Barriers and Challenges to Making Referrals for Treatment and Services for Opioid Misuse in Family Planning Settings

Abstract

Background:

In this opioid overdose epidemic, women are an overlooked group seeing increasing rates of overdose death. Implementation challenges have prevented evidence-based interventions from effectively reaching women who misuse opioids, with gaps in access to effective treatment and services. Family planning clinics could serve as important points of contact for referral to needed treatments and services. The study explores how family planning staff knowledge and attitudes related to opioid misuse serve as potential barriers and challenges in making referrals for evidence-based services and treatments.

Methods:

In 2018, we conducted a national online survey of family planning staff, assessing knowledge and attitudes of treatments and services for opioid misuse.

Results:

A total of 691 family planning staff completed the survey. Most respondents agreed that opioid misuse was a major problem in their community (86.0%) and identified challenges in responding to it, including a lack of treatment access (70.3%), the absence of in-house behavioral health staff (67.2%), and unfamiliarity with local treatment providers (54.1%). Respondents reported low levels of acceptability for syringe services programs (46.0%), medications such as methadone and buprenorphine (55.4%), and naloxone to reverse opioid overdose (60.1%). Controlling for other factors, race/ethnicity, urbanicity, workplace role, and substance use training were associated with differences in acceptability.

Conclusions:

Family planning settings could play a critical role in connecting women who misuse opioids to treatment and services. Strategies are needed to increase the acceptability of evidence-based interventions and the feasibility of having family planning staff play a linkage role.

Introduction

Opioid misuse and opioid use disorder (OUD) among women remain under-addressed public health issues, with 3.7% of women reporting opioid misuse in the previous year.¹ Women are prescribed,² and fill prescriptions for, opioids at a higher rate than men. Moreover, there is evidence that women progress from substance use to substance use disorder more rapidly than men,³ with some of this attributable to gender differences in neurobiology.⁴ Opioid misuse among women puts them at increased risk of viral hepatitis^5,6 and HIV⁷ infection, as seen in recent outbreaks. Increasing rates of opioid misuse among pregnant women have been tied to increases in the incidence and spread of cases of neonatal abstinence syndrome.^8,9 Compared with men who misuse opioids, women experience a higher rate of hospitalization for opioid-related poisoning¹ and death. The Centers for Disease Control and Prevention point out that, from 1999 to 2010, prescription opioid overdose mortality increased at a greater rate among women (400%) than men (237%).¹⁰ More recent analysis demonstrated that drug overdose mortality among women aged 30–64 nearly tripled from 1999 to 2017.¹¹

Women often lack equitable access to evidence-based services and treatment for substance use. Women experience gaps in access to quality treatment for substance use disorders generally,¹² with estimates from the Substance Abuse and Mental Health Services Administration suggesting that only 10% of women in need of treatment for a substance use disorder receive it.¹³ In particular, ample evidence supports the use of medications such as methadone and buprenorphine in the treatment of OUD,^14,15 with one randomized trial showing that women experience even better outcomes than men in terms of reduction in HIV risk behaviors.¹⁶ Despite this, less than half of pregnant women admitted to treatment with heroin use disorder and less than a quarter of those with prescription OUD used medications as part of their treatment. These numbers were halved among nonpregnant women of childbearing age.¹⁷ Women also experience lower levels of access to syringe services programs due to factors such as gender-based violence.¹⁸

These gaps in accessing evidence-based treatment and services could be improved by integrating screening and referral for opioid misuse into sexual and reproductive health services, including family planning settings.¹⁹ In 2018, 3.9 million individuals received services from publicly funded family planning clinics, ranging from contraceptive education and counseling to screening/testing, referral, and counseling for pregnancy, sexually transmitted diseases, HIV, and cancer. Of these service recipients, 87% were women, and two-thirds (65%) “had family incomes at or below the poverty level” and 40% were uninsured.²⁰ Forty percent of women in the United States who access care through family planning clinics identify them as their only point of contact with the health care system.²¹ Researchers have highlighted the need to integrate screening for substance use disorders and referral to treatment and services into women's health care settings as a public health imperative.²² Family planning clinics have an important role in this integration, given the number of women who receive health care in these settings.

To date, few studies have looked into how to tap family planning clinics as a touch point for referral to other necessary public health services, including those for opioid misuse and OUD. Researchers have developed a model for integrating substance use screening and intervention into prenatal care clinics, but not family planning clinics more broadly. In this integrated care model, provider knowledge and attitudes were identified as a major barrier.²³ As such, we conducted a survey of staff from family planning clinics based on formative research²⁴ using the Consolidated Framework for Implementation Research (CFIR),²⁵ with a particular focus on the inner setting and characteristics of individuals as potential facilitators or barriers to implementation. We were especially interested in answering the following questions: Do family planning staff have the capacity and resources needed to screen and refer patients to appropriate services and treatments? Do they know about the most effective services for opioid misuse or the most effective treatments for OUD? Do they support or accept them? There is strong evidence that health care providers in general lack education and training in substance use, and many have negative attitudes toward medications for OUD and harm reduction services.²⁶

This study assessed family planning staff perceptions of opioid misuse and OUDs as a problem in their patients, perceived barriers to making referrals for relevant treatment and services, and the acceptability of evidence-based treatments and services for opioid misuse. Relationships between respondent and setting characteristics and attitudes toward treatment and services were also explored, since, consistent with CFIR, they may suggest strategies to support the implementation of screening and referral to treatments and services for opioid misuse in family planning settings.

Methods

Data collection

This study presents results of survey questions on attitudes and practices related to opioid misuse and OUD from a larger survey on attitudes and practices for substance use and screening, brief intervention, and referral to treatment (SBIRT). The survey questions were developed based on the results of a series of focus groups with family planning staff on implementation barriers to the use of SBIRT in family planning settings.²⁴ These focus groups were structured using CFIR,²⁵ with the resulting survey focusing specifically on the domains of the inner setting and characteristics of individuals as potential barriers to and facilitators of responding to opioid misuse/OUD in family planning clinics. For the purposes of this study, any health care setting providing clinical family planning services was considered a family planning clinic.

An invitation to complete the anonymous online survey was sent to 6481 email addresses of family planning staff on a national family planning listserv. The survey link was also posted on a web banner on the National Clinical Training Center for Family Planning website. The survey was hosted on a secure online survey platform (REDCap).²⁷ Participants read a standard consent-like script that explained the study purpose, and that participation was voluntary and anonymous, before proceeding to the survey. Family planning staff were identified as respondents who reported that they provided clinical family planning services or who worked at a clinic/service site that provides family planning services. Any respondent who did not meet this definition was excluded from completing the survey. The survey remained open for 20 weeks, from January to April, 2018. The University of Missouri Kansas City Institutional Review Board (IRB) approved this study as exempt with a waiver of signed informed consent.

Instruments

The survey included standard questions on demographics of the respondent and characteristics of the respondent's clinic. Specific to this study, respondents were asked yes/no questions about whether they prescribe opioids and whether their clinic provides education on opioids. Three questions asked about respondents' perceptions of OUDs and treatment availability in their community: “Opioid misuse is a major problem in my community”; “There is good access to opioid use disorder treatment in my community”; and, “I know the opioid use disorder treatment providers in my community”, scored on a 4-point scale from strongly disagree to strongly agree. Acceptability of treatment and services for OUD was assessed by asking “Based on your knowledge and experience, what treatments and services do you think should be offered to people with opioid use disorders?” with a list of seven treatments and services. Finally, an open-ended question asked, “Given the current opioid epidemic, what training do you need to better serve your patients who are using opioids?”

Data analysis

Survey results were downloaded to SAS Version 9.2 (SAS Institute Inc, Cary, NC) and data were cleaned and analyzed. Of the 711 responses, 15 were discarded because the respondents did not work in family planning settings and 5 were discarded because they did not respond to this question. The final sample size for this study was 691. Descriptive statistics are presented for all variables. Associations between attitudes toward treatment and services for opioid misuse/OUD and demographic characteristics and settings were explored using chi-square tests for categorical variables and analysis of variance (ANOVA) for continuous variables; post hoc pairwise comparisons were used when chi-square tests yielded significant results for variables with more than two response options (i.e., urbanicity, workplace role). Logistic regression was used to control for possible confounding when examining the association between different factors and acceptability of treatment and services. Variables were included in the logistic regression model based on their significance in univariate analyses. Responses to a single open-ended question were coded into themes using simple content analysis.

Results

Participants

A total of 691 eligible respondents provided complete data (Table 1). Respondents were almost all female (97.8%) and most were White (87.7%). More than two-thirds (68.8%) were ≥45 years of age. Most respondents worked as clinical providers, such as physicians, advanced practice nurses, or physician assistants (39.9%), or as nurses (30.7%). Respondents tended to be experienced practitioners, with a median of 16 years since the completion of training (interquartile range: 7–24) and 12 years working in family planning (interquartile range: 5–21). Respondents reported a median of 6 hours of education or training related to substance use (interquartile range: 2–20); nearly one in five (17.2%) reported no education or training related to substance use.

Table 1.

Characteristics of Survey Respondents and Their Work Settings

	N (%) or median (IQR)
Age
18–24	2 (0.3%)
25–34	84 (12.2%)
35–44	128 (18.6%)
45–54	183 (26.6%)
55+	290 (42.2%)
Gender identity
Female	672 (97.8%)
Male	9 (1.3%)
Other	6 (0.8%)
Race/Ethnicity
White/Caucasian	601 (87.7%)
Black/African American	45 (6.6%)
Asian/Asian American	9 (1.3%)
American Indian/Alaskan Native	4 (0.6%)
Native Hawaiian/Pacific Islander	4 (0.6%)
Middle Eastern/Arab American	1 (0.2%)
Mixed race/more than one race	21 (3.0%)
Primary role at workplace
Manager/administrator/center coordinator	158 (23.0%)
Clinical provider (NP, CNM, PA, MD, DO)	274 (39.9%)
Nurse	211 (30.7%)
Health educator/counselor/health care associate	22 (3.2%)
Other	22 (3.2%)
Years since completed training	16 (7–24)
Years working in family planning	12 (5–21)
Hours of education/training related to substance use	6 (2–20)
Prescribe opioids
Yes	101 (14.9%)
No	578 (85.1%)
Urbanicity
Urban	229 (33.4%)
Suburban	129 (18.8%)
Rural	327 (47.7%)
Principal work setting
Health department	417 (60.4%)
Hospital based	27 (3.9%)
Planned parenthood	32 (4.6%)
Free-standing family planning organization	65 (9.4%)
Community health center/FQHC	112 (16.2%)
Tribal health center	3 (0.4%)
University- or school based	27 (3.9%)
Other (e.g., correctional facility, federal government)	27 (3.9%)
Private foundation or nonprofit	31 (4.5%)
Behavioral health staff in clinic
Present	225 (32.8%)
Absent	461 (67.2%)

IQR, interquartile range.

Respondents hailed from a variety of geographic and clinical settings. Representation was found across all 10 standard federal regions established by the Office of Management and Budget (OMB), with the highest percentages of respondents coming from regions VII and V in the Midwest (21.8% and 17.5%, respectively) and region IV in the South (15.9%). Nearly half of respondents (47.7%) identified that their primary work location was in a rural setting. Most respondents worked at health departments (60.4%), with good representation from community health centers/Federally Qualified Health Centers (16.2%). Respondents from free-standing family planning organizations made up about one-tenth of the sample (9.4%).

Feasibility of referring for services/treatment

Few respondents reported that they prescribed opioids at their practice (14.9%). Of those who did, just over half (59.0%) reported that their clinic provided patient education on opioids. Most respondents agreed or strongly agreed that opioid misuse was a major problem in their community (86.0%). Most respondents also agreed or strongly agreed that there was not good access to substance use treatment (70.3%). Over half disagreed or strongly disagreed that they knew the treatment providers in their community (54.1%), and only about one-third of respondents identified that there were behavioral health staff at their clinic (32.8%).

Training needs

Results of content analysis regarding training needs resulted in five key themes. The most common theme was the desire for a structured approach, such as SBIRT, to deal with opioid misuse and OUD among patients. Of the 358 respondents who answered the question, nearly half (40.2%) asked for training on one or more of the components of SBIRT or training that approximated the SBIRT model, such as “identifying those with opioid use disorder and how to counsel individuals to get treatment” or “training on questioning, counseling, and referring to addiction programs.” Another respondent described the objective of these trainings as “How to have those difficult conversations. How to motivate change in a client; make them feel empowered.”

The second most frequently mentioned theme was a need for knowledge about local resources for patients who misuse opioids (n = 110, 30.7%). Many respondents explicitly requested referral options for patients, including that “community referral resources are our greatest challenge.” Another respondent described the downstream impact of the lack of resources: “We need more resources in the immediate area to refer patients. There is too much waiting for motivated patients; who then relapse.” Other respondents tied this lack of resources to structural aspects of their clinics: “However the lack of facilities to refer pts [patients] to is a problem as I live and work in a rural area,” and “We are a small family planning clinic we don't have the time, space or training to set up something like that.”

The third and fourth most frequent themes were both identified in 17.3% of responses, respectively. Respondents were interested in general information about opioids and OUD as well as geographically relevant information, including “Updated local, regional and state information about the known opioid problems here, regional trainings about opioid addiction.” Equally, respondents wanted assistance in implementing a response to opioid misuse and OUD, such as “Administrative support and tailoring of appointments to be able to provide appropriate services,” or “How to bill correctly for any time spent with patient for adequate payment.” Another respondent provided details around implementation challenges:

“While behavioral health and primary care are more closely integrated in our network of clinics than they have been in the past, they still have different admin structures. Also, substance abuse records have an extra level of privacy/security attached—the bar for sharing information on substance abuse treatment is much higher than for sharing other forms of PHI [protected health information] and so clinicians have no way of tracking referrals or of determining client progress, unless the patient volunteers this information.”

Finally, few respondents explicitly mentioned a need for training around medications for OUD (10.6%), with one respondent sharing, “I would like to see all providers at my clinic trained in suboxone prescribing.” Even fewer respondents mentioned a need for training in harm reduction interventions, including naloxone to reverse opioid overdose (5.6%) such as “best practices/legal issues in providing Narcan kits and sterile needles for IV drug use.” In some cases, respondents described a desire for training that was at odds with medications for OUD, with one participant sharing that they wanted “training on methods to discontinue opioids that include things other than replacement medications.” This corresponds to attitudes described below related to the acceptability of these services.

Acceptability of referral options for OUD

Respondents were asked to report which of a list of treatments and services should be offered to patients with OUD, including medications such as methadone and buprenorphine, detoxification, addiction counseling, recovery support, mutual help groups, naloxone, and syringe services programs (Table 2). Almost all respondents endorsed the use of addiction counseling (90.5%) and recovery support services (87.0%), while support was lowest for syringe services programs (46.0%) followed by medications such as methadone and buprenorphine (55.4%), and naloxone to reduce opioid overdose (60.1%).

Table 2.

Acceptability Among Survey Respondents of Treatments and Services for People with Opioid Use Disorders

What treatments and services do you think should be offered to people with OUDs?	N (%)
Addiction counseling	625 (90.5)
Recovery support services	601 (87.0)
Mutual help groups like Narcotics Anonymous	489 (70.8)
Detoxification from opioids	442 (64.0)
Providing naloxone to reduce overdose	415 (60.1)
Medications such as methadone and buprenorphine	383 (55.4)
Syringe services programs	318 (46.0)

OUD, opioid use disorder.

Further exploration was made of the relationship between respondent and work setting characteristics and acceptability of the three treatments and services rated as least acceptable (medications for OUD, syringe services programs, and naloxone to reduce overdose), with results shown in Table 3. Since females made up the overwhelming majority of respondents, associations based on gender were not explored. Race/ethnicity of respondent was significantly associated with acceptability of syringe services programs, with White respondents significantly more likely to endorse syringe services programs than non-White respondents. Participant responses also varied by primary workplace role, with respondents who identified as nurses being less likely to endorse all three interventions compared with administrative staff and clinical staff. Finally, the number of hours of training related to substance use was significantly associated with higher levels of acceptability of almost all treatments and services, with respondents who reported >6 hours of training on substance use (based on median split) being more likely to endorse medications for OUD, naloxone, and syringe services programs, as well as detoxification and mutual help groups (latter two not shown in the table).

Table 3.

Acceptability of Treatment and Harm Reduction Services by Survey Respondent Demographic and Setting Characteristics

	What treatments and services do you think should be offered to people with OUDs?
	Medications for OUD		Syringe services programs		Naloxone to reduce overdose
	Percent	(p-Value)^*	Percent	(p-Value)^*	Percent	(p-Value)^*
Race
White	56.0	(0.34)	48.1	(<0.01)	60.4	(0.60)
Non-White	50.0	(0.34)	27.1	(<0.01)	57.1	(0.60)
Primary workplace role
Manager/administrator	64.6	(<0.01)	50.6^a	(<0.01)	70.3	(<0.01)
Clinical provider	66.4		52.9^a		66.8
Nurse	39.3		35.6^b		47.9
Hours of training
>6	65.8	(<0.01)	58.1	(<0.01)	72.2	(<0.01)
≤6	51.1	(<0.01)	37.9	(<0.01)	51.2	(<0.01)
Urbanicity
Urban	65.9^a	(<0.01)	50.7^a	(0.03)	63.3	(0.08)
Suburban	65.1^a		51.9^a		65.9
Rural	44.7^b		41.0^b		56.0
Clinic size
Small (<40 patients/week)	50.5	(<0.01)	41.2	(<0.01)	57.9	(0.13)
Large (40+ patients/week)	60.8	(<0.01)	51.4	(<0.01)	63.6	(0.13)
Behavioral health staff
Present	62.7	(<0.01)	45.8	(0.92)	61.8	(0.49)
Absent	51.8	(<0.01)	46.2	(0.92)	59.0	(0.49)

p-Values calculated based on results of chi-square tests.

Values significantly different than ^bvalues according to pairwise post hoc comparison.

Related to work setting, degree of urbanicity was significantly associated with attitudes toward medications for OUD and syringe services programs. Respondents who worked in urban or suburban settings were significantly more likely to endorse methadone and buprenorphine as well as syringe services programs compared with those who worked in rural settings. Clinic size was also significantly associated with acceptability of medications for OUD and syringe services programs, with respondents at larger clinics (≥40 patients per week; based on median split) more likely to endorse these options than those who worked at smaller clinics. Respondents who worked in settings where behavioral health staff were present were more likely to support the use of methadone and buprenorphine for OUD than those who worked in settings that did not have behavioral health staff on site.

Given that several respondent-level and work setting characteristics were associated with the acceptability of medications for OUD, syringe services programs, and naloxone to reduce opioid overdose, multivariate logistic regression models were developed to control for possible confounding and further explore these relationships. All multivariate results are presented in Table 4.

Table 4.

Acceptability of Treatment and Harm Reduction Services Controlling for Survey Respondent Demographic and Setting Characteristics

	Medications for OUD	Syringe services programs	Naloxone to reduce overdose
	Adjusted OR ^* (95% Wald)	Adjusted OR ^a (95% Wald)	Adjusted OR ^a (95% Wald)
Race
White	REF	REF	REF
Non-White	0.694 (0.370, 1.301)	0.332 (0.168, 0.654)	1.181 (0.631, 2.209)
Hours of training
>6	REF	REF	REF
≤6	0.651 (0.450, 0.942)	0.451 (0.316, 0.644)	0.417 (0.291, 0.599)
Workplace role
Manager/administrator	1.951 (1.184, 3.214)	1.115 (0.682, 1.824)	2.087 (1.283, 3.395)
Clinical provider	1.908 (1.227, 2.966)	1.375 (0.888, 2.128)	1.948 (1.299, 2.922)
Nurse	REF	REF	REF
Urbanicity
Urban	2.085 (1.314, 3.310)	1.129 (0.726, 1.757)
Suburban	2.260 (1.352, 3.775)	1.165 (0.715, 1.900)
Rural	REF	REF
Clinic size
Small (<40 patients/week)	1.111 (0.743, 1.661)	0.765 (0.520, 1.124)
Large (40+ patients/week)	REF	REF
Behavioral health staff
Present	1.439 (0.946, 2.189)
Absent	REF

Adjusted ORs calculated using multivariable logistic regression.

OR, odds ratio.

After controlling for other variables significant at the bivariate level, urbanicity, previous substance use training, and workplace role all remained significantly associated with acceptability of medications for OUD. Respondents with six or fewer hours of training in substance use (odds ratio [OR]: 0.651, 95% confidence interval [CI]: 0.450–0.942) were less likely to endorse the use of medications for OUD compared with individuals with >6 hours of training. Respondents who identified as managerial or administrative staff (OR: 1.951, 95% CI: 1.184–3.214) or clinical providers (OR: 1.908, 95% CI: 1.227–2.966) were more likely to endorse medications for OUD compared with respondents who identified as nurses. Finally, respondents who work in urban (OR: 2.085, 95% CI: 1.314–3.310) and suburban (OR: 2.260, 95% CI: 1.352–3.775) locations reported higher levels of acceptability of medications for OUD compared with respondents who work in rural locations.

Race/ethnicity and previous substance use training remained significantly associated with acceptability of syringe services programs after controlling for other characteristics significant at the bivariate level of analysis. Respondents who identified as non-White (OR: 0.332, 95% CI: 0.168–0.654) were less likely to recommend the use of syringe services programs compared with White respondents. Respondents with six or fewer hours of training in substance use (OR: 0.451, 95% CI: 0.316–0.644) were also less likely to endorse the use of syringe services programs compared with those who had >6 hours of training.

Training in substance use remained significantly associated with support for naloxone to reduce overdose after controlling for race/ethnicity and professional role. Individuals reporting six or fewer hours of training were less likely to endorse naloxone (OR: 0.417, 95% CI: 0.291–0.599) compared with individuals with >6 hours of training. Respondents who identified as managerial or administrative staff (OR: 2.087, 95% CI: 1.283–3.395) or clinical providers (OR: 1.948, 95% CI: 1.299–2.922) were more likely to endorse medications for OUD compared with respondents who identified as nurses even after controlling for other covariates.

Discussion

Results of this national survey of family planning staff highlight how the characteristics of the individual and the internal setting, two of the five CFIR domains, play key roles in determining capacity of family planning settings to respond to opioid misuse and OUD. Some of these results are consistent with perceptions of health care providers across the United States. Opioid misuse and OUD are widely acknowledged as a problem, as seen in a study by Hwang et al. where 100% of physician respondents agreed that opioid misuse was a problem in their community.²⁸ Health care providers indicate that they do not feel well educated about opioids and OUD, and are not familiar with the treatment resources in their community, which is corroborated by research showing physicians and other health care providers receive inadequate training in how to address substance use disorders in their patients.^29

–33 This lack of training in how to address substance use allows negative attitudes toward individuals who use drugs to proliferate unchecked, resulting in provision of poorer health care to these patients.³⁴

Barriers to accessing medications for OUD include a lack of trained prescribers and negative attitudes and misconceptions about such medications,³⁵ which was evident in the low level of support expressed among survey respondents. Concerns that medications for OUD merely replace one addiction with another remain widespread among both community members and health care professionals.³⁶ Health care provider skepticism may contribute to lower levels of referral or prescriptions for medications for OUD, resulting in access gaps in large parts of the country.³⁷

When asked which treatment services should be provided to people with OUD, just over half of respondents reported that medications such as methadone and buprenorphine should be provided to people with OUD, whereas almost all reported that addiction counseling and recovery support services should be provided. This finding points to the lack of education and stigma regarding the most effective treatments for OUD. While addiction counseling and recovery support services are important components of a comprehensive treatment program, research clearly shows that medications are the most effective treatment for OUD.³⁷ Moreover, multiple national clinical guidelines recommend the use of medications such as methadone and buprenorphine as treatment for OUD,^38
–40 and state that medications should not be withheld from patients who are not interested in or ready for addiction counseling or recovery support services. Similarly, clear and overwhelming evidence demonstrates that harm reduction services such as naloxone and syringe services programs are effective in reducing opioid overdose deaths^41,42 and the transmission of blood-borne diseases such as HIV and hepatitis C,^43
–45 respectively. Even so, less than two-thirds of respondents reported that naloxone should be offered to people with OUD, and less than half of respondents reported that syringe services programs should be offered. Despite increasing acceptability of naloxone over the years, the level of acceptability of naloxone seen in this study is much lower than that seen in primary care providers in other recent studies.⁴⁶ Acceptability of syringe services programs in this group, on the contrary, is roughly equivalent to that seen among staff at substance use treatment programs.⁴⁷

In exploring acceptability of treatment and services for OUD as a potential barrier to implementing screening and referral services into family planning settings, this study primarily identified characteristics of individuals²⁵ as influencing factors. This study showed that race/ethnicity, urbanicity, and workplace role are related to acceptability of treatment and services among family planning staff, even after controlling for other potential confounders. Further research should explore how these factors relate to acceptability of harm reduction interventions, especially syringe services programs and medications for OUD. The number of hours of training on substance use also remained significantly associated with acceptability of treatment and harm reduction services even after controlling for possible confounders, suggesting that training and education may improve acceptability of these evidence-based interventions. Training has been observed to have positive effects on improving knowledge and attitudes related to substance use,²³ but more work needs to be done to determine causality and the extent to which training can increase the acceptability of OUD interventions among health care providers generally and family planning staff in particular.

Content analysis of responses to the training needs question corroborated the findings from our previous focus group study²⁴ and highlighted the importance of several CFIR domains. The main theme- respondents were looking for training on elements of SBIRT- highlights the importance of the characteristics of the intervention. Interestingly, the second theme on the need for information on local resources and referral sources underscores a key finding about how the outer setting relates to the capacity of family planning settings to respond to opioid misuse and OUD, despite the fact that this CFIR domain was not a focus of this survey. Similarly, another theme on the need for implementation assistance and support is rooted in the characteristics of the individual, but also encompasses other CFIR domains. Process was clearly articulated as a need in this theme as were aspects of the inner setting, such as electronic health records and the need for specific screening tools and protocols. These themes suggest that training of individual staff, while critical, should be accompanied by organizational capacity-building assistance to support change management and organizational infrastructure in tandem with building staff knowledge and self-efficacy.

Limitations

Limitations of this study include the response rate, representativeness of the sample, and use of cross-sectional methods. Our use of multiple recruitment methods (email and website link) renders us unable to determine a fully accurate response rate. The 691 respondents represent 10% of the known sample (the 6481 email addresses invited to participate). Regarding the representativeness of the sample, little workforce data are available regarding staff of family planning clinics. A recent report estimated the family planning workforce in Title X-funded clinics at 3595 full-time equivalent clinical providers, 70% of whom were midlevel nurse practitioners, nurse midwives, and physician assistants, and 23% of whom were physicians.²⁰ Our sample included ∼40% clinical providers. No studies have reported the demographics of family planning staff, so we do not know how representative this sample is of the overall field with respect to these characteristics.

Due to the cross-sectional nature of the study, we cannot infer causal relationships between amount of training and acceptability of treatment and harm reduction services. This points to an avenue for future directions in research on how to integrate a response to opioid misuse and OUD into family planning settings. Dissemination and implementation research could determine if training is effective in increasing acceptability of evidence-based treatments and services for OUD among family planning staff. As this survey was developed to focus on characteristics of the individual and inner setting as barriers to or facilitators of SBIRT implementation in family planning settings, future research should explore how other domains from the CFIR framework, such as the outer setting, characteristics of the SBIRT intervention, and process, relate to the capacity of family planning staff and clinics to respond to opioid misuse and OUD among their patients. Moreover, qualitative and mixed-methods research could further explore the attitudes of family planning staff around the acceptability of treatment and harm reduction services, as well as explain how these attitudes come to vary based on key characteristics identified in this study (e.g., race/ethnicity).

Implications

This study illustrates a clear need for training among family planning staff in how to screen and refer patients to evidence-based interventions to stem morbidity and mortality related to opioid misuse and OUD, as well as how to identify appropriate local resources. The National Clinical Training Center for Family Planning is charged with providing training and continuing education to licensed providers working in approximately 4000 service sites across the country. The results of this study along with data collected through needs assessments and other training evaluations will inform the development of training modules to meet the needs of family planning staff. In the age of COVID-19, with relaxed policy barriers increasing access to medications for OUD for patients, there are additional opportunities to train health and social services providers across the country to support the implementation of evidence-based treatments and services to address opioid misuse and its negative consequences.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported in part by the Department of Health and Human Services, Substance Abuse and Mental Health Services Administration TI026442 and Department of Health and Human Services/Office of Population Affairs/Office of Family Planning Grant #5 FPTPA006002-09-00.

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