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Bergman AA, Oberman RS, Taylor SL, Kranke B, Chang ET. Prescribing and Acceptance of Medications for Opioid Use Disorder in VA Primary Care: Veteran and Provider Perspectives. J Gen Intern Med 2024:10.1007/s11606-024-08703-z. [PMID: 38587730 DOI: 10.1007/s11606-024-08703-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/23/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Medications to treat opioid use disorder (MOUD) such as buprenorphine/naloxone can effectively treat OUD and reduce opioid-related mortality, but they remain underutilized, especially in non-substance use disorder settings such as primary care (PC). OBJECTIVE To uncover the factors that can facilitate successful prescribing of MOUD and uptake/acceptance of MOUD by patients in PC settings in the Veterans Health Administration. DESIGN Semi-structured qualitative telephone interviews with 77 providers (e.g., primary care providers, hospitalists, nurses, addiction psychiatrists) and 22 Veteran patients with experience taking MOUD. Interviews were recorded, transcribed, and analyzed thematically using a combination a priori/inductive approach. KEY RESULTS Providers and patients shared their general perceptions and experiences with MOUD, including high satisfaction with buprenorphine/naloxone with few side effects and caveats, although some patients reported drawbacks to methadone. Both providers and patients supported the idea of prescribing MOUD in PC settings to prioritize patient comfort and convenience. Providers described individual-level barriers (e.g., time, stigma, perceptions of difficulty level), structural-level barriers (e.g., pharmacy not having medications ready, space for inductions), and organizational-level barriers (e.g., inadequate staff support, lack of nursing protocols) to PC providers prescribing MOUD. Facilitators centered on education and knowledge enhancement, workflow and practice support, patient engagement and patient-provider communication, and leadership and organizational support. The most common barrier faced by patients to starting MOUD was apprehensions about pain, while facilitators focused on personal motivation, encouragement from others, education about MOUD, and optimally timed provider communication strategies. CONCLUSIONS These findings can help improve provider-, clinic-, and system-level supports for MOUD prescribing across multiple settings, as well as foster communication strategies that can increase patient acceptance of MOUD. They also point to how interprofessional collaboration across service lines and leadership support can facilitate MOUD prescribing among non-addiction providers.
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Affiliation(s)
- Alicia A Bergman
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA.
| | - Rebecca S Oberman
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA
| | - Stephanie L Taylor
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Health Policy and Management, University of California, Los Angeles Fielding School of Public Health, Los Angeles, CA, USA
| | - Bridget Kranke
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA
| | - Evelyn T Chang
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Division of General Internal Medicine, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Soyer EM, Frost MC, Fletcher OV, Ioannou GN, Tsui JI, Edelman EJ, Weiner BJ, Bachrach RL, Chen JA, Williams EC. Perspectives of clinical stakeholders and patients from four VA liver clinics to tailor practice facilitation for implementing evidence-based alcohol-related care. Addict Sci Clin Pract 2024; 19:3. [PMID: 38200496 PMCID: PMC10782537 DOI: 10.1186/s13722-023-00429-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 11/29/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Unhealthy alcohol use (UAU) is particularly dangerous for people with chronic liver disease. Liver clinics may be an important setting in which to provide effective alcohol-related care by integrating evidence-based strategies, such as brief intervention and medications for alcohol use disorder. We conducted qualitative interviews with clinical stakeholders and patients at liver clinics in four Veterans Health Administration (VA) medical centers to understand barriers and facilitators of integrating alcohol-related care and to support tailoring of a practice facilitation implementation intervention. METHODS Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed and qualitatively analyzed using a Rapid Assessment Process (RAP) guided by the CFIR. RESULTS We interviewed 46 clinical stakeholders and 41 patient participants and analyzed findings based on the CFIR. Clinical stakeholders described barriers and facilitators that ranged from operations/clinic resource-based (e.g., time and capacity, desire for additional provider types, referral processes) to individual perspective and preference-based (e.g., supportiveness of leadership, individual experiences/beliefs). Patient participants shared barriers and facilitators that ranged from relationship-based (e.g., trusting the provider and feeling judged) to resource and education-based (e.g., connection to a range of treatment options, education about impact of alcohol). Many barriers and facilitators to integrating alcohol-related care in liver clinics were similar to those identified in other clinical settings (e.g., time, resources, role clarity, stigmatizing beliefs). However, some barriers (e.g., fellow-led care and lack of integration of liver clinics with addictions specialists) and facilitators (e.g., presence of quality improvement staff in clinics and integrated pharmacists and behavioral health specialists) were more unique to liver clinics. CONCLUSIONS These findings support the possibility of integrating alcohol-related care into liver clinics but highlight the importance of tailoring efforts to account for variation in provider beliefs and experiences and clinic resources. The barriers and facilitators identified in these interviews were used to tailor a practice facilitation implementation intervention in each clinic setting.
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Affiliation(s)
- Elena M Soyer
- Department of Health Systems and Population Health, University of Washington School of Public Health, 3980 15th Ave NE, Seattle, WA, 98195, USA.
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA.
| | - Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, 3980 15th Ave NE, Seattle, WA, 98195, USA
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
| | - Olivia V Fletcher
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
| | - George N Ioannou
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
- Department of Medicine, University of Washington School of Medicine, 325 9th Ave, Seattle, WA, 98104, USA
| | - Judith I Tsui
- Department of Medicine, University of Washington School of Medicine, 325 9th Ave, Seattle, WA, 98104, USA
| | - E Jennifer Edelman
- Yale Schools of Medicine and Public Health, 367 Cedar Street, ES Harkness, Suite 401, New Haven, CT, 06510, USA
| | - Bryan J Weiner
- Department of Health Systems and Population Health, University of Washington School of Public Health, 3980 15th Ave NE, Seattle, WA, 98195, USA
- Department of Global Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Rachel L Bachrach
- Department of Psychiatry, University of Michigan Medical School, 1301 Catherine St., Ann Arbor, MI, 48109, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Ann Arbor, MI, 48105, USA
| | - Jessica A Chen
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
- Department of Psychiatry and Behavioral Science, University of Washington School of Medicine, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, 3980 15th Ave NE, Seattle, WA, 98195, USA
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
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Fortney JC, Ratzliff AD, Blanchard BE, Johnson M, Ferro L, Austin EJ, Williams EC, Duncan MH, Merrill JO, Thomas J, Kitay B, Schoenbaum M, Heagerty PJ, Saxon AJ. Does Screening for Opioid Use Disorder in Primary Care Increase the Percentage of Patients With a New Diagnosis? Ann Intern Med 2023; 176:1431-1433. [PMID: 37844317 PMCID: PMC10823879 DOI: 10.7326/m23-1369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Affiliation(s)
- John C Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington; Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington; and Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, Washington
| | - Anna D Ratzliff
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, and Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, Washington
| | - Brittany E Blanchard
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, Washington
| | - Morgan Johnson
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, Washington
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, Washington
| | - Elizabeth J Austin
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, Washington
| | - Emily C Williams
- Department of Health Systems and Population Health, School of Public Health, University of Washington, and Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, Washington
| | - Mark H Duncan
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, Washington
| | - Joseph O Merrill
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington
| | | | - Brandon Kitay
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, Georgia
| | | | - Patrick J Heagerty
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington
| | - Andrew J Saxon
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, and Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, Washington
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Miller-Rosales C, Busch SH, Meara ER, King A, D’Aunno TA, Colla CH. Internal and Environmental Predictors of Physician Practice Use of Screening and Medications for Opioid Use Disorders. Med Care Res Rev 2023; 80:410-422. [PMID: 37036056 PMCID: PMC10949918 DOI: 10.1177/10775587231162681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
Medications for opioid use disorder (MOUD) remain highly inaccessible despite demonstrated effectiveness. We examine the extent of screening for opioid use and availability of MOUD in a national cross-section of multi-physician primary care and multispecialty practices. Drawing on an existing framework to characterize the internal and environmental context, we assess socio-technical, organizational-managerial, market-based, and state-regulation factors associated with the use of opioid screening and offering of MOUD in a practice. A total of 26.2% of practices offered MOUD, while 69.4% of practices screened for opioid use. Having advanced health information technology functionality was positively associated with both screening for opioid use and offering MOUD in a practice, while access to on-site behavioral clinicians was positively associated with offering MOUD in adjusted models. These results suggest that improving access to information and expertise may enable physician practices to respond more effectively to the nation's ongoing opioid epidemic.
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Affiliation(s)
| | | | | | - Ashleigh King
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Thomas A. D’Aunno
- Wagner Graduate School of Public Service, New York University, New York, NY
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Congressional Budget Office, Washington, DC
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