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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 38  |  Issue : 1  |  Page : 32-37

Common barriers and facilitators of addiction treatment among treatment-seeking population


Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India

Date of Submission15-Dec-2021
Date of Acceptance08-Jan-2022
Date of Web Publication30-Mar-2022

Correspondence Address:
Dr. Ankita Chattopadhyay
Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, Room No. 4096, 4th Floor, Teaching Block, New Delhi 110-029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_368_21

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  Abstract 


Background and Aims: In the process of treatment for substance use disorders, patients experience many barriers and facilitators related to treatment. This study aimed to ascertain the barriers and facilitators of addiction treatment in treatment-seeking population of patients with substance use disorders. Methods: A defined questionnaire was developed on the basis of qualitative work to assess the barriers and facilitators among adult patients with opioid and/or alcohol use disorders seeking care at a dedicated addiction treatment facility. Results: We recruited a total of 96 male patients. The mean age of the sample was 30.8 years. The most common barriers were feeling like taking substances when depressed, stressed, or angry; having difficulty while not having substances; and lack of willpower to quit the substances. The most common facilitators of treatment were quitting addiction for a better future (e.g., marriage and children); good response from the doctor; facing the harmful consequences of substance use; having effective medicine and treatment; substance use causing health deterioration; and the need to fulfill family responsibilities. Higher educational attainment and better socioeconomic status were associated with fewer barriers and facilitators of treatment. Conclusion: Some barriers and facilitators are endorsed more commonly by patients who seek services for addiction treatment. Efforts are required to minimize the barriers and utilize facilitators so that patients are able to engage in treatment more easily.

Keywords: Barriers, facilitators, questionnaires, substance use disorders


How to cite this article:
Chattopadhyay A, Sarkar S, Mandal P, Sood E, Thakur A. Common barriers and facilitators of addiction treatment among treatment-seeking population. Indian J Soc Psychiatry 2022;38:32-7

How to cite this URL:
Chattopadhyay A, Sarkar S, Mandal P, Sood E, Thakur A. Common barriers and facilitators of addiction treatment among treatment-seeking population. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 May 25];38:32-7. Available from: https://www.indjsp.org/text.asp?2022/38/1/32/341337




  Introduction Top


Substance use disorders are an important concern all over the world and in India.[1],[2] These include disorders associated with both illicit (such as cannabis and heroin) and licit substances (like alcohol). Substance use disorders affect a substantial proportion of the population in India, and the most common substances of use are alcohol, tobacco, cannabis and opioids.[3],[4] Substance use disorders not only produce health impairment but also cause substantial social and economic burden on the society. The impact of substance use disorders can be in the form of loss of earnings due to absenteeism from work, loss of financial resources when expended on substances, perpetuation of domestic violence, occurrence of familial and social disruption, and lowering judgments that facilitates risky behaviors.[5],[6],[7],

Patients with substance use disorders can be helped with provision of medical care. Efficacious treatment options are available for alcohol, opioid, and tobacco dependence.[8],[9],[10],[11] Regular treatment can help patients to keep off substances of use, and lead to social and occupational reintegration. This applies particularly to some substances like alcohol and opioids, for which effective medical treatment is available for the amelioration of withdrawal symptoms, and for prevention of relapse to substances. Improved patient outcomes are beneficial for the family as well, as the family members are significantly affected due to substance use disorders.[12] Often, they are the family members who provide help in the treatment-seeking process by providing motivation, information, and finances.

Patients with substance use disorders experience many barriers to treatment services.[13],[14],[15],[16] Access and affordability are major issues that affect the health-care seeking in India. Many times, patients do not seek treatment or continue treatment due to the barriers in the care seeking process. This is applicable to the treatment of substance use disorders and contributes to relapse to substance-taking behavior and recurrence of the health and psycho-social adverse consequences due to substance use. The treatment gap for mental health problems including substance use disorders has been significant, and it has been estimated that more than half of those individuals with problematic substance use may not be under treatment. Understanding the barriers to treatment from the perspective of the service users can be helpful in addressing their concerns. Similarly, facilitators of treatment can inform about the factors that help patients to seek treatment and continue their treatment. However, the literature related to barriers and facilitators for health-care seeking in India is limited. Hence, the present study has been planned to understand the barriers and facilitators to health-care seeking among substance users using a questionnaire-based approach.


  Methods Top


This study was conducted at an addiction treatment facility in a city in north India. The treatment facility has clinical care, research, education, and policy under its mandate and is affiliated with a reputed medical school. The addiction treatment facility has 50 bedded inpatient services and provides outpatient and inpatient medically-oriented care, supplemented with psychological and social interventions. Patients with alcohol and/or opioid use disorders primarily form the clientele. Patients from several north Indian states seek services at the center.

The barriers and facilitators of addiction treatment which emerged from the thematic analysis of a previous work were used to draw the items for the present questionnaire. Different formats of framing of the questionnaire were considered by the investigators including Likert rated, and yes or no format. Consideration was also given toward the number of questions. The number of questions was aimed to be suitable for easy application, at the same time, comprehensive to provide the details sought in the process. It was decided that the questionnaire should be self-rated (rather than interviewer-rated) for easy administration and wider usage. When illiterate participants are encountered, then the scale could be administered by someone who was able to read and write. The questionnaire was aimed to be applicable to both the genders as female substance users also seek treatment and were recruited in the study.

The initial questionnaire had Likert-rated items and was developed in Hindi, the local language of the region. Preliminary use in few patients identified words that were difficult to be followed and were rephrased to more understandable phrases. Patients had reported difficulty in following through the Likert-rated items, and hence the questionnaire responses were changed to yes or no format. The questionnaire that was developed contained 40 barriers and 26 facilitators of treatment. The patients could endorse as many barriers and facilitators as were ever applicable for them. The English version was developed based upon the Hindi version, by translation by the investigators. Content equivalence was checked by the investigators and bilingual experts[2] and was found to be acceptable. The final questionnaire was then applied to consenting adult patients who were seeking treatment for alcohol and/or opioid dependence. Application of the scale was done in a single sitting by one of the investigators (E.Sood or S.Sarkar). The study had institutional ethics committee approval.

Statistical analysis was done using SPSS version 21 (IBM Corp, Armonk, NY, USA). The demographic and relevant clinical data were presented using mean, standard deviation, frequencies, and percentages. Inferential statistics to understand the relationships between variables was done using various parametric and nonparametric tests. A P < 0.05 was considered statistically significant. For the barriers and facilitators, missing values were treated as “no” responses, while missing value imputation were not done for other demographic and clinical variables.


  Results Top


A total of 100 patients were approached for the application of the questionnaire. Four participants did not provide responses. Thus, usable data was presented from 96 participants. The demographic characteristics of the 96 patients included in the study are depicted in [Table 1]. All the participants were males, the mean age being around 30 years. The average education was 10 completed years (i.e., matriculation). A majority of the participants were married and lived in an extended/joint family. Opioid use disorder was the commonest substance of abuse being taken by the patients in the present sample.
Table 1: Demographic and clinical variables of the sample (n=96)

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The barriers and facilitators reported by the patients are summarized in [Table 2] and [Table 3], respectively. The most common barriers were feeling like taking substances when depressed, stressed, or angry; having difficulty while not having substances; and lack of willpower to quit substances. The most common facilitators of treatment were quitting addiction for a better future; good response from the treatment providers; having faced the adverse consequences of substances use; having effective treatment strategies; substances causing health deterioration; and needing to fulfill family responsibilities.
Table 2: Barriers to addiction treatment

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Table 3: Facilitators of addiction treatment

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The mean number of barriers reported was 20.7 (±7.7) within a range of 1–39. The mean number of facilitators reported was 22.5 (±2.4) within a range of 9–26. The relationship of number of barriers and facilitators of treatment and the age, education, and per-capita income is presented in [Table 4]. It was seen that higher educational attainment and a higher per-capita income was associated with a smaller number of barriers and facilitators. Furthermore, a greater number of barriers were related to a greater number of facilitators, and higher educational attainment was related to greater per-capita income. The barriers and facilitators were not associated with marital status, employment status, and living arrangement. However, those presenting with opioid use disorders as a complaint were likely to experience more barriers (22.4 vs. 17.2, P < 0.01) and facilitators (23.0 vs. 21.5, P < 0.05).
Table 4: The relationship of barriers and facilitators with parametric data

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  Discussion Top


The present study highlights some barriers and facilitators of addiction treatment among patients reaching treatment services. The sample comprised exclusively of males, reflecting the general preponderance of males among the population who seek treatment of substance use disorders. The prevalence of substance use among females is lower, and they experience additional access barriers, resulting in lower proportion of women treatment seekers.[17] Yet, they are likely to be an important subgroup who should be focused in substance using specific population subgroups. The mean age of the sample was in early thirties, comparable to literature from the center and elsewhere in the region,[18],[19],[20] but lower than the average age of patients in treatment-seeking population in other regions.[21] Opioid was the most common substance of abuse in this population, which was similar to other studies from the region.[19],[22]

A large number of barriers were noted by the patients during their lifetime. The most common barriers were feeling like taking substances when depressed, stressed, or angry; having difficulty while not having substances; and lack of willpower to quit addiction. The first barrier pertains to craving in particular situations, which leads to discontinuation of treatment or impediment to treatment processes.[23] The other issue faced was of withdrawal symptoms encountered by the patients. The discomfort experienced due to withdrawal symptoms often may become a deterrent to quitting substances and even seeking treatment, especially when effective treatment is not available or there are issues in access to treatment. Another related aspect was lack of “will power” for quitting substances. This in some way relates to loss of control over substances, which leads to the inability to quit the substances of use. There were some factors which were endorsed by a minority of the participants, such as bad effects of medicine, staff misbehavior, and records of treatment forgotten or lost. These imply that adverse effects of the treatment approaches and the treatment center procedures, ambience and functioning also matter, though maybe to a lesser extent.[24],[25]

This is in contrast to the western literature where the most common barriers cited are lack of accessibility of treatment or long waitlists for specialist care or insurance barriers.[26],[27] Though shame in the process of treatment-seeking has been reported by some participants, it does not come across as one of the most common barriers as is the case in other parts of the world. Stigma has usually been cited as an important barrier in treatment-seeking in this population, but the participants in our study mentioned stigma only in the form of shame to divulge the information to family members or shame as perceived in front of other patients in the hospital.

The most common facilitators of treatment were quitting addiction for a better future. The consideration that one would need to quit substances to improve the life situation impelled many patients to seek treatment. Availability of effective treatment approaches along with a favorable approach from the treatment setting also facilitate treatment. Patients facing adverse consequences of substance use including deterioration of health were other factors which led to seeking treatment services. Multiple facilitators seemingly were applicable for each of the patients included in the present study. Family pressure for treatment was the least frequently endorsed option in this sample. This was contrary to another study done in India from the addiction clinician perspective, where the most facilitators for substance use disorder treatment included informed and caring family members, friends, and community.[28]

The present findings also suggest that better education of the participants was associated with a lesser number of barriers and facilitators of treatment. It can be argued that better education allowed participants to know how and where to access treatment, and actually make steps to access treatment, and possibly a better understanding of the treatment process leading to a lower number of barriers. Consequently, they required a lesser number of facilitators to cross the threshold to make them come for treatment. Similar inference can be made for the association of better economic status (as reflected from higher per-capita income) with lower number of barriers and facilitators of treatment, as economically better off patients were able to access treatment more easily.

The implications of the present findings are that a variety of barriers and facilitators of addiction treatment are applicable in a given patient with addictive disorders. All these factors could be largely grouped into individual and systemic factors and they probably act in complex conjunction with each other at a variety of levels. The policymakers, healthcare providers, and family members need to take cognizance of the issues that deter patients away from treatment at different levels. Adequate information about treatment services being available, and providing information about the substance use disorders and their treatment can possibly help in improving uptake of services. Communication training of the service providers attempts to make services more accommodating, and using safer treatment services may be able to encourage treatment access.

The strength of the study includes developing a questionnaire-based on in-depth qualitative understanding of barriers and facilitators of addiction treatment pertinent to the Indian setting. The limitations include a limited sample size and having only male participants, absence of using concurrent or divergent validity to ascertain the barriers and facilitators, lack of a factor analysis on the responses, and absence of checking temporal stability and language equivalence in a bilingual patient population. The findings relate to treatment-seeking population, and may not reflect the barriers and facilitators of nontreatment seeking substance-using population. Furthermore, each of the barriers and facilitators was given equal weightage, though the salience of each barrier or facilitators might be different at different points in time. A lifetime's perspective was used to assess the barriers and facilitators, though the questionnaire can be modified to ascertain the current (i.e., last 1 month) barriers and facilitators.


  Conclusion Top


The current study identified various barriers and facilitators of addiction treatment in India. Cognizance of these factors may help in translating to better access to addiction treatment facilities. Future studies can look at whether barriers and facilitators are similar in the community setting as in the clinical setting, whether the findings are similar in different age groups and different regions, and whether the profile of barriers and facilitators are similar across both the genders. It would also be useful to see whether addressing these barriers and facilitators help in improving treatment satisfaction, reduce the “treatment gap” of addiction treatment, and lead to better outcomes of patients. Catering to the barriers and facilitators of treatment can also be done in a progressive incremental manner to optimize resource allocation and improve treatment access and provision.

Acknowledgment

Nil.

Financial support and sponsorship

The study was partly funded by ICSSR IMPRESS grant – P535/229/2018 19.

Conflicts of interest

There are no conflicts of interest.



 
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This paper has won the Anil Malhotra Award at the XXVIII National Conference of Indian Association for Social Psychiatry, Imphal, 26-28 November 2021.



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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