Table 3 Motivation-Related Barriers and Facilitators

Motivation (Automatic) [Barrier]

MD/NP

Perception that primary care providers are unfamiliar with Naltrexone for AUD.

“Anytime you have a service like this, the clinics [...] outside the hospital in different cities, basically, just refuse to deal with it and send everybody to the hospital... Whenever we establish one of these services, the clinic starts sending us those patients rather than referring through the usual mechanism” -Attending

Persuasion: Dispel ED provider misconceptions of primary care and reassure that AUD management exists in primary care.

Motivation (Automatic) [Barrier]

MD/NP/ RN/CSW

Staff feel powerless in helping AUD patients, and that attempting to treat them is futile.

“I guess I find it a challenge that I’m good at managing short-term, but I feel basically helpless in helping them get more definitive management of their problem.” -Attending

Persuasion: Use of encouraging examples and vignettes in conference. Liken to management of other chronic conditions, where success is expected to be gradual and is measured by progress.

Modeling: Establish champions among MDs, Residents, and RNs that will model behavior and reiterate success stories.

Motivation (Automatic) [Barrier]

MD/NP/ RN/CSW

Staff bias against patients who use alcohol.

“There’s that coarse and vulgar term used, that goes ‘metabolize to freedom,’ where you try to get them to the point where, clinically, they’re relatively sober in their clinical state and they’re safely able to discharge.” -Attending

Modeling: Model alternative terminology, i.e. replace “metabolize to freedom” with “metabolize to screening.”

Motivation (Automatic) [Barrier]

MD/NP/ RN/CSW

Staff implicit bias of non-English speakers may be affecting their care.

“Our patients specifically, probably a language barrier. I think foremost. Just because we deal with a huge Hispanic population. For a lot of people, English isn’t their first language. So that’s going to be a big barrier. You know, Not quite understanding why, if they’re drinking a 12-pack a day for 10 years straight, and they decide to stop suddenly—they don’t quite understand why they’re shaking and anxious. So that’s one. I think that’s quite a big barrier” -RN

Modeling: Demonstrate cultural humility in approach to AUD management. Avoid “othering” of non-English speakers and AUD patients.

Training: Regular implicit bias training for ED staff.

Motivation (Automatic) [Facilitator]

MD/NP/ RN/CSW

Positive opinion of medication assisted treatment and new initiatives among staff.

“More so, recently, I feel like there’s just more resources and potentially more knowledge and more advocates for these patients and I feel like there’s a higher rate of success in getting these patients to the next tangible step and not necessarily leaving them out into the void.” -Attending

Modeling: Continue to use the Bridge Clinic’s OUD management precedent as a model that can be used for AUD treatment.

Enablement: Use positive opinion of opioid use disorder MAT to encourage the adoption of naltrexone as a treatment option for AUD.