Application of the COM-B model to patient barriers and facilitators of retention in medication treatment for opioid use disorder in rural Northeastern United States: A qualitative study

Introduction: Medications for opioid use disorder (MOUD) reduce illicit opioid use and overdose mortality, but effectiveness remains limited by poor treatment retention. Understanding multilevel barriers and facilitators to retention from the patient perspective can guide intervention strategies to improve retention.Methods: We conducted semi-structured telephone interviews to elicit perspectives of individuals with opioid use disorder (OUD) currently (n = 19) and formerly (n = 16) receiving treatment from a multi-clinic outpatient MOUD program in Pennsylvania in July 2020 to January 2021. The Capability, Opportunity, Motivation, Behavior model provided a theoretical framework for analysis.Results: Based on interview themes, physical, rather than psychological, capability was more salient to MOUD engagement, and pertained to individual-level factors such as side effects, withdrawal, and the degree to which MOUD addressed participants' need for pain management. Co-existing mental health conditions also challenged participants' physical ability to attend appointments. The opportunity domain contained both physical and social aspects. Physical opportunity for MOUD engagement centered on community-level factors related to MOUD access (e.g., distance, transportation) and clinical-level factors including program policies. Themes related to social opportunity included interpersonal influences-such as therapeutic and social support-and stigma associated with OUD and MOUD. Motivation emerged as the dominant domain for patients. Reflective motivation factors included individual-level factors such as participants' recognition of their addiction and "readiness" to quit illicit opioid use, attitudes toward MOUD, future treatment expectations, motivation to engage in MOUD, and perceived consequences of disengagement. Automatic motivation factors included the degree to which MOUD created a sense of normalcy for participants and the use of illicit drugs to numb emotions.Conclusions: Factors at the individual, interpersonal, clinical, community, and societal levels influenced patients' capability, opportunity, and motivation to engage in MOUD. Understanding such factors can inform implementation strategies to improve retention.