The structural, political, and cultural contexts through which the implementation process will proceed.
Perception of Need to Change and Fit with Values and Workflow
Not only is actual concrete support for pharmacotherapy important, such as providing training and supervision time, EHR and information technology supports, and financial and other incentives for providers,374 the perception of organizational support is important.406 Perceived organizational support was strongly associated with adopting and prescribing buprenorphine, and perceived lack of support was associated with reluctance to prescribe.406 Gordon et al.391 reported that a perceived lack of buy-in by senior leadership for pharmacologic treatment produced a "no push" attitude by providers. Pharmacotherapy is perceived as a highly intensive intervention with a difficult patient population, and some providers already consider themselves significantly burdened with medically ill patients.391 This was not found during NORC's site visits. Leadership at the health centers were supportive of pharmacotherapy, expressed strong interest in building capacity to provide such services, and did not report that such treatment was reserved for "difficult" patients or that such patients were burdensome.
Organizational Incentives and Rewards
Perceived lack of resources (e.g., time, space, and staff) and absence of continuing education training are commonly reported barriers.337, 350, 351, 352, 356, 357, 361, 363, 364, 365, 368, 369 Although mandated training is described as a barrier that inhibits the adoption of buprenorphine pharmacotherapy, PCPs also complain that they lack training. Respondents across multiple studies report that increased access to continuing education would facilitate their adoption of pharmacotherapy.350, 351, 352, 355, 356, 357, 358, 359, 362, 365, 368, 370 Lack of access to experts or mentors to guide implementation, educate staff about pharmacological treatment, and act as resources for providers has been widely reported.337, 357, 358, 363 PCPs also note a general lack of time for delivering pharmacotherapy and for the administrative tasks associated with treatment protocols.351, 352, 358, 361, 363, 364, 365, 368