Are x-waiver trainings enough? Facilitators and barriers to buprenorphine prescribing after x-waiver trainings

Practice Changes 6 Months Following a Physical Therapist Training Program Regarding Opioid Use and Misuse Screening and Assessment: A Qualitative Study

BACKGROUND

The U.S. Preventive Services Task Force recommends that all healthcare providers be trained to screen for misuse and/or opioid use disorder. An opioid misuse training program for physical therapists was developed and implemented. The purposes of this research were to (1) understand whether the participants found the training useful, (2) understand if they instituted practice changes that resulted from the training, and (3) understand barriers to implementing the skills learned in the training.

METHODS

Four separate 30-minute virtual training sessions were provided (1 session every 2 weeks). The topics included an introduction to the opioid crisis, screening, assessing, and communicating with patients and with the healthcare team about opioid misuse. A final training manual was distributed after the final training session at which time participants were asked to implement what they learned in the training. Semi-structured interviews were conducted with all training program participants (n = 13) approximately 6 months after the final training session. Rapid content analysis was used to understand the perceptions of and barriers to implementing what the physical therapists learned in the training.

RESULTS

Generally, the participants found the training important and useful and strengthened their perceptions of physical therapists' role in screening for opioid misuse. Compared to the opioid misuse-related content of the training, most found it easier to implement general opioid-related content such as asking whether their patients were taking an opioid. Few participants screened any of their patients for opioid misuse. Barriers to implementation included concerns about how the patient might respond to being asked about their opioid use.

CONCLUSION

These findings provide insight into physical therapists' perceptions of an opioid misuse training program and the challenges with implementing what they learned in the program. Future training could incorporate activities such as role-playing to improve participants' comfort with screening for opioid misuse.

Perspectives of substance use disorder counselors on the benefits and drawbacks of medications for opioid use disorder

BACKGROUND

Medications for opioid use disorder (MOUD) are among the best tools available to combat the opioid epidemic. Yet, use of MOUD among people with opioid use disorder (OUD) remains low. Interventions to increase MOUD access in the United States have largely focused on improving organizational capacity and addressing funding barriers, yet stigma toward MOUD may inhibit uptake even where MOUD is readily available. Non-prescribing substance use disorder (SUD) treatment professionals (e.g. counselors) likely have considerable influence on a client's choice to initiate and adhere to MOUD, but beliefs that counselors convey about MOUD in interaction with clients are understudied. The current study explores what advantages and disadvantages that counselors communicate about buprenorphine, methadone, and naltrexone.

METHODS

From June to December 2021, we surveyed counselors from publicly-funded SUD treatment agencies under a municipality-wide mandate to offer MOUD to all clients with OUD. Counselors were asked to describe, in a free-response format, the most important advantages and disadvantages to communicate to their clients about taking buprenorphine, methadone, and naltrexone. Counselor responses were coded for one or more advantage and disadvantage.

RESULTS

A total of 271 SUD counselors from 29 agencies in the Philadelphia Metropolitan Area completed the survey, generating 1,995 advantages and disadvantages across three types of MOUD. The most frequently reported advantage across all three types of MOUD was their ability to reduce cravings and illicit drug use. The most frequently reported disadvantage related to the potential for some types of MOUD to develop long-term medication dependence.

CONCLUSIONS

As the availability and variety of MOUD treatment options continue to expand, it is important that SUD counselors are equipped with evidence-based recommendations for OUD care. We identified misalignments with the MOUD-prescribing evidence base and stigmatizing language toward MOUD within counselors' responses, highlighting the potential to refine training materials for MOUD and mitigate stigmatizing beliefs.

Examining the Relationship Between Local Governmental Expenditures on the Social Determinants of Health and County-Level Overdose Deaths, 2017-2020

CONTEXT

Prior studies have examined the social determinants of health (SDOH) characteristics of counties with elevated rates of overdose deaths. However, this research often ignores variation in upstream governmental investment in these SDOH categories.

OBJECTIVE

To examine the association of local governmental investments in SDOH with drug overdose mortality at the county level, controlling for demographic and socioeconomic characteristics.

DESIGN

Longitudinal analysis from 2017 to 2020.

SETTING

United States counties.

PARTICIPANTS

3126 counties.

MAIN OUTCOME AND MEASURES

The primary study outcome was county overdose death rates per 100 000 population taken from the Centers for Disease Control and Prevention. The main predictor of interest was the per capita average of local governmental expenditures in public health, social service, and education drawn from the US Census of Governments, categorized into quartiles. Covariates included county-level socioeconomic and demographic characteristics as well as county-level SUD services from the AHRQ SDOH Database.

RESULTS

In longitudinal multivariate linear regression models with state and year fixed effects, counties in the highest 3 quartiles of SDOH spending had significantly lower rates of overdose deaths compared with counties in the lowest quartile of SDOH spending; in particular, counties in quartile 2 had an average of 9.09 fewer overdose deaths per 100 000 population (95% CI: -12.58, -5.60), counties in quartile 3 had an average of 13.18 fewer deaths per 100 000 population (95% CI: -17.56; -8.80), and counties in quartile 4 had an average of 13.92 deaths per 100 000 population (95% CI: -19.16, -8.68).

CONCLUSIONS

Our findings demonstrate that higher levels of local governmental investments in SDOH were associated with significantly lower rates of overdose death in US counties after controlling for socioeconomic and demographic characteristics. Going forward, research should focus on determining causality in this relationship, the mechanisms through which this relationship occurs, as well as assess the impact of local public health expenditures allocated toward SUD prevention and treatment specifically on substance use outcomes at the local level.

The Implementation Climate for Integrating Buprenorphine Prescribing into Rural Primary Care

BACKGROUND

Rural communities have been significantly affected by opioid use disorder (OUD) and related harms but have less access to evidence-based medications for opioid use disorder (MOUD), such as buprenorphine. Given the shortage of specialists in these areas, rural primary care is an important setting to expand buprenorphine access, but implementation is limited.

OBJECTIVE

To explore implementation climate factors that support or hinder buprenorphine implementation in rural primary care.

DESIGN

A qualitative study design using in-depth interviews.

PARTICIPANTS

Primary care physicians, nurse practitioners (NPs), and physician associates (PAs) practicing in rural Ohio counties.

APPROACH

Between December 2022 and March 2023, we interviewed participants about their perspectives on buprenorphine prescribing, including using rural primary care as an implementation setting for buprenorphine. Using a deductive, framework-based approach, codes were grouped based on the Consolidated Framework for Implementation Research (CFIR) inner setting factors that contribute to a positive implementation climate for an intervention.

KEY RESULTS

Three implementation climate constructs emerged as decision points for whether to implement buprenorphine in rural primary care: (1) relative priority: the extent to which OUD treatment should be prioritized over other chronic diseases; (2) compatibility: whether buprenorphine prescribing protocols are compatible with the rural primary care setting; (3) tension for change: the extent to which current buprenorphine access shortages in rural communities can be tolerated. Participants expressed mixed perspectives on whether the implementation climate in rural primary care currently supports buprenorphine prescribing.

CONCLUSION

Implementation strategies targeted toward the implementation climate are critical to support buprenorphine prescribing in rural primary care.

The Development of an Opioid Misuse Training Program for Physical Therapists: A Learning Community Approach

INTRODUCTION

Musculoskeletal pain and opioid misuse frequently co-occur.

REVIEW OF THE LITERATURE

The US Preventive Services Task Force calls for all health care providers to be trained to screen for misuse and/or opioid use disorder. The purpose of this study was to develop and implement an opioid misuse training program that could be used by physical therapists.

SUBJECTS

Thirteen practicing physical therapists were invited to participate in a curriculum development project.

METHODS

Using the Curriculum Framework, a collaborative learning approach was used to develop an opioid misuse training program and training manual for physical therapists. Four training sessions were provided virtually every 2 weeks. Topics included an introduction to the opioid crisis, screening, assessing, and communicating with patients and with the health care team about opioid misuse. Each didactic session was followed by a participant feedback session where participants provided recommendations on improving the training content and their impressions on the barriers and facilitators to incorporating the training into practice. A companion training manual was created and sent to participants for comment. Participants were asked over email to describe whether and how they incorporated training materials into clinical practice during the training curriculum.

RESULTS

All participants attended sessions 1-3. Twelve (92.3%) attended the fourth session. Based on the participants' feedback, training sessions were edited, and a companion training manual was finalized and distributed to each participant. After the fourth session, 9 participants (69.2%) reported using what they learned in the training. During the participant feedback sessions, participants regarded the training as important. Some participants expressed barriers to discussing opioids with patients and concerns about whether the training was within physical therapists' scope of practice.

DISCUSSION AND CONCLUSION

An iteratively developed training program for physical therapists to address opioid misuse was acceptable, feasible, and provided immediate practice change by most participants.

Improving access to buprenorphine for rural veterans in a learning health care system

OBJECTIVE

To describe a learning health care system research process designed to increase buprenorphine prescribing for the treatment of opioid use disorder (OUD) in rural primary care settings within U.S. Department of Veterans Affairs (VA) treatment facilities.

DATA SOURCES AND STUDY SETTING

Using national administrative data from the VA Corporate Data Warehouse, we identified six rural VA health care systems that had improved their rate of buprenorphine prescribing within primary care from 2015 to 2020 (positive deviants). We conducted qualitative interviews with leaders, clinicians, and staff involved in buprenorphine prescribing within primary care from these sites to inform the design of an implementation strategy.

STUDY DESIGN

Qualitative interviews to inform implementation strategy development.

DATA COLLECTION/EXTRACTION METHODS

Interviews were audio-recorded, transcribed verbatim, and coded by a primary coder and secondary reviewer. Analysis utilized a mixed inductive/deductive approach. To develop an implementation strategy, we matched clinical needs identified within interviews with resources and strategies participants had utilized to address these needs in their own sites.

PRINCIPAL FINDINGS

Interview participants (n = 30) identified key clinical needs and strategies for implementing buprenorphine in rural, primary care settings. Common suggestions included the need for clinical mentorship or a consult service, buprenorphine training, and educational resources. Building upon interview findings and in partnership with a clinical team, we developed an implementation strategy composed of an engaging case-based training, an audit and feedback process, and educational resources (e.g., Buprenorphine Frequently Asked Questions, Rural Care Model Infographic).

CONCLUSIONS

We describe a learning health care system research process that leveraged national administrative data, health care provider interviews, and clinical partnership to develop an implementation strategy to encourage buprenorphine prescribing in rural primary care settings.

A Statewide Consultation Helpline for Rapid Linkage to Services for Youths With Opioid Use Disorder and Other Substance Use

OBJECTIVE

The authors examined the initial implementation of the Indiana Adolescent Addiction Access (AAA) program, modeled on the widely disseminated Child Psychiatry Access Program framework. The AAA program developed a statewide consultation helpline to connect health care providers with adolescent addiction specialists.

METHODS

The AAA line was staffed by a coordinator, who fielded initial questions, and on-call clinical specialists (social workers, nurse practitioners, psychiatrists, and psychologists), who were paged to complete telephone consultations and provide care recommendations. When necessary, AAA providers offered urgent clinical assessments and initiated treatment. Descriptive analyses were performed for key variables over the first 21 months of AAA operations.

RESULTS

From July 2021 to March 2023, a total of 125 consultations were completed. Most callers were health care providers (71%) or parents (27%). Calls pertained to youths ages 10-18 years (mean±SD age=16.4±1.3; 62% of callers were male, 84% White, and 11% Black), with concerns around cannabis (63%), opioids (38%), and other substances. About 26% of calls related to an overdose, and 41% of cases were rated as severe. Recommendations included starting new medications (17%) or outpatient therapy (86%), and 17% of consultations resulted in urgent evaluations.

CONCLUSIONS

The Indiana AAA program helps overcome key barriers to adolescent substance use treatment. Increasing the capacity to initiate medication for opioid use disorder and other treatment rapidly through consultation and direct care is a promising, scalable approach for preventing overdose deaths among youths.

Integrating Buprenorphine for Opioid Use Disorder into Rural, Primary Care Settings

BACKGROUND

Medications for opioid use disorder (MOUD) including buprenorphine are effective, but underutilized. Rural patients experience pronounced disparities in access. To reach rural patients, the US Department of Veterans Affairs (VA) has sought to expand buprenorphine prescribing beyond specialty settings and into primary care.

OBJECTIVE

Although challenges remain, some rural VA health care systems have begun offering opioid use disorder (OUD) treatment with buprenorphine in primary care. We conducted interviews with clinicians, leaders, and staff within these systems to understand how this outcome had been achieved.

DESIGN

Using administrative data from the VA Corporate Data Warehouse (CDW), we identified rural VA health care systems that had improved their rate of primary care-based buprenorphine prescribing over the period 2015-2020. We conducted qualitative interviews (n = 30) with staff involved in implementing or prescribing buprenorphine in these systems to understand the processes that had facilitated implementation.

PARTICIPANTS

Clinicians, staff, and leaders embedded within rural VA health care systems located in the Northwest, West, Midwest (2), South, and Northeast.

APPROACH

Qualitative interviews were analyzed using a mixed inductive/deductive approach.

KEY RESULTS

Interviews revealed the processes through which buprenorphine was integrated into primary care, as well as processes insufficient to enact change. Implementation was often initially catalyzed through a targeted hire. Champions then engaged clinicians and leaders one-on-one to "pitch" the case, describe concordance between buprenorphine prescribing and existing goals, and delineate the supportive role that they could provide. Sites were prepared for implementation by developing new clinical teams and redesigning clinical processes. Each of these processes was made possible with the active, instrumental support of leadership.

CONCLUSIONS

Results suggest that rural systems seeking to improve buprenorphine accessibility in primary care may need to alter primary care structures to accommodate buprenorphine prescribing, whether through new hires, team development, or clinical redesign.

Buprenorphine and Opioid Use Disorder Training: Graduate Nursing Curricula Recommendations

Opioid use disorder (OUD) is a public health emergency, with a shortage of providers trained to prescribe buprenorphine for OUD treatment. We conducted a systematic review to examine advanced practice RN (APRN) and medical school programs that included OUD content or Drug Addiction Treatment Act waiver training and evaluate the outcomes of those curricular modifications. APRN and medical school programs that provided OUD content or waiver training saw improvements in students' knowledge and self-efficacy for managing buprenorphine treatment and reduced stigma toward individuals with OUD. Students' perceptions of training were largely positive, and the programs' results indicated improved practice outcomes related to the use of buprenorphine. Further inclusion of OUD content and training in APRN curricula will increase the number of capable buprenorphine prescribers, which will increase access to buprenorphine for individuals with OUD. [Journal of Psychosocial Nursing and Mental Health Services, 62(7), 17-24.].

Buprenorphine dispensing before and after the April 2021 X-Waiver exemptions: An interrupted time series analysis

BACKGROUND

Until the end of 2022, a special registration, known as the X-waiver, was required to prescribe buprenorphine in the US. Before its removal, US federal regulations trialed an X-waiver exemption, initiated on April 28, 2021, which permitted buprenorphine prescribing for up to 30 patients without additional training. We aimed to understand if these regulatory changes impacted buprenorphine dispensing.

METHODS

We conducted an interrupted time series analysis to understand changes in buprenorphine dispensing during the 26 weeks after the X-waiver exemption compared to the expected baseline trend established in the 26 weeks before using the IQVIA Longitudinal Prescription claims database. The primary outcome was number of new buprenorphine prescribers nationwide (defined as no prior buprenorphine prescription dispensed in the last 26 weeks). Segmented regression estimated relative changes in buprenorphine dispensing at 1, 13, and 26 weeks post-X-waiver change.

RESULTS

A total of 15,517,525 prescriptions filled for 1,328,172 patients (43.4 % female) ordered by 62,312 providers were included for analysis. At 26 weeks post-X-waiver change, there was no change in the number of new prescribers compared to the expected baseline trend (-2.7 % [95 % CI:-8.3,2.9]). The number of new (15.2 % [4.6,25.8]) and existing (1.7 % [0.9,2.4]) patients and patients per prescriber (4.3 % [3,5.6]) increased. Buprenorphine prescriptions reimbursed by Medicaid increased (7.5 % [6.6,8.4]) while commercial fills decreased (-3.4 % [-5.3,-1.5]).

CONCLUSIONS

The number of new prescribers did not increase six months post-X-waiver exemption while new patients continued to enter treatment at higher-than-expected rates. These findings suggest that additional interventions beyond the recent X-waiver removal may be needed to increase access to buprenorphine.

Real-World Dispensing of Buprenorphine in California during Prepandemic and Pandemic Periods

INTRODUCTION

The opioid overdose crisis in the United States has become a significant national emergency. Buprenorphine, a primary medication for individuals coping with opioid use disorder (OUD), presents promising pharmacokinetic properties for use in primary care settings, and is often delivered as a take-home therapy. The COVID-19 pandemic exacerbated the scarcity of access to buprenorphine, leading to dire consequences for those with OUD. Most existing studies, primarily focused on the immediate aftermath of the COVID-19 outbreak, highlight the challenges in accessing medications for opioid use disorder (MOUDs), particularly buprenorphine. However, these studies only cover a relatively short timeframe.

METHODS

To bridge this research gap, in our study, we utilized 33 months of California's prescription drug monitoring program (PDMP) data to provide insights into real-world buprenorphine dispensing trends since the onset of the pandemic from 2018 to 2021, focusing on outcomes such as patient counts, prescription volumes, prescriber involvement, days' supply, and dosage. Statistical analysis employed interrupted time series analysis to measure changes in trends before and during the pandemic.

RESULTS

We found no significant impact on patient counts or prescription volumes during the pandemic, although it impeded the upward trajectory of prescriber numbers that was evident prior to the onset of the pandemic. An immediate increase in days' supply per prescription was observed post-pandemic.

CONCLUSION

Our findings differ in comparison to previous data regarding the raw monthly count of patients and prescriptions. The analysis encompassed uninsured patients, offering a comprehensive perspective on buprenorphine prescribing in California. Our study's insights contribute to understanding the impact of COVID-19 on buprenorphine access, emphasizing the need for policy adjustments.

The association between longitudinal trends in receipt of buprenorphine for opioid use disorder and buprenorphine-waivered providers in the United States

AIMS, DESIGN AND SETTING

We sought to describe longitudinal trends in buprenorphine receipt and buprenorphine-waivered providers in the United States from 2003 to 2021 and measure whether the relationship between the two differed after capacity-building strategies were enacted nationally in 2017. This was a retrospective study of two separate cohorts covering the years 2003-21, testing whether the association between two trends in these cohorts changed comparing 2003 to 2016 and from 2017 to 2021, among buprenorphine providers in the United States, regardless of treatment setting. Patients receiving dispensed buprenorphine at retail pharmacies.

PARTICIPANTS

All providers who have obtained a waiver to prescribe buprenorphine in the United States, and an estimate of the annual number of patients who had buprenorphine for opioid use disorder (OUD) dispensed to them at a retail pharmacy.

MEASUREMENTS

We synthesized and summarized data from multiple sources to assess the cumulative number of buprenorphine-waivered providers over time. We used national-level prescription data from IQVIA to estimate annual buprenorphine receipt for OUD.

FINDINGS

From 2003 to 2021, the number of buprenorphine-waivered providers in the United States increased from fewer than 5000 in the first 2 years of Food and Drug Administration (FDA) approval to more than 114 000 in 2021, while patients receiving buprenorphine products for OUD increased from approximately 19 000 to more than 1.4 million. The strength of association between waivered providers and patients is significantly different before and after 2017 (P < 0.001). From 2003 to 2016, for each additional provider, there was an average increase of 32.1 [95% confidence interval (CI) = 28.7-35.6] patients, but an increase of only 4.6 (95% CI= 3.5-5.7) patients for each additional provider, beginning in 2017.

CONCLUSIONS

In the United States, the relationship between the rates of growth in buprenorphine providers and patients became weaker after 2017. While efforts to increase buprenorphine-waivered providers were successful, there was less success in translating that into significant increases in buprenorphine receipt.

Care Practices of Mental Health Clinical Pharmacist Practitioners Within an Interdisciplinary Primary Care Model for Patients With Substance Use Disorders

BACKGROUND

Clinical pharmacist practitioners (CPPs) play an increasingly important role in interdisciplinary care for patients with substance use disorders (SUDs). However, CPPs' scope of practice varies substantially across clinics and settings.

OBJECTIVES

We sought to describe CPP practices and activities within an interdisciplinary, team-based primary care clinic dedicated to treat Veterans with histories of substance use disorders, experience of homelessness, high medical complexity, and other vulnerabilities.

METHODS

We conducted a retrospective cohort study of CPP activities using Department of Veterans Affairs (VA) administrative data in 2019.

RESULTS

CPPs provided care for 228 patients, including 766 in-clinic visits, 341 telephone visits, and 626 chart reviews, with an average of 2.5 hours spent per patient per year. Patients seen by CPPs frequently experience mental health conditions and SUDs, including depression (66%), post-traumatic stress disorder (52%), opioid use disorder (OUD) (45%), and alcohol use disorder (44%). CPPs managed buprenorphine medications for OUD or chronic pain in 76 patients (33%). Most CPP interventions (3330 total) were for SUDs (33%), mental health conditions (24%), and pain management (24%), with SUD interventions including medication initiation, dose changes, discontinuations and monitoring. As part of opioid risk mitigation efforts, CPPs queried the state's prescription drug monitoring program 769 times and ordered 59 naloxone kits and 661 lab panels for empaneled patients.

CONCLUSION

CPPs managed a high volume of vulnerable patients and provided complex care within an interdisciplinary primary care team. Similar CPP roles could be implemented in other primary care settings to increase access to SUD treatment.

What Contributes to Sustainability? Examining Access to Medications for Opioid Use Disorder in Low-Adopting VHA Facilities

BACKGROUND

Successful implementation can increase the availability of evidence-based treatments but continued patient access can be threatened if there is not deliberate focus on sustainment. Real-world examples are needed to elucidate contributors to sustainability.

OBJECTIVE

We examined sustainability of outcomes of a study which tested a 12-month external facilitation intervention. The study evaluated change in access to medications for opioid use disorder (MOUD) in Veterans Health Administration (VHA) facilities in the lowest quartile of MOUD prescribing.

DESIGN

Convergent mixed-methods design.

PARTICIPANTS

Thirty-nine providers and leaders from eight VHA facilities.

APPROACH

Thirty-minute post-implementation telephone interviews explored whether barriers identified pre-implementation were successfully addressed, the presence of any new challenges, helpfulness of external facilitation, and plans for sustaining MOUD access. Interviews were analyzed using a rapid turn-around approach. VHA administrative data were used to characterize the facilities and assess their ratio of patients with an OUD diagnosis receiving MOUD (MOUD/OUD ratio) at the end of a 9-month sustainability period.

KEY RESULTS

Commonly reported contributors to sustained MOUD access included national attention on the opioid epidemic, accountability created by study participation, culture shift in MOUD acceptability, leadership support, and plans to build on initial progress. Frequently reported barriers included staffing issues and lack of MOUD-devoted time; the need to overhaul existing policies, practices, and/or processes; and fear and anxiety about MOUD prescribing. All facilities either maintained MOUD/OUD ratio improvement (n = 2) or further improved (n = 6) at the end of sustainability. Facilities with the highest and lowest ratio at the end of sustainability used a team-based approach to MOUD delivery; however, organizational setting differences may have impacted overall MOUD access.

CONCLUSIONS

Ensuring stable and consistent staff, and sufficient time dedicated to MOUD are critical to sustaining access to evidence-based treatment in low-adopting facilities. This study highlights the importance of investing in local, system-level changes to improve and sustain access to effective treatments.

Costs of implementing a multi-site facilitation intervention to increase access to medication treatment for opioid use disorder

BACKGROUND

The United States has been grappling with the opioid epidemic, which has resulted in over 75,000 opioid-related deaths between April 2020 and 2021. Evidence-based pharmaceutical interventions (buprenorphine, methadone, and naltrexone) are available to reduce opioid-related overdoses and deaths. However, adoption of these medications for opioid use disorder has been stifled due to individual- and system-level barriers. External facilitation is an evidence-based implementation intervention that has been used to increase access to medication for opioid use disorder (MOUD), but the implementation costs of external facilitation have not been assessed. We sought to measure the facility-level direct costs of implementing an external facilitation intervention for MOUD to provide decision makers with estimates of the resources needed to implement this evidence-based program.

METHODS

We performed a cost analysis of the pre-implementation and implementation phases, including an itemization of external facilitation team and local site labor costs. We used labor estimates from the Bureau of Labor and Statistics, and sensitivity analyses were performed using labor estimates from the Veterans Health Administration (VHA) Financial Management System general ledger data.

RESULTS

The average total costs for implementing an external facilitation intervention for MOUD per site was $18,847 (SD 6717) and ranged between $11,320 and $31,592. This translates to approximately $48 per patient with OUD. Sites with more encounters and participants with higher salaries in attendance had higher costs. This was driven mostly by the labor involved in planning and implementation activities. The average total cost of the pre-implementation and implementation activities were $1031 and $17,816 per site, respectively. In the sensitivity analysis, costs for VHA were higher than BLS estimates likely due to higher wages.

CONCLUSIONS

Implementing external facilitation to increase MOUD prescribing may be affordable depending on the payer's budget constraints. Our study reported that there were variations in the time invested at each phase of implementation and the number and type of participants involved with implementing an external facilitation intervention. Participant composition played an important role in total implementation costs, and decision makers will need to identify the most efficient and optimal number of stakeholders to involve in their implementation plans.

Increasing Access to Buprenorphine for Opioid Use Disorder in Primary Care: an Assessment of Provider Incentives

BACKGROUND

Primary care providers (PCPs) are essential to increasing access to office-based buprenorphine medication treatment for opioid use disorder (B-MOUD). Barriers to B-MOUD prescribing are well-documented, but there is little information regarding incentives to overcome these barriers.

OBJECTIVE

To identify optimal incentives for PCPs to promote B-MOUD prescribing and compare incentive preferences across provider and practice characteristics.

DESIGN

We surveyed PCPs using best-worst scaling (BWS) to prioritize seven potential incentives for B-MOUD prescribing (monetary compensation, paid vacation, protected time, professional development, reduced workload, service recognition, clinical resources). We then used a direct elicitation approach to determine preferred incentive levels (e.g., monetary thresholds) and types (e.g., specific clinical resources).

PARTICIPANTS

Primary care physicians and advanced practice providers (APPs) at a large Department of Veterans Affairs healthcare system.

MAIN MEASURES

B-MOUD prescribing incentive preferences and relative preference levels using descriptive statistics and conditional logistic regression with relative importance scale transformation (coefficients sum to 100, higher coefficient=greater importance).

KEY RESULTS

Fifty-three PCPs responded (73% response), including 47% APPs and 36% from community-based clinics. Reduced workload (relative importance score=26.8), protected time (18.7), and clinical resources (16.8) were significantly more preferred (Ps < 0.001) than professional development (10.5), paid vacation (10.3), or service recognition (1.5). Relative importance of monetary compensation varied between physicians (12.6) and APPs (17.5) and between PCPs located at a medical center (11.4) versus community clinic (22.3). APPs were more responsive than physicians to compensation increases of $5000 and $12,000 but less responsive to $25,000; trends were similar for medical center versus community clinic PCPs. The most frequently requested clinical resource was on-demand consult access to an addiction specialist.

CONCLUSIONS

Interventions promoting workload reductions, protected time, and clinical resources could increase access to B-MOUD in primary care. Monetary incentives may be additionally needed to improve B-MOUD prescribing among APPs and within community clinics.

Buprenorphine use and courses of care for opioid use disorder treatment within the Veterans Health Administration

BACKGROUND

Retention of patients in buprenorphine medication treatment for opioid use disorder (B-MOUD) reduces harms associated with opioid use disorder (OUD). We sought to characterize the patients receiving B-MOUD and courses of B-MOUD in a large healthcare system.

METHODS

We conducted a retrospective, open cohort study of patients with OUD who either did or did not receive B-MOUD courses within the Veterans Health Administration (VHA) from January 2006 through July 2019, using VHA clinical data. We compared patients receiving or not receiving B-MOUD, characterized B-MOUD courses (e.g., length and doses), and examined persistence, across patient characteristics, over time. We used analyses for normally or non-normally distributed continuous variables, categorical data, and persistence over time (Kaplan-Meier persistence curves).

RESULTS

We identified 255,726 Veterans with OUD; 40,431 (15.8%) had received 63,929 B-MOUD courses. Compared to patients with OUD without B-MOUD, patients with B-MOUD were younger, more often of white race, and had more co-morbidities. The frequency of new B-MOUD starts and prevalent B-MOUD patients ranged from 1550 and 1989 in 2007 to 8146 and 16,505 in 2018, respectively. The median duration of B-MOUD was 157 (IQR: 37-537) days for all courses and 33.8% patients had more than one course. The average proportion days covered was 90% (SD: 0.15), and the average prescribed daily dose was 13.44 (SD: 6.5).

CONCLUSIONS

Within a VHA B-MOUD cohort, courses increased more than 10-fold from 2006 to 2016 with nearly half of patients experiencing multiple courses. Patient demographics seem to dictate the length of courses.

Treating opioid use disorder in veterans with co-occurring substance use: a qualitative study with buprenorphine providers in primary care, mental health, and pain settings

BACKGROUND

Most people with opioid use disorder (OUD) have co-occurring substance use, which is associated with lower receipt of OUD medications (MOUD). Expanding MOUD provision and care linkage outside of substance use disorder (SUD) specialty settings is a key strategy to increase access. Therefore, it is important to understand how MOUD providers in these settings approach care for patients with co-occurring substance use. This qualitative study of Veterans Health Administration (VA) clinicians providing buprenorphine care in primary care, mental health, and pain settings aimed to understand (1) their approach to addressing OUD in patients with co-occurring substance use, (2) perspectives on barriers/facilitators to MOUD receipt for this population, and (3) support needed to increase MOUD receipt for this population.

METHODS

We interviewed a purposive sample of 27 clinicians (12 primary care, 7 mental health, 4 pain, 4 pharmacists) in the VA northwest network. The interview guide assessed domains of the Tailored Implementation for Chronic Diseases Checklist. Interviews were transcribed and qualitatively analyzed using inductive content analysis.

RESULTS

Participants reported varied approaches to identifying co-occurring substance use and addressing OUD in this patient population. Although they reported that this topic was not clearly addressed in clinical guidelines or training, participants generally felt that patients with co-occurring substance use should receive MOUD. Some viewed their primary role as providing this care, others as facilitating linkage to OUD care in SUD specialty settings. Participants reported multiple barriers and facilitators to providing buprenorphine care to patients with co-occurring substance use and linking them to SUD specialty care, including provider, patient, organizational, and external factors.

CONCLUSIONS

Efforts are needed to support clinicians outside of SUD specialty settings in providing buprenorphine care to patients with co-occurring substance use. These could include clearer guidelines and policies, more specific training, and increased care integration or cross-disciplinary collaboration. Simultaneously, efforts are needed to improve linkage to specialty SUD care for patients who would benefit from and are willing to receive this care, which could include increased service availability and improved referral/hand-off processes. These efforts may increase MOUD receipt and improve OUD care quality for patients with co-occurring substance use.

Building a statewide network of MOUD expertise using tiered ECHO® mentoring opportunities

BACKGROUND

Expanding access to workforce training for opioid use disorder (OUD) treatment continues to be a priority. This study explored the use of tiered mentoring opportunities within an ECHO® model to expand treatment capacity and develop a statewide network of medications for OUD (MOUD) expertise. ECHO® engages participants in a virtual community to learn best practices through case-based learning and interactions with experts.

METHODS

We studied two incentivized Illinois MOUD ECHO® training programs by examining aggregate demographic and prescribing data across eight training cohorts (n = 199 participants). Participants (n = 51) in the last two cohorts were evaluated with expanded pre- and post-training surveys. Qualitative interviews were completed with a subset (n = 13) to examine effects observed in the survey data.

RESULTS

For the whole group, we found a geographic expansion of the participants' prescribing capacity that reached into rural and other underserved areas in Illinois. Participants in the last two cohorts reported both increased self-efficacy for OUD treatment and increased connectedness to the addiction treatment community in Illinois. Participants who progressed through the tiered mentorship roles were found to exhibit stepwise increases in reported self-efficacy and connectedness measures.

CONCLUSION

An incentivized ECHO® program yielded substantive outcomes in terms of increased prescribing capacity across the state. The use of tiered mentoring opportunities enabled participants to develop MOUD expertise and support novice providers in a growing statewide network. There is potential to train professionals to a high level of expertise when the ECHO® model is combined with a mentorship pathway.

Buprenorphine treatment episode duration, dosage, and concurrent prescribing of benzodiazepines and opioid analgesics: The effects of Medicaid prior authorization policies

BACKGROUND

Buprenorphine is an effective medication for the treatment of opioid use disorder (OUD), but the association between prior authorization policies and quality of care for individuals receiving buprenorphine treatment is not well-understood.

METHODS

Using 2006-2013 Medicaid Analytic eXtract (MAX) data from 34 states and the District of Columbia, we identified 294,031 episodes of buprenorphine treatment for OUD among individuals aged 14-64 years. We estimated generalized difference-in-differences models to examine the association between buprenorphine prior authorization policies and changes in buprenorphine treatment quality along four dimensions: (1) duration of at least 180 days, (2) dosage of at least 8 milligrams, and concurrent prescribing of (3) opioid analgesics and (4) benzodiazepines.

RESULTS

Buprenorphine prior authorization policies were associated with an 11-percentage point reduction (p < 0.01) in the likelihood of episodes with a duration of at least 180 days in the first four years after policy implementation. The policy was not associated with changes in effective dosage or concurrent prescribing of opioid analgesics or benzodiazepines.

CONCLUSIONS

Buprenorphine prior authorization policies were associated with a sizeable and significant reduction in episodes of at least 180 days duration, underscoring the importance of identifying and removing barriers to effective and appropriate OUD care.