Dynamics of prescribing and accessing medications for opioid use disorder: a community-based systems analysis.

Background: Although medications for opioid use disorder (MOUD) are effective for treating opioid use disorder (OUD), persistent barriers still prevent patients from accessing this life-saving care. Policies to increase MOUD access have produced suboptimal results. This study presents a qualitative system dynamics model that elucidates the complexities of accessing and staying in MOUD treatment. Methods: We utilized a community-based system dynamics approach to modeling the MOUD treatment system. We engaged a cohort of system experts/stakeholders, including individuals who had received MOUD, treatment providers, and policymakers, in interviews and group model building to develop and refine a simulation model. We then created a qualitative causal loop diagram based on insights gained while developing the simulation model and a review of interview transcripts. Results: The causal loop diagram captures four key factors affecting treatment initiation, retention, and leaving: (1) fraught interactions between patients and healthcare providers; (2) stigma-driven regulation of MOUD creating a culture of fear and defensive medicine; (3) a punitive culture in clinics and opioid treatment programs offering MOUD; and (4) the internalization of the abstinence narrative contributing to premature termination of treatment. Conclusions: Our analysis highlights how interdependent and non-linear feedback processes diminish or counteract the effectiveness and sustainability of MOUD policy interventions. Due to system memory and cultural resistance to change, even rolling back reactionary policies may do little to curb established behavioral patterns. In addition, conflicting and competing strategies among various actors within the system contribute to goal misalignment and a lack of standardization of care.