Total2065%
      Client level-barriers reducedGeneral620%Barrier reduction broadly; treatment of last resort/accepts all clients
      Waiting time reduced517%Scheduled appointments not needed; less waiting for care
      Same day access27%Receive treatment on the day requested when initiating treatment
      Total1343%
      Client level — outcomes improvedClient well being413%“It works”; better outcomes; clients' are comfortable
      Patient autonomy, access, & individualization1447%Choice of modalities, clinicians, and groups; individualized; access to building and clinicians
      Robust services413%Access to physical healthcare, mental health care, substance use treatment
      Total2065%
      Community levelOpen door philosophy826%Friendly; needs met; open to all; more served
      Safety increased for clients and community516%Deaths reduced; decreased overdoses; crime reduced
      Total1342%
      Note: The “Total” number and percentage provided for each major theme represents the number of participants who reported any of the subthemes in that category. When a participant reported more than one subtheme, we only used one of the responses toward the major theme “total.”
      Table 3Disadvantages of the open-access model.
      ThemeSubthemeN%Example
      Clinician levelUneven workload310%Some staff work harder than others
      Demands high516%Unpredictable workload; feeling of being rushed
      Total1032%
      Client levelTherapeutic relationship310%More difficult for clients to form relationships with staff
      Scheduling challenging310%No scheduled appointments; feels chaotic to clients
      Total620%
      Program lack of intensity and structureMore structure needed826%Clients can “fall through the cracks”; more guidance for clients needed; increased intensity of services needed for some clients
      Total826%
      No disadvantagesNone1135%
      Note: The “Total” number and percentage provided for each major theme represents the number of participants who reported any of the subthemes in that category. If a participant reported multiple subthemes within the larger thematic category, that participant would only count as one individual for the major theme total value.

      3. Results

      3.1 Participants' demographic characteristics and counseling experience

      As we have previously described (
      • Beitel M.
      • Oberleitner L.
      • Muthulingam D.
      • Oberleitner D.
      • Madden L.M.
      • Marcus R.
      • Eller A.
      • Bono M.H.
      • Barry D.T.
      Experiences of burnout among drug counselors in a large opioid treatment program: A qualitative investigation.
      ), participants were 31 addiction counselors (18 women, 13 men) who self-identified as white (77%), Hispanic (13%), or African American (10%). Participants' mean age was 47.3 years (SD = 15.1 years) and mean years of counseling experience was 16.5 (SD = 10.7). Seventy-one percent of participants had a master's degree, 16% had a 4-year degree, and 6% had a 2-year degree. Of the remaining two participants (6%), one had a doctorate in a nonclinical field, while the other had a JD (law degree).
      In response to open-ended questions about their perceived understanding, general perceptions, advantages, and disadvantages of the open-access model of care, counselors identified two primary themes—clinician level and client level—to describe the model's impact. Participants also noted two further themes—community-level advantages and program-level disadvantages. We identified subthemes (expressed by >10% of participants) from each line of questioning. Table 1 shows subthemes from questions regarding understanding and general perceptions of the open access model. Table 2, Table 3 show subthemes from questions about advantages and disadvantages of the model, respectively.

      3.2 Descriptions/perceptions of the open-access model

      As described in our Methods section, we prompted participants with: “APT uses an ‘open-access model’ of treatment. What is your understanding of what this means?” The following codes pertain to participants' descriptive responses.

      3.2.1 Clinician level

      When asked to describe the open-access model, many participants emphasized positive impacts on their own work experiences. For example, some participants responded to the description question with “It's great.” Other responses included a description of participants' working as part of a team-based approach. Few participants described the model as decreasing physical and structural boundaries with clients.

      3.2.2 Client level

      Counselors accurately identified the major components of the open-access model: enrolling prospective eligible patients rapidly into methadone maintenance treatment irrespective of ability to pay and providing multiple group psychosocial treatment options from which patients are free to choose (without making an appointment). Participants noted that immediate access to a range of services besides methadone dosing, including medical and mental health, defined the open-access system.
      [Patients have] access to move around freely; to be part of the milieu. They have services available in the moment. It has reduced wait times for psychiatric and medical treatments … This is a place where they can come and there's not that division of us and them (Participant 25).
      These themes suggest that counselors recognize the distinguishing features of open-access from the previous traditional model involving delays in prospective clients' accessing methadone maintenance accompanied by counseling delivered individually by appointment.

      3.2.3 Community level

      The provision of medical and psychiatric services to all-comers, especially those with higher symptom acuity and with fewer financial resources, was an important theme. Counselors perceived the open-access model as a method to broaden access to methadone maintenance treatment for community members regardless of resources and background.

      3.3 Advantages of the open-access model

      In response to open-ended questions about the advantages of the open-access model, participants described three themes: clinician-level advantages, client-level advantages, and community-level advantages.

      3.3.1 Clinician-level advantages

      Participants described the open-access model as a positive experience overall for clinicians. Clinician-level descriptions of the open-access model included that it required adaptation and a team approach in which clinicians supported one another rather than having individual caseloads. This resulted in counselors having limited client care responsibilities when they were out of the office (e.g., coverage when on vacation), which, in turn, allowed them to more effectively detach psychologically from work tasks.
      There's no caseloads… you don't have specific patients on your caseload. It's rotating. Anyone can come in and speak to whatever counselor is available (Participant 27).
      When specifically asked about advantages of the model, participants reported positive reactions (e.g., “It's good”; “It's great”), their own personal experience of the model (e.g., “I like it”; “I enjoy it”), and described positive personal or counselor outcomes of the model.
      It helps the counselors. The responsibility is to focus on the client that's in front of you at the time…our main goal is just to meet clients' needs, where they're at, and go from there (Participant 22).

      3.3.2 Client-level advantages

      In describing how the open-access model worked for clients, participants reported that it increased and supported client autonomy, that it allowed increased flexibility to meet client needs, and that it was responsive to the needs and interests of clients.
      With the open-access model, there's no appointments. When a person comes into the clinic they can be treated, their needs will be met… as soon as possible. They don't have to worry about waiting around that's what I see as open-access (Participant 18).
      When prompted about advantages of the model, counselors described the reduction of barriers to enrollment as well as the ready availability of client services. Counselors described how clients have decreased difficulty accessing care in the open-access model compared with other methadone maintenance treatment programs and that clients have choice in the type of counseling services received.
      If you're here for outpatient … you can stay for 6 groups a day, or you can come [for] one. It's treatment à la carte… the clients pick what they're interested in (Participant 28).

      3.3.3 Community-level advantages

      Respondents reported that the open-access model reduced barriers to care and that it served higher acuity clients. In contrast to the client-level category, this code reflected the broader impact of having increased treatment access for the community, serving as a treatment center where the highest risk community members could receive treatment, and having a clinical setting that was open to all (e.g., accessible time and location).
      We're an organization that specializes in the treatment of addiction. We're here to help in any way that we can. Our doors are open. [People are] not turned away… [they] are given a fair hearing …[they are] not judged for what they're bringing to us (Participant 8).
      Participants reported that the facility's open-door policy also led to an increase in high acuity clients being served.
      [We] try and find a way to reduce barriers to treatment as much as possible. We work with really acute people, who are less likely to engage elsewhere, especially if there's any barriers to treatment … we reduce those barriers to try to keep them (Participant 26).
      Participants described positive impacts on the community through the open-door philosophy and that the increased access to opioid agonist treatment reduced deaths, overdoses, and crime.
      [Clients] talk about how years and years ago, how long it took to get in. The good thing is that it is saving people's lives in the community, so they're not on the street using or overdosing (Participant 17).
      We receive a lot of patients into our program… in so doing we have (brought) down the crime rates. We help people to stabilize their lives and hopefully get a job (Participant 8).

      3.4 Disadvantages of the open-access model

      In response to open-ended questions about the disadvantages of the open-access model, participants described three themes: negative clinician-level outcomes, negative client-level outcomes, and program-level concerns. However, eleven participants (35%) identified no disadvantage (e.g., participant 5 stated: “There's really no disadvantages.”).

      3.4.1 Clinician-level disadvantages

      Counselors identified several disadvantages of the open-access model on their workflow, including that the workload can be uneven and that the demands are high because of the perceived unpredictability of the work. Some counselors also voiced concern that the increased patient volume led to a lack of available building space.
      We have heavy volume … it can be unpredictable… even the building [is not able] to support the amount of people coming through here (Participant 12).
      When asked to describe their understanding of the open-access model, some counselors expressed increased safety concerns due to perceived decreased physical boundaries with clients related to the increased volume of patients and lack of appointment-making.
      There's a lot of people hanging out, there are, many of them spend the whole day here. They're loud. We can hear them in my office. They're distracting… I've lost 2 iPhones and my eyeglasses, and I'm blind as a bat! (Participant 31).

      3.4.2 Client-level disadvantages

      Counselors' perceived disadvantages of the open-access model to clients included its possible negative impact on the therapeutic relationship and difficulties with the lack of scheduled appointments.
      It can feel chaotic… if someone can see a different counselor every time, they're able to fly below the radar. That's a concern here (Participant 30).

      3.4.3 Program-level disadvantages

      Counselors identified some program-related concerns, including that the model of treatment delivery needed to be more structured and intensive for some clients, although they did not delineate negative outcomes.
      The only disadvantages I think … once they are in treatment there should be… a little bit more rigidity or more routine (Participant 9).

      4. Discussion

      This qualitative study is one of the first to examine the perceptions and experiences of addiction counselors who work in MMT programs that used the open-access model to scale up treatment capacity. Given the success of the open-access model in scaling up treatment capacity without any negative impact on retention, survival, or relapse (
      • Madden L.M.
      • Farnum S.O.
      • Eggert K.F.
      • Quanbeck A.R.
      • Freeman R.M.
      • Ball S.A.
      • Schottenfeld R.S.
      • Shi J.M.
      • Savage M.E.
      • Barry D.T.
      An investigation of an open-access model for scaling up methadone maintenance treatment.
      ), and the importance of addiction counselors in providing the psychosocial treatment component of MMT, an understanding of APT counselors' perceptions and experiences of the open-access model may be valuable to opioid treatment program managers who are considering scale up of MOUD to address the opioid crisis. Themes that emerged from interviews centered on the model's impact on counselors, clients, and the broader community. As a context for interpreting the findings, it is important to note that participants did not receive training in the open-access model prior to working at APT; thus, their responses were a result of their personal work experience.

      4.1 Description accuracy

      Following the prompt to describe “open access,” counselors were consistently able to identify key aspects of the model, including those that distinguish it from treatment-as-usual: same-day treatment access irrespective of ability to pay, team-based approach to care, no individual caseloads, and a patient-centered focus. Consistent with our expectations, counselors discussed reduced barriers to MMT access as a core feature of the open-access model. Participants also emphasized that offering clients choices about which counseling groups to attend enhanced client autonomy (see Section 4.2.2). When asked to generally describe the model, we were surprised that counselors emphasized features related to the community, including enrolling high acuity clients into MMT. We expected that counselors would be focused mainly on features of the model that relate to clients and clinicians. Across the United States, it is notable that individuals with higher versus lower psychiatric acuity experience longer wait times to MMT entry and are thus at greater risk of not entering this evidence-based treatment (
      • Gryczynski J.
      • Schwartz R.P.
      • Salkever D.S.
      • Mitchell S.G.
      • Jaffe J.H.
      Patterns in admission delays to outpatient methadone treatment in the United States.
      ). The open-access model has curtailed wait time (clients generally enroll in MMT on the same day they seek it); in doing so, this model may have dismantled a barrier to enrollment among those with high acuity. These findings are important because they suggest that the open-access model is distinctive from treatment-as-usual to first-line clinicians, and that counselors are aware both of the driving forces behind the model and its possible benefits to the community as well as to clients. The accuracy of counselors' descriptions is important since awareness may foster adherence.

      4.2 Advantages of open-access model

      In response to prompts to describe the open-access model and its advantages, participants described clinician-level, client-level, and community-level factors.

      4.2.1 Clinician level

      Counselors generally reported an overall positive experience with the open-access model. Many noted specific advantages related to shared provider responsibility for clients across teams and increased engagement of clients who were active in their choice of group attendance (as opposed to models that require clients to attend a set weekly group, or attend psychosocial treatments at increased frequency beyond the national minimum of monthly appointments). Consistent with our expectations, counselors described the removal of individual caseloads as an advantage of the model. One distinguishing feature of the open-access model is that counselors are not assigned a specific caseload of clients, nor are they required to schedule ongoing, individual sessions with clients. Instead, clients are assigned to clinical teams and are provided a range of group treatment options from which they choose and seek individual counseling as needed. Consequently, when counselors are out of the office, they have limited responsibilities related to client care, which allows them to more easily establish work-home life boundaries. The absence of individual caseloads among counselors in the open-access model contrasts with the large individual caseloads that community mental health clinicians often experience (
      • Hromco J.G.
      • Moore M.W.
      • Nikkel R.E.
      How managed care has affected mental health case management activities, caseloads, and tenure.
      ). Other providers have implemented group treatments for office-based buprenorphine/naloxone due to group treatment's cost-effectiveness (
      • Sokol R.
      • Albanese M.
      • Albanese C.
      • Coste G.
      • Grossman E.
      • Morrill D.
      • Roll D.
      • Sobieszczyk A.
      • Schuman-Olivier Z.
      Implementing group visits for opioid use disorder: A case series.
      ;
      • Sokol R.
      • Albanese M.
      • Chew A.
      • Early J.
      • Grossman E.
      • Roll D.
      • Schuman-Olivier Z.
      Building a Group-Based Opioid Treatment (GBOT) blueprint: A qualitative study delineating GBOT implementation.
      ). Our findings that counselors employed in MMT programs that use an open-access treatment model perceive their work as challenging but also feel that they focus less on work when out of the office extend prior studies that counselors experience less burnout when they view their work as nonrepetitive and when they treat clients who demonstrate clinical improvements (
      • Beitel M.
      • Oberleitner L.
      • Muthulingam D.
      • Oberleitner D.
      • Madden L.M.
      • Marcus R.
      • Eller A.
      • Bono M.H.
      • Barry D.T.
      Experiences of burnout among drug counselors in a large opioid treatment program: A qualitative investigation.
      ).

      4.2.2 Client level

      One goal of the open-access model was to reduce barriers to MMT access and retention. A public health mission to both increase access to evidence-based treatment in response to the opioid crisis and mitigate the stigma that clients who attend MMT programs experience informed this goal (
      • Earnshaw V.
      • Smith L.
      • Copenhaver M.
      Drug addiction stigma in the context of methadone maintenance therapy: An investigation into understudied sources of stigma.
      ;
      • Olsen Y.
      • Sharfstein J.M.
      Confronting the stigma of opioid use disorder—And its treatment.
      ;
      • Smith L.R.
      • Mittal M.L.
      • Wagner K.
      • Copenhaver M.M.
      • Cunningham C.O.
      • Earnshaw V.A.
      Factor structure, internal reliability and construct validity of the methadone maintenance treatment stigma mechanisms scale (MMT-SMS).
      ). Counselors brought up client-level benefits of the open-access model both when asked directly about advantages and when asked to describe the model. When describing the open-access model, counselors stated that the structure of the open-access program fostered choice and this choice empowered clients. As expected, this theme emerged when asked about the advantages of the open-access model, with participants saying it fostered client choice, autonomy, and well-being. Autonomy and choice are related to self-efficacy, a central concept in successful self-management of chronic medical conditions (
      • Bodenheimer T.
      • Lorig K.
      • Holman H.
      • Grumbach K.
      Patient self-management of chronic disease in primary care.
      ). Future studies should examine if open-access models impact patient-reported self-efficacy and whether this relates to treatment retention.
      Counselors emphasized that logistical aspects of the open-access model (reduced waiting time/same-day treatment access, elimination of scheduled appointments, and enrolling eligible individuals irrespective of their resources) reduced barriers to MMT access for prospective clients and provided client-centered psychosocial services. Enrolling eligible patients in MMT irrespective of their ability to pay also addresses a significant barrier to self-management of chronic medical conditions (i.e., lack of financial resources) (
      • Jerant A.F.
      • von Friederichs-Fitzwater M.M.
      • Moore M.
      Patients’ perceived barriers to active self-management of chronic conditions.
      ). Waiting times of at least one month for methadone maintenance are common in the United States (
      • Andrews C.M.
      • Shin H.-C.
      • Marsh J.C.
      • Cao D.
      Client and program characteristics associated with wait time to substance abuse treatment entry.
      ) and prior research has found that individuals referred to MMT from the criminal justice system, those with lower educational levels, those with co-occurring psychopathology, or those who are of racial/ethnic minority status are at increased risk of not enrolling in methadone maintenance when faced with such long intake waiting times (
      • Gryczynski J.
      • Schwartz R.P.
      • Salkever D.S.
      • Mitchell S.G.
      • Jaffe J.H.
      Patterns in admission delays to outpatient methadone treatment in the United States.
      ). Thus, it seems counselors view the primary goals of the open-access model, which were to broaden access and minimize waiting time, as advantages. Future research should systematically examine if demographic changes occur following a program's transition to the open-access model, particularly in terms of these historically marginalized groups who are disproportionally disadvantaged (
      • Gryczynski J.
      • Schwartz R.P.
      • Salkever D.S.
      • Mitchell S.G.
      • Jaffe J.H.
      Patterns in admission delays to outpatient methadone treatment in the United States.
      ;
      • Madden L.M.
      The US substance abuse treatment system as an expression of culture.
      ) and whether the provision of open-access mitigates “institutionalized stigma” among those enrolled in methadone maintenance (
      • Harris J.
      • McElrath K.
      Methadone as social control: Institutionalized stigma and the prospect of recovery.
      ).

      4.2.3 Community level

      Counselors suggested that certain aspects of the open-access model benefitted the local community. These benefits centered on the idea that any member of the community could receive timely, standard-of-care treatment, and that these changes enabled more vulnerable members of the community to do so (i.e., those with higher psychiatric acuity, fewer financial resources). When asked to describe the advantages of the open-access model, counselors noted that increased enrollment provided the perceived benefits of decreased overdoses, mortality, and crime to the community. We did not expect that community impacts would arise as a theme because we thought they would be less noticeable to counselors than changes within the clinic. Prior findings about the effectiveness of MOUD in attenuating risk of infection with HIV and hepatitis C, and in reducing opioid overdose, all-cause mortality, and crime support the perceived community advantages of methadone maintenance scale-up (
      • Volkow N.D.
      • Frieden T.R.
      • Hyde P.S.
      • Cha S.S.
      Medication-assisted therapies—Tackling the opioid-overdose epidemic.
      ). The extent to which perceived community advantages offsets the previously reported stigma associated with being an addiction counselor merits further research (
      • Oberleitner D.E.
      • Marcus R.
      • Beitel M.
      • Muthulingam D.
      • Oberleitner L.
      • Madden L.M.
      • Barry D.T.
      “Day-to-day, it’sa roller coaster. It’s frustrating. It’s rewarding. It’s maddening and it’s enjoyable”: A qualitative investigation of the lived experiences of addiction counselors.
      ).

      4.3 Disadvantages

      Counselors also highlighted disadvantages of the open-access program, particularly within the client-related and clinician-related themes. These concerns may be important for any opioid treatment program to consider when attempting scale up. Although APT has implemented interventions to address some of these perceived shortcomings (see below), future research on the open-access model should examine how to further mitigate these possible disadvantages.

      4.3.1 Clinician level

      We anticipated that clinicians would experience the reduced emphasis on the one-to-one relationship with clients as a primary negative personal impact. Although therapeutic relationship arose as a theme when discussing disadvantages to clients (see Section 4.3.2), we were somewhat surprised that it did not emerge more frequently as a perceived disadvantage to clinicians. We were surprised that some clinicians reported uneven workloads and high perceived demands as disadvantages of the open-access model. It appears that the high volume of clients in the open-access model presents challenges in the day-to-day work of some clinicians. Since clients select the type and time of groups that they attend, clinicians do not determine the flow of clients at APT as much as might occur in other treatment settings that offer counseling one-on-one by appointment.
      Consistent with other findings on reduced waiting time, the implementation of the open-access model at APT was associated with an increase in psychiatric acuity among clients enrolled in methadone maintenance (
      • Gryczynski J.
      • Schwartz R.P.
      • Salkever D.S.
      • Mitchell S.G.
      • Jaffe J.H.
      Patterns in admission delays to outpatient methadone treatment in the United States.
      ;
      • Madden L.M.
      The US substance abuse treatment system as an expression of culture.
      ). Although this represents a good public health outcome (
      • Madden L.M.
      The US substance abuse treatment system as an expression of culture.
      ), an unintended consequence may have been that some counselors perceived the increase in both volume of clients and level of acuity as challenging, or in some cases, threatening. In response to the findings from this quality improvement project, supervisors at APT now assess and address these concerns with addiction counselors, and APT has strengthened its onsite provision of clinical training opportunities (e.g., assessing and managing comorbid psychopathology) with free continuing education units offered to licensed providers (e.g., licensed clinical social workers). Program managers from opioid treatment programs who wish to implement the open-access model may also benefit from implementing these strategies.

      4.3.2 Client level

      When outlining client disadvantages, counselors noted how the structural changes inherent in the open-access model may be challenging to navigate for certain patients. We anticipated that clinicians would experience the diminished emphasis on of the traditional individual therapeutic relationship as a drawback for clients. Indeed, some clinicians reported that the lack of an assigned counselor may limit formation of a therapeutic relationship. We were surprised that some counselors highlighted how patients might experience the absence of appointment-making as chaotic. Both clients and clinicians may be more familiar with treatment settings where individual counseling by appointment is the norm. Specifically, some clinicians described clients with high clinical needs who struggled to take advantage of useful therapeutic opportunities, despite their availability (e.g., counseling groups, onsite primary care, and psychiatric services). Some counselors also expressed frustration that they were unable to do more for those clients who they perceived as having great need but were not engaging in treatment; although counselors' noted that these clients did not represent the typical client who they served. In response to these concerns, the administrators at APT strengthened intensive outpatient programing for patients who continue to exhibit illicit opioid use or psychiatric distress. Whether the team-based approach to treatment inherent in the open-access model and the availability of multiple counseling groups from which clients choose facilitate an increased institutional, rather than individual provider, alliance is unclear (
      • Pulido R.
      • Monari M.
      • Rossi N.
      Institutional therapeutic alliance and its relationship with outcomes in a psychiatric day hospital program.
      ).

      4.3.3 Community level

      A surprising finding was that counselors did not generate any community disadvantages, either in their description of the open-access model or when directly asked about its disadvantages. Public discourse about the opioid crisis has involved negative perceptions from some community members about this evidence-based treatment (
      • Heimer R.
      • Hawk K.
      • Vermund S.H.
      Prevalent misconceptions about opioid use disorders in the United States produce failed policy and public health responses.
      ), including misconceptions that substance use treatment facilities incur increased crime (
      • Boyd S.J.
      • Fang L.J.
      • Medoff D.R.
      • Dixon L.B.
      • Gorelick D.A.
      Use of a “microecological technique” to study crime incidents around methadone maintenance treatment centers.
      ;
      • Furr-Holden C.D.M.
      • Milam A.J.
      • Nesoff E.D.
      • Johnson R.M.
      • Fakunle D.O.
      • Jennings J.M.
      • Thorpe Jr., R.J.
      Not in my back yard: A comparative analysis of crime around publicly funded drug treatment centers, liquor stores, convenience stores, and corner stores in one mid-Atlantic city.
      ). Counselors' perceptions in this study regarding the efficacy of methadone maintenance to reduce opioid use, opioid-related overdose, and all-cause mortality align with scientific evidence (
      • Volkow N.D.
      • Frieden T.R.
      • Hyde P.S.
      • Cha S.S.
      Medication-assisted therapies—Tackling the opioid-overdose epidemic.
      ). Despite the devastating toll that untreated OUD has taken on U.S. communities, many still have inadequate access to MOUD (
      • Abraham A.J.
      • Andrews C.M.
      • Harris S.J.
      • Friedmann P.D.
      Availability of medications for the treatment of alcohol and opioid use disorder in the USA.
      ); the extent to which misconceptions about MOUD approaches are related to inadequate access to MOUD in these communities is unclear.

      4.4 Limitations and future directions

      This study had several limitations. Although the coded responses from the interviews yielded potentially important themes related to counselors' perceptions and experiences of implementing the open-access model, we did not collect data from community members or patients to corroborate these themes. Counselors who we interviewed for the current study had chosen to work within the open-access treatment model and their perceptions and experiences of open-access may not reflect those of other addiction counselors. For example, counselors who have a negative response to open-access may have left APT to work in a traditional opioid treatment program. To protect the anonymity of counselor responses, we did not ask them about their previous work experiences during interviews. Some of the counselors included in the current study may have limited work experience outside of this open-access model and their understanding and perceptions of the treatment model might be different from those counselors who have worked in settings that provide alternative models of care. We drew participants from methadone maintenance programs that a single not-for-profit, community-based organization in Connecticut operated. The extent to which study findings generalize to addiction counselors who work in programs with different treatment models or in different geographic locations is unclear.
      Future studies should assess clients' experiences of being treated in opioid treatment programs that use the open-access model. Clarity about which facets of the open-access model, if any, promote client autonomy and well-being would be useful. Our knowledge base would also benefit from research that examines which clinicians and clients respond favorably or unfavorably to the open-access or other models that are designed to enhance access to MOUD. Research should further examine the disadvantages of the open-access model that counselors described as well as how this model compares with and differs from other treatment models that these counselors have encountered in their work. Given the emphasis on team-based treatment in the open-access model, investigators should consider examining individual and institutional alliances among patients to determine whether these different alliances affect treatment outcomes.

      4.5 Conclusion

      Counselors who work in opioid treatment programs that have used an open-access model to increase treatment capacity report benefits to themselves, their clients, and the public. Research should explore the perceived disadvantages that counselors outlined and address these disadvantages so that programs can scale up MMT.

      Author statement

      This quality improvement study was funded by the APT Foundation, Inc., and a grant from the U.S. NIH/NHLBI to Dr. Barry (MPI; U01 HL150596-01). The findings of this study were presented in part at the 81st Annual Scientific Meeting of the College on Problems of Drug Dependence—San Antonio, TX, June 16, 2019. The study in this manuscript represents original research, has not been submitted for publication elsewhere, and has not been published in whole or in part in any other peer-reviewed media. All relevant ethical safeguards have been met in relation to subject protection.

      Declaration of competing interest

      All authors declare that they have no conflicts of interest over the past five years to report as related to the subject of the report.

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