Table 2 Factors impacting MOUD receipt for patients with co-occurring substance use, organized by TICD Checklist domains

Individual health professional factors

Providers’ awareness of recommendations

•In general, participants reported that there are not clear recommendations around buprenorphine care for patients with co-occurring substance use in guidelines or training

•Other information sources may shape providers’ approaches (e.g., colleagues, doing their own research)

•Participants generally agreed that patients using other substances should receive MOUD, but varied in how they viewed their primary role (i.e., providing the care vs. facilitating linkage to higher-level care)

Other individual health professional factors

•Some providers may lack relevant knowledge/skills/experience

•Providers have a range of perceptions/attitudes that may impact their approach (safety/other concerns; beliefs about appropriateness of non-SUD care setting; harm reduction philosophy; patient-centered approach)

Providers’ perceptions of patient factors

•Life instability related to co-occurring substance use may create barriers to receiving MOUD care

•Fear of disclosing co-occurring substance use may be a barrier to receiving MOUD care

•Patients may or may not prefer to receive MOUD in an SUD specialty setting, which may be impacted by addiction-related stigma

Professional interactions

•Collaboration with SUD experts may facilitate buprenorphine provision for patients with co-occurring substance use outside of SUD specialty settings, or facilitate linkage to SUD specialty care

•Siloed care/expertise may make it more difficult to adequately support these patients

•Existing VA efforts to integrate primary care and mental health may not adequately address SUD care

Incentives and resources

Within participants’ clinics

•Lack of adequate time with patients to address complex issues may be a barrier

•Lack of nursing and other staff may be a barrier

Outside participants’ clinics

•Low accessibility of SUD specialty clinics may be a barrier to linking patients to higher-level MOUD care and/or additional care for other SUDs

•Availability of other higher-level SUD care (e.g., detox, residential treatment) may be too low

•Mental health and social services provided though the VA may help patients with co-occurring substance use engage in MOUD care, but there may be barriers to accessing these services

Capacity for organizational change

•Clinic policies/treatment agreements banning other substance use may have become more flexible in recent years to encourage increased provision of buprenorphine

•Some SUD specialty clinics may still have strict rules around other substance use or generally require more structured care, which may present barriers for some patients with co-occurring substance use

•Leadership in primary care, mental health and pain clinics may vary in their support of buprenorphine provision for this population

Social, political and legal factors

•Telehealth does not seem to greatly impact providers’ approach to treating OUD among patients with co-occurring use, but may make it more difficult to assess other substance use

•Telehealth may have increased access to SUD specialty services for some patients in rural areas, however the COVID-19 pandemic may have also decreased provision of these services

•Cannabis legalization/normalization may have made some providers more willing to provide buprenorphine care to patients who use cannabis

•Concerns about overdose risk related to a rise in fentanyl use may increase providers’ sense of urgency of providing buprenorphine regardless of other substance use