Research Article

Introduction

Rates of opioid-related morbidity and mortality continue

at epidemic levels. In 2016, an estimated 2.1 million

people in the United States (McCance-Katz, 2018)

and 26.8 million people worldwide were living with

opioid use disorder (OUD; Strang et al., 2020). In the

United States specifically, the crisis is most pronounced

in rural regions, which have experienced the largest

increase in the rate of fatal overdose to opioids over the

past decade (Mack et al., 2017). Excessive opioid prescribing

and illegal diversion of these prescriptions have

driven the expansion of the crisis in rural areas, where

morbidity parallels mortality and prescription opioid

overdose rates are more than twice those in urban areas

(Mack et al., 2017). This holds true in the rural counties

of northern New Mexico, where the national opioid crisis

emerged in the late 1990s (Rossen et al., 2017), and

has remained a persistent hot spot in the national opioid

crisis ever since (Scholl et al., 2019).

The epidemic is largely driven by the overprescribing

of opioids to treat chronic pain, which can be tracked to

rural America (Monnat & Rigg, 2016) where higher rates

of labor-based occupations cause an increased risk of

work-related injury and an associated disability due to

chronic pain (Florence et al., 2012). In rural communities,

use of prescription opioids to manage chronic pain

can be perceived as less harmful than heroin and even

necessary to maintain steady employment (Keyes et al.,

2014), embedding their use into the structure of rural culture.

Because prescription opioids are less intoxicating,

more difficult to access due to heightened prescription

surveillance, and more expensive when purchased illegally

(Brady et al., 2016; Meyer et al., 2014), many rural

prescription opioid misusers transition to injection heroin

use (Cicero & Kuehn, 2014). This conversion has led to a

dual prescription opioid and heroin crisis in rural regions,

which is exacerbated by a lack of access to health care

services, including specialty services such as mental

health and substance use treatment.

938689QHRXXX10.1177/1049732320938689Qualitative Health ResearchScorsone et al.

research-article2020

1Regis University, Denver, Colorado, USA

2The University of New Mexico, Albuquerque, New Mexico, USA

3Pacific Institute for Research and Evaluation, Albuquerque, New

Mexico, USA

4El Centro Family Health, Espaola, New Mexico, USA

Corresponding Author:

Krista L. Scorsone, Loretto Heights School of Nursing, Regis

University, 3333 Revd., Denver, CO 8022

Overcoming Barriers: Individual

Experiences

Abstract

Medication-assisted treatment (MAT) for opioid use disorder (OUD) is accessed half as often in rural versus urban

areas in the United States. To better understand this disparity, we used a qualitative descriptive approach to explore

the experiences of individuals with OUD seeking MAT in rural New Mexico. Guided interviews were conducted with

20 participants. The frameworks of critical social theory, intersectionality theory, and the brain opioid theory of social

attachment were used to guide data analysis and interpretation. Thematic content analysis derived five major themes

which identified novel barriers and facilitators to MAT success, including a perceived gender disparity in obtaining

MAT, challenges in building a recovery-oriented support system, and the importance of navigating a new normal social

identity. This deeper knowledge of the experiences and perspectives of rural individuals with OUD could serve to

address the rural-urban MAT disparity, leading to enhanced recovery capacity and transformative policies.

Keywords

opioid use disorder; medication-assisted treatment; rural health; health care disparities; qualitative description; New

Mexico

2104 Qualitative Health Research 30(13)

Substance abuse prevention and treatment remain a

national priority, with increased access to treatment providers

and substance use services set as a benchmark goal

as outlined in Healthy People 2020 (U.S. Department of

Health and Human Services, 2012). Yet significant disparities

in substance abuse treatment persist nationally in

rural areas. Rural individuals seeking treatment for OUD

are affected by environmental, economic, and systemlevel

barriers, which include a lack of mental health providers,

geographic misdistribution of substance use

treatment facilities, income-related impediments, health

care insurance gaps, and logistical issues related to the

physical isolation of rural communities (Lister et al.,

2020)

Medication-assisted treatment (MAT) is an evidencebased

treatment for OUD that includes the use of medications

combined with counseling and behavioral therapies

(National Institute on Drug Abuse, 2016; Substance

Abuse and Mental Health Services Administration, 2016;

World Health Organization, 2017). MAT includes three

Food and Drug Administration (FDA)-approved pharmacotherapies:

buprenorphine, methadone, and naltrexone.

The opioid receptor agonists buprenorphine and methadone

reduce cravings and symptoms of opioid withdrawal

by binding to opioid receptors in the brain, whereas the

opioid antagonist naltrexone functions by blocking the

signaling pathway that supports the rewarding effect of

opioids (Brady et al., 2016). MAT is an evidence-based

and cost-effective treatment that reduces opioid-related

morbidity and mortality, dependence on illicit opioids,

the rate of needle-borne infectious disease, and the incidence

of illegal behavior, with evidence also suggesting

improved social and occupational outcomes following

treatment (Jones et al., 2015; Sigmon, 2014).

Although MAT's efficacy has driven it to become

widely available, both nationally and in New Mexico

(NM; Komaromy et al., 2016), it is accessed less frequently

rurally, a phenomenon that may contribute to the

higher drug overdose death rate in rural communities.

Overall, the factors underlying the reduced use of MAT to

treat OUD in rural versus urban areas are poorly defined,

and there is little information about how the experiences

of rural individuals seeking MAT impact this disparity.

Study Purpose

As NM ranks among the top for opioid-related deaths in

rural counties, this qualitative descriptive study aimed to

explore the knowledge and perspectives of individuals in

rural NM with OUD regarding MAT and to describe their

experiences seeking MAT. An enhanced contextual

understanding of the experiences and perspectives of this

group may help to address the gap in our understanding

about barriers to seeking MAT in rural areas and may

uncover opportunities to enhance individual and community

recovery capacity.

Method

Study Design and Theoretical Framework

We used a qualitative descriptive approach, embracing

naturalistic inquiry, to describe the experience of individuals

with OUD, with the goal of producing a comprehensive

summary of specific occurrences experienced by

individuals (Sandelowski, 2000, 2010). By using this

approach, the research team was able to explore the perspectives

of rural individuals seeking MAT in depth and

in their own words, ultimately providing a straightforward

description of the patient-level barriers.

Critical social theory, intersectionality theory, and the

brain opioid theory of social attachment informed data

analysis and interpretation. Critical social theory

addresses institutionalized inequities with the goal of creating

transformative opportunities for social action while

fostering community empowerment (Kincheloe et al.,

2011). In this research, we used critical social theory to

examine the socially constructed and historically constituted

overarching power relations at the macro level. Our

integration of intersectionality theory facilitated our

exploration of multiple and interconnected systems of

oppression, assisting in our analysis of the social identities

and societal power dynamics that are inherent in all

health care experiences (Carbado et al., 2013; Crenshaw,

1991). Individuals with OUD inadvertently become

enmeshed in these overarching power systems as they

seek to acquire and use MAT. Integrating the brain opioid

theory of social attachment provided a framework to

explore how experiences of social loss affected opioid

use and led to feelings of disconnection and separation

distress (Inagaki et al., 2016; Machin & Dunbar, 2011;

Nocjar & Panksepp, 2007; Zellner et al., 2011). Given

that OUD is characterized by persistent social, occupational,

financial, and legal problems resulting in feelings

of rejection and disconnection, individuals may seek

exogenous opioids because they abate feelings of separation

distress.

Together, these complementary theories grounded this

research theoretically, offering a lens through which the

interconnecting forces that influence opioid use and its

treatment in rural environments were viewed (Figure 1).

Overall, we posited that OUD and obtaining MAT occurs

in the context of dynamic and multifaceted relationships

between individuals and environments that both overlap

and intersect at macro and micro levels, creating a risk

environment. This risk environment is broadly defined as

the space in which a variety of factors interact to affect

both the production and reduction of drug harms (Rhodes,

Scorsone et al. 2105

2002, 2009). This integrated theoretical model was used

to uncover ways to overcome stigma related to OUD and

MAT, to promote social justice, and to enhance individual

and community recovery capacity.

Study Location and Context

Due to the persistent, historical, and continuous presence

of population-wide OUD in this region, New Mexico's

Rio Arriba County has been identified as the epicenter of

the opioid overdose crisis in rural America. Between

2011 and 2015, it had the highest rate of drug-related

deaths of any county in the United States (Rossen et al.,

2017), with 85.8 deaths per 100,000 people, more than

five times the national average 16.4 deaths per 100,000

people during that same time frame (New Mexico

Department of Health, 2017). Rio Arriba County is a culturally

diverse region (Garcia, 2010; Zentella, 2004) that

is designated as rural by the Federal Office of Rural

Health Policy which defines rurality as all population

centers and land area not included in urbanized areas of

50,000 or more people, or in urban clusters of between

2,500 and 50,000 people (Health Resources and Services

Administration, 2017).

In 2017, Rio Arriba County had a population of

40,040, comprising 70.8% Hispanic or Latino, 19.7%

American Indian or Alaska Native, and 12.7% White,

non-Hispanic, or non-Latino (U.S. Census Bureau, 2016).

The local community is recognized for its resilience and

tight-knit established family and social networks and

there is a strong spiritual connection to the land (Trujillo,

2009). Given these demographic and cultural characteristics,

Rio Arriba County was a useful setting to study the

experiences of rural individuals with OUD seeking MAT,

to explore the multicultural aspects of OUD and its treatment,

and to identify factors that promote health and

recovery.

Sampling and Recruitment

We used a purposeful sampling strategy to recruit participants

from a rural primary care health clinic in northern

NM that provided MAT (buprenorphine and naltrexone,

but not methadone). A recruitment flyer was posted in the

waiting and exam rooms with the cooperation of the

director of the clinic's opioid treatment program. We

recruited 20 participants who had experience with OUD

and MAT according to the following inclusion criteria: 18

years of age or older, living in northern NM, met

Diagnostic and Statistical Manual of Mental Disorders

(5th ed.; DSM-5; American Psychiatric Association,

2013) criteria for OUD, and had current or prior experience

with MAT (Supplemental Table 1). We excluded

anyone who was unable to provide informed consent, or

could not read, understand, or speak English. Interested

potential participants contacted the principal investigator,

Krista Scorsone, directly, either in person or by phone.

All of the interviews took place in a location that was

mutually agreed upon by Krista Scorsone and the participant,

and were selected based on criteria for safety and

privacy.

Ethical Considerations

The overseeing university reviewed and approved the

research protocol. A waiver of written consent was

approved by the Human Research Protections Office, and

verbal consent was sought. Due to the historical mistrust

in the target population regarding participation in health

research, we obtained a waiver of documentation of consent

to enhance the quality of data and increase feasibility

for recruitment.

Data Collection

Data included a demographic questionnaire and audiorecorded,

guided interviews. These audio-recorded interviews

ranged between 40 and 90 minutes. We used an

interview guide (Table 1) to prompt discussion about

experiences regarding MAT. Data also included extensive

field notes, which included observations and nonverbal

communication.

Individuals

Seeking MAT

Brain Opioid Theory

of Social Aachment

Interseconality

Theory

Crical Social

Theory

Economic

Social

Physical

Policy

Risk Environment

Macro

s AT

Econom

Macr

Micro

Figure 1. Theoretical framework model. Depiction of

the integrated theoretical framework used to ground this

research.

2106 Qualitative Health Research 30(13)

The initial interviews were followed by a second phase

of follow-up interviews with nine of the original participants

to solicit feedback on our preliminary analysis.

These follow-up interviews were procedurally similar to

the initial interviews. Once participants were briefed on

their rights as research subjects and provided verbal consent,

they were given a brief summary of preliminary

findings. As we reviewed these findings with the followup

interview participants, we asked them to comment on

the resonance of these themes as they related to their personal

experiences with MAT and OUD. The participants

also gave their impressions regarding the overall fit of the

research findings to their understandings of the larger

community experience of living with OUD.

Data Analysis

Data analysis was an iterative process that we conducted

simultaneously with data collection to improve accuracy

in the interpretation of the data, with concurrent analysis

informing the process of additional data collection

(Thorne, 2000). We transcribed the audio-recorded interviews

verbatim, and our field notes were incorporated

into the transcripts as observational notes. Krista Scorsone

reviewed every transcript for accuracy while listening to

the corresponding audio recording. We used the NVivo12

software package to facilitate our qualitative data analysis.

We analyzed all the qualitative data using conventional

content analysis involving open, axial, and selective

coding (Hsieh & Shannon, 2005). Our iterative process of

analysis took the following course: We first read through

the transcripts multiple times, creating annotations and

drawing connections between field notes and across

interviews. These multiple readings led to the development

of initial thematic codes, which we then applied

across all the interviews. The research team met regularly

to discuss and modify the codes until we reached consensus

regarding the thematic coding scheme. We maintained

a detailed audit trail throughout the research

process documenting all methodological decisions. Our

continued analysis and thorough documentation of

impressions led to the emergence of labels for the open

coding scheme, which we then assessed for patterns and

grouped into meaningful clusters. As we developed thematic

clusters, we reviewed these preliminary results

with participants to aid in member-checking. This iterative

process continued until we reached data saturation,

the point at which the interview transcripts supported prevailing

themes and did not generate any emerging novel

themes (Patton, 2015). Sampling was determined by saturation

of the analysis. Throughout the data collection and

analysis process, we kept reflexive notes to identify and

separate the researchers' experiences, assumptions, and

values from the methodological decisions made, ensuring

that the thematic coding of the data best represented the

participant's perspectives.

We established methodological rigor by ensuring that

the components of trustworthiness relevant to qualitative

research were addressed (Krefting, 1991; Thomas &

Magilvy, 2011). We used triangulation, the process of

checking against qualitative interviews, participant observations,

field notes, memos, and other relevant documents

(Patton, 2015), to reduce bias and enhance credibility. The

follow-up member checking interviews with participants

occurred to solicit evaluative feedback of the preliminary

findings. This allowed us to ensure that the results reflected

their experiences, beliefs, and perspectives and not our

isolated interpretations of the information they shared

with us in their interviews. We collected key demographic

information to provide a rich description of these participants.

This allows us to ensure transferability where possible,

although because this is a small and tightly knit

community, we cannot disclose the full extent of the

demographic data we collected. We kept field notes documenting

every phase of the research process which provided

a thorough audit trail and enhanced trustworthiness

and dependability of the data (Creswell, 2013; Krefting,

1991; Thomas & Magilvy, 2011; Thorne, 2008). Also

enhancing credibility, we practiced reflexivity throughout

the course of data collection and data analysis. Related to

this, Krista Scorsone is a psychiatric nurse practitioner

with experience working with individuals diagnosed with

Table 1. Interview Guide.

Question Number Question

Question 1 Can you tell me about your experience with opioid use?

Question 2 Can you tell me about a time when you sought help for opioid use?

Question 3 When you sought treatment, why did you do so? Prompt: What was the experience like?

Question 4 What are your views about MAT?

Question 5 How do others in your community view MAT?

Question 6 What is your everyday experience with using MAT? Prompts for this question were based on the

participant's experience regarding firsthand use or observations of others' use of MAT.

Question 7 How can healthcare providers and the community support you in achieving your best health?

Note. MAT = medication-assisted treatment.

Scorsone et al. 2107

substance use disorders, including OUD. Although she

had no prior relationship with the recruited participants,

critical self-reflection of prior assumptions and values was

necessary to distinguish her role as a researcher rather

than as a provider in the context of this research. To protect

against researcher bias and to ensure trustworthiness,

Krista Scorsone routinely discussed her thoughts with

other members of the research team.

Findings

Participant Demographics

We recruited 20 participants, 10 men and 10 women,

who were either receiving, had been denied, or opted

out of MAT treatment. Key participant demographics

are presented in Supplemental Table 1. The average

age of the participants was 36, ranging from 23 to 63.

The self-identified racial/ethnic profile was a mix of

Hispanic, Spanish, and American Indian. The average

number of years using opioids was 13; 10 participants

reported using only heroin, one participant reported

using only prescription pain pills, and nine participants

reported using both pills and heroin.

Descriptive Themes

A total of five descriptive themes related to MAT emerged

from the data: "It's Hard to Have to Wait," "Suboxone Is

Better, But You're Still Hooked," "Able to Live a Normal

Life," "Staying Clean," and "No Matter What, You're

Labeled." These themes reflected individual-level, health

care system-level, and community-level facilitators and

barriers (Figure 2) which are fully described below.

It's Hard to Have to Wait. Participants described several

challenges in obtaining MAT. Notably, the greatest barrier

was the long waitlist for both methadone- and

Figure 2. Thematic model. Descriptive themes reflecting individual-level, health care system-level, and community-level

facilitators and barriers.

Note. MAT = medication-assisted treatment.

2108 Qualitative Health Research 30(13)

buprenorphine-based treatment. Participants mentioned

that only one methadone maintenance program was

available locally, with little movement on the wait list.

Some participants described trying to gain access to

methadone in surrounding counties, but this was difficult

for them due to financial and travel limitations.

Openings often emerged at the last minute and they had

to be ready and able to show up immediately for an initial

appointment to enter the program. Frequently, the

inconvenience of the system and long waits discouraged

them from seeking treatment altogether:

There's never room. It's always full. I've tried to get on it a

few times, and it's a hassle. There are never enough times

available. Like, if you go sign up, and there's openings, you

have to be there like by 4 in the morning, just to have a spot

at 9. Then, they're only taking-there's like 30 people waiting,

and they're only taking not even half of them, maybe 10

people will get signed in if they're lucky.

Similarly, participants found it challenging to locate a

provider willing and able to prescribe buprenorphine.

Restrictions on the number of patients who could be

treated by any one provider also led to long wait lists and

prolonged periods of time before treatment could be initiated.

When they were finally ready to seek MAT, the

experience of waiting and being denied access was frustrating,

and some of the participants said this caused them

to give up. In addition, to initiate treatment with buprenorphine,

participants were required to submit a urine sample

proving their opioid use:

I had just gotten out of jail, and I didn't want to start using

heroin again, so I came here [clinic] right away.

Unfortunately, in order to start the Suboxone program, you

have to be in withdrawal from heroin. You can't be clean and

start, which I think is so stupid. When they told me that, they

basically told me, "You have to go out and get dirty to start

the program," so I didn't start, and then I ended up doing it

anyway. I just never came back.

An important novel finding was a perceived gender disparity

among both male and female participants regarding

access to MAT. Female participants, particularly

those who were pregnant, felt they were able to access

buprenorphine more easily than male participants. As a

result, female participants who were in a relationship

with a male partner who was either on a MAT wait list or

unable to access buprenorphine said they felt pressure to

share their medications.

Access was so limited, some male participants contemplated

committing low-level drug crimes as a means

to expedite access to MAT through jail diversion treatment

programs. For those who faced long wait times, the

use of the criminal justice system was considered to be

their only option. These obstacles drove participants to

rely on diverted buprenorphine prescriptions while waiting

to formally start MAT. Participant experiences with

MAT diversion included selling buprenorphine, having

their prescription stolen, or buying diverted buprenorphine

prescriptions. In each circumstance, the diverted

buprenorphine was used to prevent opioid withdrawal for

themselves or for someone else. Participants feared the

legal risks associated with diversion but felt that it was

preferable to buying heroin.

Suboxone Is Better, But You're Still Hooked. Participants

favored buprenorphine over both heroin and methadone.

All of the participants had some experience taking

buprenorphine, and most were familiar with Suboxone,

the sublingual formulation of buprenorphine which they

referred to as "sub." They described many advantages of

buprenorphine over heroin, notably that it is legal and

having access to a legal prescription and a full-month

supply eliminated the physical, social, emotional, and

legal risks that are associated with heroin use. Buprenorphine

allowed them to avoid the sickness of withdrawal

which was compared with the pain of dying.

All participants said they preferred buprenorphine

over methadone. When compared with buprenorphine,

methadone use was believed to be associated with various

disadvantages including tooth loss and becoming

"swollen." Participants who had not taken methadone

but had knowledge about it expressed additional concerns

that chronic methadone use caused noticeable

cachexia. These physical side effects were perceived to

be a sign of methadone use and heroin addiction, and

easily observable by others in the community. This led

to stigma, which combined with the physical discomfort

of the drug to make methadone intolerable. They also

reported feeling intoxicated from the methadone, and

polysubstance use while on methadone was common

practice. When comparing methadone to buprenorphine,

one participant said,

I prefer to be either one way or the other. Like with

methadone, you get high, and you still feel like you're using

drugs when you're on the drug, because you're high. With

Suboxone, you don't get high, you just getI don't know

what youpretty good, too, because it helps you to make

better choices. You're more alert, and your head starts to

unfog. You start to clean up. You get back in your state of

mind. With methadone, I think you just stay [high], but then

some people like that. Some people don't want to be straight

or sober. They just want something to where they could get

high and do whatever and go about their day, and methadone

is the answer for them.

Although buprenorphine was the preferred treatment,

participants did not like being dependent on it. Like with

Scorsone et al. 2109

heroin, prolonged and sustained use of the medication led

to dependency. They described their experience as "still

hooked" and that treatment with buprenorphine had

enabled them to become a "functioning addict." Although

there was positive impact on quality of life with buprenorphine,

physiological dependence on it caused difficulty

separating one opioid addiction from another:

I don't think there's any real difference, because even if you

get prescribed it, it's still being hooked on a drug. You still

need it. If you don't have it, you still get sick from it.

Whether you get it from a doctor, or you get it from the

streets, it's still being dependent on a drug . . . . I can do

everything I have to do, but at the end of the day, all I'm

worried about is doing my sub [buprenorphine], getting my

sub. "I need to get my prescription. I need to go to the

doctor." It's the same thing.

Participants described several situations that could prevent

them from accessing buprenorphine including cost,

issues with insurance, insufficient pharmacy supply, and

medications being stolen. Most participants were hypervigilant

about checking their prescriptions and refilling

as soon as they were able to avoid being without medication

and the resulting withdrawal symptoms. Participants

described withdrawal symptoms from Suboxone as

severe, which motivated them to maintain their treatment.

Nevertheless, despite the many benefits of

buprenorphine, participants felt conflicted about their

feelings related to the medication.

Able to Live a Normal Life. Participants described MAT as

critical to helping them live a functional, productive, and

normal life. Prior to initiating treatment, participants

described themselves as already dead because they were

entrenched in a continuous cycle of opioid-seeking

behaviors. Access to MAT enabled them to break free

from the pattern of isolation, social withdrawal, and illegal

activities to support their illicit opioid use. This

prompted a desire to live again:

You're normal again. You're not like your old you. Now, you

want to be around family. You want to go to family gettogethers.

You want to live. You want to do things. You don't

just want to stay in a room and just shoot all day.

Participants valued the sense of freedom that MAT with

buprenorphine facilitated, particularly feeling a sense of

liberation from being tethered to feeding their heroin

dependence. Participants felt relieved not to have to

worry about the sickness of opioid withdrawal, which

was a novel occurrence that many had not experienced

for several years. Importantly, participants described the

positive feelings that developed from being responsible

for and in control of their buprenorphine prescriptions:

Suboxone just makes you normal. That's it. That's all it does.

It puts you to be normal, to live normal. The Suboxone, to

me, it's like I use it like as a crutch, because I know it helps

me with my pain, but I don't take advantage of it. I don't

ever take over more than I'm supposed to. I take it as I'm

supposed to. As I'm taking it the way I'm supposed to, it

works that way. I keep with the program.

Overall, participants were proud to share their treatment

successes. Taking their medications as prescribed facilitated

their enhanced autonomy and self-responsibility for

their recovery.

In recovery and on MAT, participants felt as though

they were able to live a normal life, yet they still viewed

themselves as different from others who have not shared

their experience of living with opioid addiction. They

described a separate reality, distinct from that which a

"normal" person might experience. This required a negotiation

of their identity within a separate and parallel

world. In recovery, participants were required to deal

with the physical, social, emotional, and legal consequences

of their opioid use. As difficult as this was, participants

found power in the conviction that through their

recovery they could help others:

It's hard. Hopefully, I can help people to try to get better. I

tell them, "You'll never be perfect. You're going to be

scarred for the rest of your life, but you can help yourself,

and you can help other people." That's the only thing we can

do. We can't go back and fix the people we hurt or ourselves

that we hurt, but we can carry on and try to make it better for

everybody else.

Staying Clean. Staying clean was a requirement for living

a functional, productive, and normal life and participants

discussed the significance of building a support system.

The process of staying clean from heroin while on

buprenorphine was characterized by relapses, but participants

typically reached a point where they just stopped

using. Because illicit opioid use is an epidemic in the

community where the participants lived, refraining from

heroin use was difficult at first because of entrenched personal

relationships that drew participants into relapse.

Finding new friendships and healthy environments was

particularly challenging, and it often took time:

You get weak at the time, or you're trying to get high, or you

just want to feel different, you still go back to it. It's not

because I'm not doing what I'm supposed to do. It's just

because in that one moment, I got weak, or I got too stressed

out and turned to what I knew what would comfort me or

what would comfort me prior to that the best.

Participants valued their relationships with their MAT

prescribers, which was foundational to recovery. They

appreciated having a provider committed to helping them

2110 Qualitative Health Research 30(13)

during times of weakness and setback. When they did

experience a relapse, they could be honest about their circumstances;

within the safety of a supportive provider-

patient relationship, participants learned to accept

responsibility and to be accountable for their behaviors,

fostering a therapeutic connection that served to facilitate

recovery and self-confidence. Notably, across care settings,

inconsistencies in the policies regulating MAT

access were also mentioned. Participants commented on

variability in health care providers' knowledge level

about OUD and MAT, with some providers having limited

experience. Some encountered providers with negative

biases and who were dismissive of their health

concerns once it was understood that the participant was

on MAT. Participants intentionally avoided providers

who were judgmental and that they could not trust.

In addition to taking medications and having a supportive

medical care provider, participants found counseling

and support groups to be helpful in facilitating

recovery. In general, participants preferred self-help over

therapist-led groups because they found it therapeutic to

be around others who also had a history of opioid use and

were in recovery. They found it difficult to connect with

therapists who had not shared the experience of being

addicted themselves. Participants discussed using

Narcotics Anonymous (NA) but did not always feel supported

in their recovery: "they [NA members] look at

Suboxone as a drug, because to them, they don't accept it.

Like I go to NA meetings, and they don't accept it as

treatment. They tell me that I'm still on drugs."

No Matter What, You're Labeled. Despite treatment successes

with MAT, participants still experienced stigma in

the community. Once participants were identified as having

an addiction to opioids, they were labeled as such.

Community perceptions related to opioid misuse were

consistently negative, which perpetuated feelings of loneliness,

rejection, and social isolation. Unfortunately, this

label did not go away with time and sustained sobriety.

Participants described feeling as if they were always

being judged by others. Participants voiced a strong

desire to have others in the community treat them with

dignity, respect, and as a human being. Participants suggested

this could be accomplished by changing language

commonly used when referring to individuals with OUD.

Routine use of insensitive rhetoric associated with the

word "addict" was hurtful, and it perpetuated social marginalization.

There was a belief that if the members of the

community could move beyond labeling and judging,

true opportunities to heal would emerge:

I think they should stop labeling addicts as addicts.

They're just people who have scars. They're just people

who are hurting. They're people who lack something in

their life, whether it's spiritual guidance, or love, or

whatever it is. Feeling lonely, anything, whatever it is that

makes them use. Help people to show them that there's

more to them than drugs.

Community members were viewed to have limited

knowledge about MAT, which contributed to the belief

that buprenorphine is a replacement for heroin, and just

another drug of addiction. In many cases, family members

and others in the community assumed that when

someone was taking their buprenorphine prescription,

they were doing it to get high. Thus, participants were

considered to be "still addicted" despite the fact they

were in recovery and no longer using heroin.

Participants also identified opioid overdose to be a

public concern and noted their experiences with stigma in

this context. Specifically, to counteract the life-threatening

respiratory depression caused by opioid overdose,

naloxone (trade name Narcan) was made available to participants,

their families, and others in the community who

had received opioid overdose prevention training. Despite

the obvious advantages to making access to this life-saving

medication available, community members were perceived

to misunderstand how enhanced Narcan

availability would save lives and improve the health of

the community as a whole. Without a concerted effort to

teach the community about the utility of Narcan, participants

believed that a new understanding that could alleviate

labeling would not be achieved:

You see it, too, about people about Narcan: "Us taxpayers

have to pay for Narcan for these people that are overdosing.

Why do we have to pay for it?" A lot of people don't choose

addiction. It just happens, or it's a family thing sometimes.

It's just hard. Like I say, people that have never experienced

it and never done drugs in their life, they don't know. They

don't understand it. A lot of people will be like, "That damn

drug addict. I don't know. They should just die already. Who

cares? Get over it."

Overall, participants expressed a desire for more educational

opportunities focused specifically on OUD and

MAT to facilitate community awareness, and access to

recovery-oriented resources to effectively deal with the

opioid epidemic in their community.

Discussion

Application of the Theoretical Frameworks

The frameworks of critical social theory, intersectionality

theory, and brain opioid theory of social attachment

informed data analysis and interpretation, offering a lens

through which the experiences of rural individuals seeking

MAT were critically analyzed. Application of this

Scorsone et al. 2111

integrated theoretical model permitted exploration of

how individual and social identity within the context of

larger societal, political, historical, and environmental

contexts intersect to shape the culture of opioid use and

the recovery capacity of individuals seeking treatment in

rural NM. The concepts discussed below highlight the

major facilitators and barriers that the rural participants in

this study encountered when accessing MAT.

Waiting to Access MAT

MAT has remained largely inaccessible in rural areas due

to systemic issues that include geographic misdistribution

of methadone clinics and prescriptive restrictions on

buprenorphine (Dick et al., 2015; Jones et al., 2015).

Although the number of providers with the ability to prescribe

buprenorphine-based MAT is increasing in both

urban and rural areas, there remains inadequate treatment

capacity in northern New Mexico. This study confirmed

this, revealing that long wait lists for both

methadone and buprenorphine represented a key systemlevel

barrier and a predominant factor driving buprenorphine

diversion. Concerns about buprenorphine diversion

have also been cited as a key barrier to expanding MAT

access (Carroll et al., 2018) and misuse of medication is

consistently cited by rural providers as a central impediment

to integrating buprenorphine-based MAT into their

clinical practice (Andrilla et al., 2017, 2019; Lin et al.,

2018). However, existing literature indicates that illicit

purchase of diverted buprenorphine is driven mainly by

inadequate access to MAT, and when it occurs, it is

undertaken mainly for the purpose of self-treatment

(Carroll et al., 2018; Schuman-Olivier et al., 2010). Our

findings support these conclusions and extend them by

revealing gender-based disparities and the lack of consideration

of OUD as a family issue, particularly in cases

of spouse or partner-sharing of the drug to avoid withdrawal

symptoms.

Pregnancy and Perceived Gender Disparity

Concerning gender differences, pregnant women experienced

an advantage when attempting to obtain treatment.

Related to substance use treatment, a previous study

identified that rural women who experienced lengthy

delays gained immediate treatment access upon becoming

pregnant (Kramlich et al., 2018). Related to OUD,

because MAT with buprenorphine or methadone is

known to reduce maternal substance abuse and improve

health outcomes for the mother and the unborn child

(Klaman et al., 2017; Short et al., 2018), public efforts to

expand access to MAT have been initiated for this specific

population (Short et al., 2018). The National

Practice Guidelines for the use of medication in the

treatment of OUD recommend that pregnant women

receive opioid agonist medications rather than paradigms

centered on abstinence (American Society of Addiction

Medicine, 2015); our findings confirmed that these

efforts are being implemented at the community level.

For pregnant women living in a home environment

where active opioid misuse was taking place, there was a

desire on the part of these women to share their medications,

to help their partner avoid opioid withdrawal. The

unintended consequence of this policy has led to a gender

disparity that drives male participants to contemplate

committing low-level drug crimes as a means to expedite

access to treatment. Despite the moral conflict and legal

consequences of committing a crime, the cost of criminal

behavior outweighed the risk of overdosing and dying, a

novel realization highlighted in this study.

Preference for Buprenorphine

Long-standing beliefs about negative side effects of

methadone in individuals suffering from OUD are documented

in the literature (Gryczynski et al., 2011), with

individuals voicing a preference to avoid methadone

clinics (Yarborough et al., 2016). Aligning with this, participants

in this study perceived buprenorphine to be the

superior MAT pharmacotherapy, expressing negative

attitudes about methadone. In addition to the perceived

negative physical side-effects of methadone, several policy-

level factors contributed to the overall preference for

buprenorphine. Federal regulations governing methadone

maintenance programs routinely require daily

attendance, where the methadone is dispensed on-site

and is rigorously monitored to minimize diversion and

the risk of overdose (Hansen et al., 2016). These policies

based on strict surveillance and daily presence exert

direct external social control on individuals with OUD

and have been cited as key reasons for voluntarily discontinuing

methadone maintenance treatment (Rozanova

et al., 2017).

Interestingly, although the participants in this study

were all aware of MAT pharmacotherapy with methadone

and buprenorphine, none of them were aware of naltrexone

as an approved MAT treatment for OUD, nor had

they been offered this as an option. Unlike methadone

and buprenorphine, there are no prescriptive restrictions

on the use of the naltrexone to treat OUD (Bart, 2012;

Dennis et al., 2015), it does not induce euphoric effects,

lead to physiological dependence or cause symptoms of

withdrawal upon abrupt cessation (Dennis et al., 2015).

Thus, for individuals describing their everyday experience

with MAT as freeing as though they were "still

hooked on a drug," naltrexone could represent a preferable

alternative, alleviating stigma related to not being

opioid-free while on MAT pharmacotherapy.

2112 Qualitative Health Research 30(13)

Able to Live a Normal Life

A previously published qualitative study identified a deep

desire for individuals diagnosed with OUD to return to a

more normal life (Wilson et al., 2018). Extending this, we

discovered that MAT with buprenorphine enabled participants

to achieve this goal and actually begin living what

they defined to be a more normal life. Public attitudes

about MAT, the participants' own experiences with OUD

and being dependent on a medication embodied the feeling

of irreversible change, but life still felt more normal.

This new normal became more consistent with what is

culturally considered to be typical, that is, maintaining

employment, caring for dependents, interacting with others

in more socially acceptable ways. Participants recognized

a difference in themselves, forcing them to construct

a separate social world embedded in the culture of recovery.

These findings support the notion that expansion of

access to MAT as a social mandate could help people

return to normal life from a life of OUD.

Recovery From OUD

MAT pharmacotherapy, combined with psychosocial interventions,

is associated with reduced rates of opioid use and

overdose, retention in treatment, and improved social functioning

(Krawczyk et al., 2018). However, there is limited

access to traditional evidence-based psychosocial treatments

for substance use disorders in most rural areas due to provider

and facility shortages (Pullen & Oser, 2014), leaving

many individuals with OUD needing to rely on self-help and

peer-recovery interventions such as NA. NA conceptually

represented an option because it was accessible and could

provide support. However, NA has historically been guided

by the 12-step, sobriety-based model, which requires abstinence

from all opioids (White, 2011). Individuals receiving

MAT are not considered abstinent, and participants in this

study indicated that this led to prejudice because they were

viewed by NA peers to be substituting one opioid addiction

for another. This aligns with previous research indicating

that the NA philosophy requiring opioid abstinence contributes

to bias against MAT (Krawczyk et al., 2018). The concept

is cited in official NA marketing literature explaining

that although any individual is welcome to attend NA, fellow

members may express negative opinions about MAT (

NA, 2016). This type of stigma related to MAT may have a

detrimental influence on treatment outcomes, begging for

targeted psychosocial interventions that preserve the advantages

of NA but recognize the importance of the pharmacotherapy

that MAT requires.

Stigma and Social Identity

For individuals with OUD, their status as addicts forms

their social identity, which is situated within intersecting

power relations to yield social marginalization

(Netherland, 2012). A change to a recovery identity is

critical for success, and positive social relationships trigger

treatment-seeking behaviors (Dingle et al., 2015),

underlying the importance of reassembling social networks

to promote and sustain recovery (Draus et al.,

2015). This study aligns with these previous findings in

that "staying clean" required participants to find and

establish new social environments, with relapses associated

with failure to transition from preexisting relationships

that were rooted in social contexts that involved

opioid misuse. Given the level of decades-long entrenchment

that the epidemic has in Rio Arriba County, reorienting

social relationships to mitigate exposure to

situations involving opioid misuse is a challenge that

undoubtedly perpetuates the cycle of addiction.

MAT Provider Relationship

Previous research has documented the importance of the

patient-provider relationship in sustaining substance use

treatment, with respect, empathy, and inclusion cited as

essential therapeutic aspects (Kramlich et al., 2018).

Findings presented here align with this work; participants

highlighted these same values as vital in their MAT provider

relationships, emphasizing how these factors were

critical to creating the sense of safety and a platform for

controlling their own recovery. However, participants

perceived a gap in knowledge, and in some cases bias,

among health care providers they encountered in various

other medical subspecialties. A lack of education and

insufficient training have also been identified as providerlevel

barriers that inhibit MAT initiation (Oliva et al.,

2011; Rosenblatt et al., 2015). While policy initiatives

have supported the general expansion of MAT, prescribing

buprenorphine to treat OUD is not a requirement for

providers. Knowledge and training gaps across care settings

drive the bias among providers in various specialties

that influenced the perspectives of individuals

participating in this study.

Targeted Education and Community-Based

Interventions

Aligning with a previous study (Hewell et al., 2017), this

research also revealed a general desire on the part of the

participants to have enhanced education opportunities

about OUD and MAT availability in the community.

Participants repeatedly voiced concern that MAT was

generally viewed by the public as replacing one opioid

addiction with another. Stigmatizing perceptions about

substance use are known to persist in the general public

(Ashford et al., 2018; Barry et al., 2014; Netherland,

2012). The historically accepted view of addiction as a

Scorsone et al. 2113

social and/or moral problem has contributed to negative

perceptions of individuals' who struggle with OUD, providing

the rationale for discrimination and labeling of

those who are afflicted. For individuals with OUD, their

"addicted" status formed their social identity, which is

situated within conflicting power relations to yield social

exclusion. This was borne out in this study: while using

heroin, participants were labeled "an addict," and yet,

after they were in treatment and receiving MAT, they

were labeled as "still addicted" and thus perpetually marginalized.

To help overcome the opioid epidemic and to

mitigate the destructive impact of stigma, targeted community-

based outreach programming, supported by community

members, leaders, and individuals in recovery,

would be valuable.

Related to stigma, a previously unappreciated negative

public perception about Narcan by community members

was identified. Current public health recommendations

suggest that opioid overdose prevention efforts should prioritize

Narcan dissemination to families, friends, and individuals

with OUD (Mattson et al., 2018) because of its

efficacy reversing the physical effects of opioid overdose,

including death (Keane et al., 2018). Despite the obvious

benefits of making Narcan available, there was a perceived

lack of understanding among certain members of

the community, begging for targeted education to overcome

negative perceptions and misunderstandings about

this life-saving intervention.

Implications and Future Directions

To tackle the disproportionate rate of opioid-related morbidity

and mortality among rural Americans, key system-

level barriers addressing the disparity in access to

MAT must be addressed. From a policy perspective, a

wait-list-dependent barrier to MAT creates a missed

opportunity to provide access to a life-saving intervention.

A potential policy solution would require all providers

to be educated in the treatment of OUD to reduce

bias and to ensure a continuum of care for individuals

receiving MAT. This would directly expand buprenorphine-

based MAT access and would address the novel

key barrier discovered in this study related to the male

gender as a barrier to MAT.

Notably, pregnant women were often living in a

relationship with a partner suffering from OUD lacking

access to MAT, prompting these women to help

their partner avoid opioid withdrawal by sharing their

own medication. For pregnant women, this raises the

risk of both buprenorphine diversion and potential

relapse to heroin. This information supports development

of therapy paradigms targeting maternal, family,

and fetal health, which must be prioritized within the

context of holistic health for the entire family. Overall,

the sociocultural dynamics of the family environment

and greater community must be considered.

All of the recruited participants in this study self-identified

as being either male or female. Individuals with

diverse gender identities were not actively recruited, and

all of the participants in this study self-reported a traditional

binary mode of gender identity. A future consideration

is to better understand the role of gender and how it

impacts access to MAT. Thus, further research in this

field should also include participants who identify with

more diverse gender identities.

Finally, to help overcome the opioid epidemic and to

mitigate the destructive impact of stigma, targeted community-

based programming, supported by community

members and leaders and individuals themselves in

recovery, would be valuable. Community connections

and their capacity for promoting recovery represents an

inherent strength and opportunity for resilience that could

be synergized with family and group support, further nurtured

by targeted education and outreach.

Study Limitations

The central limitation of this study is that the findings are

within the specific context of rural northern New Mexico

and people who live with OUD, a population with a unique

and diverse cultural and racial context. We countered

these limitations by providing rich description, which

enhances transferability where possible, but we recognize

that this is a unique and special population from a demographic

and historical standpoint. Restricting the focus

solely to these individuals with OUD does not optimally

inform on the experiences of urban individuals, or individuals

from other regions of the country, and it excludes

the perspectives and knowledge of other key stakeholders,

including providers, family members, and community

members. Input from a broader group of stakeholders is

important to fully understand the dynamics that influence

experiences with MAT, and future studies could shed further

light on the issues by addressing these perspectives.

In addition, participants were recruited from a clinic that

does not provide methadone treatment for OUD. Our sampling

strategy allowed us to include participants who had

experience with methadone-based MAT at other health

care clinics, which partially moderates this limitation.

Conclusion

Overall, the present study has uncovered several previously

unappreciated individual-, system-, and community-

level factors that contribute as either barriers or

facilitators to MAT utilization in a rural community in

northern NM. These were categorized broadly to involve

MAT barriers, preference for buprenorphine-based MAT,

2114 Qualitative Health Research 30(13)

achieving and navigating a new normal life, and dealing

with the pervasive nature of stigma in various niches of

the community. Incorporating the novel perspectives

from this research into the ongoing national dialogue on

MAT utilization could shape system-level approaches to

maximizing treatment success. Specific to the participants

in this research, interventional strategies based on

the findings reported here could help shape the pursuit of

treatment and recovery on the individual level; this would

be transformative in their lives, within their families and in their community.

Please answer the following questions using a casp qualitative checklist.

1. Was there a clear statement of the aims of the research? (Yes/No/Can't Tell)

Explain:

1. Is a qualitative methodology appropriate? (Yes/No/Can't Tell)

Explain:

1. Was the research design appropriate to address the aims of the research? (Yes/No/Can't Tell)

Explain:

1. Was the recruitment strategy appropriate to the aims of the research? (Yes/No/Can't Tell)

Explain:

1. Was the data collected in a way that addressed the research issue? (Yes/No/Can't Tell)

Explain:

1. Has the relationship between researcher and participants been adequately considered? (Yes/No/Can't Tell)

Explain:

Section B: What are the results?

1. Have ethical issues been taken into consideration? (Yes/No/Can't Tell)

Explain:

1. Was the data analysis sufficiently rigorous? (Yes/No/Can't Tell)

Explain:

1. Is there a clear statement of findings? (Yes/No/Can't Tell)

Explain:

Section C: Will the results help locally?

1. How valuable is the research?

Explain:

1. Referring to your textbook - what is the Level of Evidence for this study?

Explain: