Module 4: Trusting, Compassionate, Therapeutic Relationships – Topic I Recognize barriers to receptiveness to treatment related to opioid use.

Learning Objectives

By the end of this topic, the student should be able to:

• Describe barriers to treatment and how they apply to opioid use and opioid use disorder.
• Describe logistical barriers to services (e.g., stigma, financial constraints, work) that members of marginalized groups experience.

Key Concepts

• Many barriers exist for individuals who seek treatment and are both internal (intrapersonal) and external (relational, logistic, and societal).
• Identifying and understanding these barriers is a first step in supporting individuals with substance use disorders.
• For women with substance use disorders, some barriers are unique and impede treatment:
• Lack of childcare
• Fear of stigma
• Lack of family support
• Lack of financial support
• Comorbid mental health issues
• Cultural barriers can also exist for members of visible minority groups when fear of bringing shame to the family can be a concern for those using opioids.
• It is important to address the underlying challenges Indigenous peoples may face with social services and medical treatment (related to racism, trauma, poverty, homelessness, or other health determinants) to tackle the root causes of substance use.

Barriers to Treatment

Certain groups in society experience more barriers to receiving care for opioid use. Identifying and understanding these barriers is a first step in supporting individuals with substance use disorders.

While it is important to understand each individual’s experience and perspective on the barriers unique to their situation, categorizing lived experiences and personal perspectives is helpful to remove those barriers that prevent treatment.

Rapp et al. (2006) surveyed 312 individuals about to enter treatment using the Barriers to Treatment Inventory, a 59-item self-report scale, to identify what they perceived as barriers to treatment.

The following broad categories with supporting quotations are reasons cited from the Rapp et al. (2006) sample. Participants were predominately male, over the age of 18 years, had previous experience with substance use and misuse, were not working, and were court referred for treatment.

Barriers Specific to Women

Some barriers faced by women with substance dependency issues are unique and can prevent them from seeking treatment. Women enter treatment at lower rates than men. Some of the contributing factors preventing women from seeking treatment were identified by Taylor (2010) as follows:

Lack of Childcare

• Some women are unable to access treatment services because they do not have care for their children.
• Compounding this is the stigma associated with a substance use disorder and women’s fear of losing their children to child welfare because they have a substance use disorder.
• During the intake process, women often list the lack of care for their children as a deterrent to beginning treatment.
• According to research, the children of women with substance use disorders are more likely to enter and remain in foster care longer than children who are in foster care as a result of abuse or neglect (Taylor, 2010).

Most addiction treatment programs do not provide childcare, and some will not admit women with children into treatment programs. Women are most likely to complete a long-term residential treatment when they are able to have their children with them.

Fear of Stigma

Women with substance use disorder experience a significant amount of stigma.

• Women are more likely than men to experience shame and embarrassment in substance use treatment programs, and shame and embarrassment about their lives keep women from accessing treatment services.
• There is a correlation between women with substance use disorder and those with a history of sexual abuse (which may have led to other illegal activities such as prostitution and drug-selling or drug-using behaviours).
• Negative attitudes of health and social service providers and responses that stigmatize women can deter them from accessing care (Carter, 2002).

Lack of Family Support

• Women tend to lose the support of family members because of their substance use and other associated behaviours (e.g., stealing, prostitution).
• Women are more likely than men to experience disapproval from family and friends about engaging in treatment programs.
• If a woman started using because of a relationship with a man who was also using, treatment may compromise this relationship.

Lack of Financial Support and Treatment Accessibility

• The cost of private treatment is prohibitive to most people.
• Because of a lack of gender equality in the workforce, women are less likely to be able to afford treatment programs.
• Subsidized treatment programs typically have long waitlists.

Co-occurring Substance Use and Mental Health Issues

• Women with substance use disorder are more likely than their male counterparts to have experienced trauma such as sexual assault, incest, and sexual violence. They are also more likely to have experienced domestic violence, homelessness, and victimization.
• Between 30 and 59 percent of women with substance use disorders are also experiencing posttraumatic stress disorder (Cohen & Hein, 2006)
• Up to 80 percent of women seeking treatment for substance use report sexual and/or physical assault (Khoury et al., 2010).
• Women with substance use disorders are more likely than men to have mental health issues such as depression, anxiety, eating disorders, and low self-esteem.
• Some treatment facilities are not prepared or equipped to treat co-occurring mental health issues.

Cultural Barriers to Treatment

Two other groups mentioned in the literature regarding barriers to treatment are Asian Americans and those who live in the Pacific islands, who underuse substance abuse treatment services (Le Meyer et al., 2009; Yu et al., 2009). SAMHSA (2004) reported that these two groups have high rates of substance use compared to other ethnic groups in the United States.

Fong and Tsuang (2007) identified that cultural factors may prevent Asian Americans from seeking treatment as a result of embarrassment or shame.

• This group reported avoiding substance abuse treatment “because revealing an SUD to the community may bring shame to their family, and family members pressure the individual with an SUD to try to solve the problem within the family” (Sakai et al., 2005; Park et al., 2010).
• Fong and Tsuang (2007, p.57) added that the reluctance to seek outside assistance reflects the “family’s inability to solve the situation and may be inconsistent with the cultural mandate to maintain an appearance of harmony within the family.”

Another study identified that barriers to supporting individuals with substance use disorder included being unfamiliar with the treatment process and worrying about the impacts of treatment on an individuals’ ability to meet family obligations (Masson et al., 2013).

• Conversely, some families in the study did see the merit of substance abuse treatment and pressured the substance user to enter and complete treatment (Masson et al., 2013).

Barriers Specific to Indigenous Peoples

Indigenous peoples also experience many barriers in accessing treatment for opioid use disorder. Differences in culture and approaches to harm reduction are one barrier to treatment faced by Indigenous peoples.

Western harm reduction approaches (such as safe consumption sites, clean needle distribution, naloxone, and opioid substitution therapy) can be useful; however, for many Indigenous peoples, harm reduction is a way of life, not tied to substance use but “embedded within traditional knowledge systems that see the spiritual world, the natural world, and humanity as inter-related” (Interagency Coalition on AIDS and Development, 2019, p. 7).

In 2019 the Interagency Coalition on AIDS and Development noted in a report titled Indigenous Harm Reduction = Reducing the Harms of Colonialism that

“the drugs alone are not the crisis, and as long as we continue to focus just on the drugs, we will see one [crisis] fall and another rise up in its place. The real crises [in First Nations, Inuit and Métis communities] are the historic and current factors [of colonization] that place some populations at higher risk of harmful drug use than others”

Additionally, not all First Nations, Inuit, or Métis, or communities and individuals within each of these groups, agree that harm reduction is a valid or viable approach to treating harmful use of substances.

Within the Indigenous community, women with substance use issues report difficulties using conventional systems of care. These barriers include:

• fear of forced treatment or criminal prosecution,
• fear of losing custody of children,
• lack of treatment readiness,
• coexisting mental illness,
• guilt,
• denial or embarrassment regarding their substance use,
• stigma, and
• lack of transportation (Curet & His, 2002).

Questions

What are some systemic barriers women can face in receiving treatment for opioid use or opioid use disorder?

a. Lack of childcare

b. Lack of financial support

c. Lack of mental health services

d. All of the above

Correct!

Incorrect. The correct answer is d.

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In collective societies, where the family plays a more pivotal role, a person may not seek treatment for which of the following reasons?

a. This may bring shame to the family.

b. Drug use is not accepted as a social norm.

c. The person cannot take time away from family responsibilities.

d. The expense associated with treatment is too high.

Correct! While all the answers hold some degree of truth, a is the most reported reason for not seeking treatment by people in collective societies.

Incorrect. The correct answer is a. While all the answers hold some degree of truth, a is the most reported reason for not seeking treatment by people in collective societies.

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Is there a common understanding among Indigenous peoples that abstinence is the preferred route of treatment.

a. Yes, and it is due to the high prevalence of substance use within this group.

b. No, harm reduction as a treatment method is more acceptable than abstinence.

c. There is a range of opinions within the Indigenous community as to the preferred approach.

Correct! An ongoing debate in many Indigenous communities is centred on the perceived dichotomy of abstinence versus harm reduction. In some First Nations, Inuit, or Métis communities, particularly those in northern, rural, or remote areas, even the phrase harm reduction is contentious.

Incorrect. The correct answer is c. An ongoing debate in many Indigenous communities is centred on the perceived dichotomy of abstinence versus harm reduction. In some First Nations, Inuit, or Métis communities, particularly those in northern, rural, or remote areas, even the phrase harm reduction is contentious.

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References