Perceptions of Methadone Maintained Clients About Barriers and Facilitators to Help-Seeking Behavior

Adeline Nyamathi, ANP, PhD, Donna McNeese Smith, RN, EdD, Steven Shoptaw, PhD, Malaika Mutere, PhD, Allan Cohen, MA, MFT, Israel Amrani, MFT, Louis Morales, JD, Viviane de Castro, PhD (1) University of California, Los Angeles, School of Nursing; (2) University of California, Los Angeles, Family Medicine; (3) Bay Area Addiction, Research and Treatment, Inc.; (4) University of California, Los Angeles, Department of Psychiatry and Biobehavioral Science Submitted 21 March 2007; revised 11 May 2007; accepted 21 June 2007.

the inability to solve ones' own problems, the need for a job, and religious and legal encouragement. 7 Among a clinic sample of HIV-positive substance users, homelessness was found to be a particularly significant barrier to medical service utilization. 8 However, personal and community resources were found to facilitate their use of health care services. Significant correlates to help seeking behavior among these IDUs included high-quality experiences of case management (an important source of assistance for navigating the health care system) and health insurance. Positive perceptions of the treatment providers' dedication and engagement have also been observed to enhance substance users' help seeking behavior. 9 General health care-seeking behaviors still remain an unfortunate challenge for substance users and needs further investigation. 10 Although substance users clearly utilize health service resources, most commonly the emergency room, for the myriad of physical problems they experience, 11 outpatient visits nevertheless remain suboptimal. 12 Additional perspectives provided by health care professionals on barriers for substance users in seeking treatment include the clients' lack of insurance, and agency bureaucracy. Treatment staff members have also cited lack of appropriate programs and the societal stigmatization of addicts as barriers to help seeking. 13 The present study describes the first phase of a mixedmethod (qualitative and quantitative) approach to understanding the barriers and facilitators of help seeking for substance and general health care treatment in a group of methadone-maintained clients, the majority of whom were also problem or heavy drinkers.

METhOdS design
A convenience sample of 41 MMAs attending a methadone clinic in Los Angeles were recruited for focus group discussions about the barriers and facilitators they experienced in seeking general health care as well as substance treatment.
The clinic population numbered over 400 and were balanced in terms of minority and white subgroups. This communitybased, qualitative study engaged key leadership and staff of the clinic to assist in the study design, the refinement of the semistructured interview guide (SSIG) that guided the focus groups, and analysis of the findings.
MMA participants were eligible if they were over the age of 18   interested, after informed consent for the screening had been read and signed in a private room in the methadone maintenance clinic, the research staff administered a brief questionnaire to gather sociodemographic data and a screener for alcohol use and severity. Immediately after these documents were completed, a focus group was formed with discussions facilitated by very experienced qualitative researchers using a SSIG in private areas within the site. Each of the focus groups was audio-recorded on a cassette tape, with notes on nonverbal communication and other observations captured by a qualitative co-researcher. All respondents were paid $10 at the completion of the 1-hour focus groups.
As appropriate to community-based participatory action research, community members were involved in the study design, assessment measures, study implementation, and interpretation of findings. The first author worked very closely with community co-author (AC) in all aspects of the study before grant submission and with ongoing study implementation after funding was obtained. This included forming the research questions, selecting the research site, and guiding the study implementation and analysis. This collaboration formed when the community partners invited the primary author to join them in designing the study. The concept of focusing on alcohol using methadone-maintained clients was the area of interest of the community partners. In addition, other community leadership, as reflected in co-authors, assisted throughout the study implementation and provided feedback and review of study findings and analysis. They also assisted in refining the SSIG in a culturally and linguistically appropriate manner. This included rephrasing of sentences and adding or deleting questions that were originally drafted by the primary author and the primary community partner.
Moreover, the entire community of counselors, nurses, and physicians at the site met with the research team frequently and provided feedback relative to the results and implications.
Involvement of our community partners from the methadone maintenance site is a strength of the study and has led to a greater understanding of the phenomena of help-seeking barriers and facilitators experienced by these clients. Table 1 displays the SSIG questions.

data Analysis
Upon completion of the focus group sessions, the investigators oversaw transcription and content analysis of the taped recordings. The analysis was done directly from the

Sociodemographic Information
The participants ranged in age from 24 to 73 years (mean,

Treatment Needs
For many methadone-maintained clients, services that were needed included drug and alcohol treatment as well as general health care, which ranged from the normal healthy occurrences, such as childbirth, to services for managing serious crisis experiences such as internal bleeding, severe victim- Although lack of familiarity with available government programs created barriers for some, many clients also commented on the discouragingly long wait to see a physician for a medical problem. Some participants also advised that clients with chronic medical conditions such as diabetes and heart disease tended to ignore their health problems, simply because of the bother involved in seeking care. and alcohol treatment raised some other concerns for focus group participants. One man expressed the concern that "inhome"(residential) drug programs were a "rip off" because money is taken from homeless clients, and when the 6-month program was up, "they sent [the client] right back out there on the street with nothing." Another male was concerned that sober-living programs make it difficult to reenter if one were to "slip-up and have a drink." These programs require clients that have consumed alcohol to detox before being readmitted, which takes about 45 days. This was perceived as excessive.

Feelings of
Several males offered a number of observations from Narcotics Anonymous (NA) meetings relating to the staff running the meetings. The most serious concern was that people who were perceived as never being drug users were "claiming to be sober." However, according to one, "they are hooked on NA meetings, they are clique-ish and judgmental; and they push the message that you don't have any power on your own [in order] to reinforce dependency on their NA meetings." Also, these participants noted these leaders would be continually smoking cigarettes and drinking coffee throughout the NA meetings which was viewed as hypocritical. "They just changed addictions!" As one woman explained: That's why I don't like going to NA, because you've got these people who barely f *** ing ever did anything! Don't know what it's like, except they snorted a little cocaine . . . And they're out there, self-righteous, spouting all the crap from the meetings.
Another female added: "Yeah! But they've never stuck a needle in their neck; they've never OD-ed; they never had to sell their a ** ; they've never had to commit a crime. For another addict, loving themselves was considered important, because when that stops, the drug abuse starts.
"They abuse their body 'cos they don't care." Building selfesteem was considered important by many as well as trying to provide resources for housing, job skills, and so on. For others, it was financial aid, legal aid, and spiritual support.
As one male described: for those who have lost their jobs due to alcoholism, once they kick the habit an aid would be some kind of support or referral-system for jobs, activities, etc. to transition back into society . . . rather than going back to joblessness and potential homelessness, which would be a major setback.
Participants were quite interested in having an alcohol treatment program offered in the midst of the methadone clinic. A small number of clients wished that they could also receive help from getting off methadone, for which one male conceded "This here's like a business. And their business is to keep us . . . drinking this stuff." Use of Support Groups. A number of clients reiterated the need for support. They advised identifying the group of people who were serious about changing their lives, and having a support group with fun activities for them to engage in together.
Two males agreed that "understanding" and "listening" would be important in the healing process as would having a therapist who demonstrates empathy, acceptance, and the ability to listen without prejudice. This was considered more important than a trained experienced counselor who creates barriers because they lack these key ingredients.4 Several of the women emphasized the need to have "some- that would direct them to an appropriate place to stay. As one male contended, "A person who is detoxing needs to be around other people who are reinforcing supportive messages, not isolated with their own problems and negative script." A related concern was raised on dwelling heavily on the "I am a drug addict" type of scenario, and missing the point that addiction is a symptom, not the problem itself. As this participant explained, the problem is people having "living problems . . . financial problems" and they turn to drugs and/or alcohol to cope. Another help-seeking avenue that was not perceived as primary care provider. Last, but not least, if they return to crime to support an opiate addiction, the costs multiply by thousands.
If private physicians and nurse practitioners were able to dispense methadone, under the same controlled standards used for buprenorphine, and could also then provide the medical care, this might provide a more equable situation.
Relationships with an alcohol abuse treatment center would also be essential, as well as availability of psychiatric assessment and counseling. This policy change could go a long way toward creating equity in our system of treatment for former opiate addicts.
Much of the consensus of participants was that barriers were on a more personal level at general health care facilities, and there is a great need to counter the experience of discrimination by health care professionals who were often culturally alienated, inauthentic, judgmental, or hypocritical in their dealings with MMAs. Moreover, because mental health problems and substance use often share a close association, the need to consider this relationship as it relates to future directions for education and research is critical.
Findings from this study should assist in designing training programs for nursing, medical, and allied health professionals so that care delivery can be provided in a culturally appropriate and group-sensitive manner. Such programs should include the interplay of methadone treatment, the costs and risks to society if clientele return to opiate use, and methods of communication, treatment, and referral.
Limitations include a subset of methadone-maintained clients who may not be generalizable to the population of methadone-maintained clients who may have differed in terms of drug or alcohol use in different states or countries worldwide. Use of a small incentive may also have influenced their motivation to participate.

ACkNOWlEdgMENTS
Funded by the National Institute on Alcohol Abuse and Alcoholism, #AA015759. The author would like to extend tremendous gratitude for the support and involvement and leadership of the entire BAART staff in this research endeavor.
Special thanks to Cindy James for her careful preparation of this manuscript.