Extended-Release Naltrexone: A Qualitative Analysis of Barriers to Routine Use

• The Consolidated Framework for Implementation Research structured a qualitative analysis of features of extended-release naltrexone that inhibited use for the treatment of alcohol and opioid use disorders.
• The processes of ordering, storing, and using and the cost of extended-release naltrexone were characteristics of the intervention that reduced use.
• Features of the outer setting (environment) that inhibited use included requirements for patients with opioid use disorders to be opioid free for 7 to 10 days and health plan formulary, benefit management, and reimbursement policies.
• Program cultures, resistance to change, and weak linkages with primary care for ongoing injections also affected routine use of the medication.

The Medication Research Partnership (a national health plan and nine addiction treatment centers contracted with the health plan) sought to facilitate the adoption of pharmacotherapy for alcohol and opioid use disorders. Qualitative analysis of interviews with treatment center change leaders, individuals working for the manufacturer and its technical assistance contractor, and health plan managers extracted details on the processes used to order, store, bill for, and administer extended-release naltrexone. Qualitative themes were categorized using domains from the Consolidated Framework for Implementation Research (intervention characteristics, outer setting, inner setting, and provider characteristics).Characteristics of XR-NTX that inhibited use included the complexity of ordering and using the medication; cost was also a barrier. Outer setting barriers reflected patient needs and external health plan policies on formulary coverage, benefit management, and reimbursement. Program structures, the lack of physician linkages, a culture resistant to the use of medication, and unease with change were inner setting elements that limited use of XR-NTX. Patient stereotypes and a lack of knowledge about XR-NTX affected practitioner willingness to treat patients and prescribe XR-NTX. The Consolidated Framework for Implementation Research provided a useful lens to understand and interpret the processes affecting access to XR-NTX.