Provider and patient perspectives on barriers to buprenorphine adherence and the acceptability of video directly observed therapy to enhance adherence

BACKGROUND: Buprenorphine effectively reduces opioid craving and illicit opioid use. However, some patients may not take their medication as prescribed and thus experience suboptimal outcomes. The study aim was to qualitatively explore buprenorphine adherence and the acceptability of utilizing video directly observed therapy (VDOT) among patients and their providers in an office-based program. METHODS: Clinical providers (physicians and staff; n = 9) as well as patients (n = 11) were recruited from an office-based opioid treatment program at an urban academic medical center in the northwestern United States. Using a semi-structured guide, interviewers conducted individual interviews and focus group discussions. Interviews were digitally recorded and transcribed verbatim. Transcripts were independently coded to identify key themes related to non-adherence and then jointly reviewed in an iterative fashion to develop a set of content codes. RESULTS: Among providers and patients, perceived reasons for buprenorphine non-adherence generally fell into several thematic categories: social and structural factors that prevented patients from consistently accessing medications or taking them reliably (e.g., homelessness, transportation difficulties, chaotic lifestyles, and mental illness); refraining from taking medication in order to use illicit drugs or divert; and forgetting to take medication, especially in the setting of taking split-doses. Some participants perceived non-adherence to be less of a problem for buprenorphine than for other medications. VDOT was viewed as potentially enhancing patient accountability, leading to more trust from providers who are concerned about diversion. On the other hand, some participants expressed concern that VDOT would place undue burden on patients, which could have the opposite effect of eroding patient-provider trust. Others questioned the clinical indication. CONCLUSIONS: Findings suggest potential arenas for enhancing buprenorphine adherence, although structural barriers will likely be most challenging to ameliorate. Providers as well as patients indicated mixed attitudes toward VDOT, suggesting it would need to be thoughtfully implemented.