A qualitative assessment of attitudes about and preferences for extended-release naltrexone, a new pharmacotherapy to treat opioid use disorders in Ukraine

Abstract

Numerous individual barriers, including negative attitudes toward opioid agonist therapies (OAT), have undermined HIV prevention efforts in Ukraine where the epidemic is concentrated in people who inject drugs (PWID). The recent availability of extended-release naltrexone (XR-NTX), an opioid antagonist, provides new opportunities for treatment and prevention, but little is known about patient preferences. We conducted qualitative analysis using focus groups (FG) of PWID recruited based on OAT experience: currently, previously, and never on OAT in five Ukrainian cities. FG included 199 PWID in 25 focus groups. Focus group transcripts were coded and analyzed using a modified grounded theory approach to identify common themes and domains related to attitudes about and preferences for XR-NTX, relative to other treatments. Interest in XR-NTX was supported if supervised opioid withdrawal and psychological support were assured. Other factors supporting XR-NTX included a focus on younger PWID early in their injection career and motivated for recovery. Perceptions of recovery included not receiving psychoactive medications like methadone or buprenorphine. With more information, XR-NTX could be a viable option for PWID in Ukraine, especially if concerns regarding withdrawal and psychological support are adequately addressed.

Using nominal group technique to identify barriers, facilitators, and preferences among patients seeking treatment for opioid use disorder: A needs assessment for decision making support

“…This study also compares specific pharmacotherapy strategies to each other, including newer, long-acting formulations. Ambivalence about XR-NTX is similar to other studies which suggested low acceptability in about half of participants (Ahamad, Milloy et al 2015, Springer, Brown et al 2015, Friedmann, Wilson et al 2018, Marcus, Bojko et al 2018, with reluctance to stop using opioids ("readiness"), and concern for the discomfort of opioid withdrawal (Marcus, Bojko et al 2018). Our findings emphasized the concern about induction, the leading concern for BPN-SL, which can be influenced by prior unsupervised use.…”

“…Notwithstanding these limitations, our study of treatment-experienced patients with OUD is unique in characterizing and prioritizing patients' perspectives about barriers and facilitators for initiation, preferences, and retention in a variety of medication options. While studies have looked at acceptability of BPN-SL (Sohler, Weiss et al 2013, Fox, Maradiaga et al 2015 and XR-NTX (Zaaijer, Goudriaan et al 2016, Marcus, Bojko et al 2018, there are no studies to date that address long acting OAT (BPN-IMP) nor ask patients to compare and rank-order newer medications to each other and the standard bearer, methadone. Additionally, our study is unique in using a method (nominal group technique) not previously used in this population, and in that it was conducted specifically as a needs assessment for a decision intervention to be used in the same target population Understanding how patients prioritize attributes in OUD treatments leads to better characterization of preferences, decision-making, and acceptability of novel therapies, which can inform patient-centered interventions, like decision-support tools, to improve initiation and retention in therapy.…”

“…Some known barriers include beliefs (Uebelacker, Bailey et al 2016), especially for methadone, that medications are harmful, worsen physical health, "trade one addiction for another" (Pinto, Maskrey et al 2010), and that "coming off it is worse than heroin itself" (Schwartz, Kelly et al 2008). For XR-NTX, people fear the detoxification process or believe it is for an idealized patient that differs from themselves (Marcus, Bojko et al 2018). Negative feelings about medications combined with low motivation for treatment reduce medication uptake (Ridge, Gossop et al 2008).…”

Perceptions of extended-release naltrexone, methadone, and buprenorphine treatments following release from jail

“…The possible appeal of opioid-free medication modalities is not exclusive to CJS populations. Two recent non-US qualitative studies documented a general interest and willingness to receive XR-NTX treatment as an alternative to opioid agonist therapies [3, 29, 30]. Overall, active and recent XR-NTX participants noted reduced cravings, were satisfied with a monthly injection as opposed to daily dosing, and credited XR-NTX’s lack of misuse and diversion potential and non-association with negative MOUD treatment stigmas.…”

Factors influencing recruitment to a randomised placebo-controlled trial of oral naltrexone and extended release implant naltrexone: Qualitative study

“…Notably, these concerns do not appear to have influenced recruitment to trials of Probuphine®, a sustained-release buprenorphine implant (Ling et al, 2010;Rosenthal et al, 2013). Indeed, suspicion of implantable formulations seems to have received little attention outside of our own empirical qualitative research (Neale et al, 2018b), and appears to contrast with studies on the acceptability of injectable XR-NTX (Ahamad et al, 2015;Haase et al, 2016;Marcus et al, 2017;Marcus et al, 2018;Zaaijer et al, 2016). Given that the market of long-acting extended-release medications for OUD is expanding (Barnwal et al, 2017;Hegde, Singh & Sarkar, 2013;Lorman, 2018;Sigmon & Bigelow, 2016;Walsh et al, 2017), attitudes to such medications require further investigation, not least in light of concerns regarding the uptake of Probuphine® implants in the US (Titan Pharmaceuticals, 2018).…”