Increasing Capacity for Treatment of Opioid Use Disorder in Rural Primary Care Practices

Linda Zittleman; Kristen Curcija; Donald E. Nease; Mary Fisher; L. Miriam Dickinson; John F. Thomas; Ashley Espinoza; Christin Sutter; Jennifer Ancona; Jodi Summers Holtrop; John M. Westfall

doi:10.1370/afm.2757

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RE: Increasing Capacity for Treatment of Opioid Use Disorder in Rural Primary Care Practices
Andrew J Russell and Lorraine S Wallace

Published on: 24 March 2022
RE: Journal Club discussion on Increasing Capacity for Treatment of Opioid Use Disorder in Rural Primary Care Practices
Abbey Zacharski, Joseph Berei, Alison Gustafson, Jessie Kirk and Katherine Walka

Published on: 11 March 2022
RE: Increasing Capacity for Treatment of Opioid Use Disorder in Rural Primary Care Practices
Neil Korsen

Published on: 16 February 2022

Published on: (24 March 2022)
Page navigation anchor for RE: Increasing Capacity for Treatment of Opioid Use Disorder in Rural Primary Care Practices
RE: Increasing Capacity for Treatment of Opioid Use Disorder in Rural Primary Care Practices
Andrew J Russell, Undergraduate, The Ohio State University
Other Contributors:
Lorraine S Wallace, Associate Professor- College of Medicine
It is certainly undeniable that opioid use disorder (OUD) is a significant crisis in the United States, especially in rural communities. Importantly, rural opioid-related mortality rates have increased over 600% in non-metropolitan counties over the last twenty years.1 It is crucial that more attention is drawn to this issue, as in many parts of the country, patients are viewed through the lens of the stigma that is often associated with addiction. As evidenced by your findings, IT MATTTRs training enables primary care teams to deliver quality treatment, specifically with buprenorphine, to those suffering from OUD. The results show that the number of patients with a buprenorphine prescription increased significantly because of the IT MATTTRs program. The most important conclusion that can be drawn from these findings is that the IT MATTTRs program can truly affect the approach primary care teams take regarding OUD treatment.
Furthermore, it is vital that primary care practice-based networks included in the study were able to successfully implement parts of the IT MATTTRs program needed to increase treatment delivery. This demonstrates that the program was reasonable for a practice to follow, suggesting that practices with similar resources in other locations may be able to enact similar policies. Although specific data from each practice was not provided as part of this report, available data indicates that the IT MATTTRS program was able to reach the goal of increas...
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It is certainly undeniable that opioid use disorder (OUD) is a significant crisis in the United States, especially in rural communities. Importantly, rural opioid-related mortality rates have increased over 600% in non-metropolitan counties over the last twenty years.1 It is crucial that more attention is drawn to this issue, as in many parts of the country, patients are viewed through the lens of the stigma that is often associated with addiction. As evidenced by your findings, IT MATTTRs training enables primary care teams to deliver quality treatment, specifically with buprenorphine, to those suffering from OUD. The results show that the number of patients with a buprenorphine prescription increased significantly because of the IT MATTTRs program. The most important conclusion that can be drawn from these findings is that the IT MATTTRs program can truly affect the approach primary care teams take regarding OUD treatment.
Furthermore, it is vital that primary care practice-based networks included in the study were able to successfully implement parts of the IT MATTTRs program needed to increase treatment delivery. This demonstrates that the program was reasonable for a practice to follow, suggesting that practices with similar resources in other locations may be able to enact similar policies. Although specific data from each practice was not provided as part of this report, available data indicates that the IT MATTTRS program was able to reach the goal of increasing the frequency at which buprenorphine was administered. In the future, could this research be expanded to evaluate a potential difference in health outcomes for patients treated as a result of the program? Additionally, could this same technique be applied in practices in other rural areas around the country, provided they have access to similar resources? Thank you for your research regarding such a critical healthcare issue.

Reference
1. Rigg KK, Monnat SM, Chavez MN. Opioid-related mortality in rural America: Geographic heterogeneity and intervention strategies. Int J Drug Policy. 2018;57:119-129. doi: 10.1016/j.drugpo.2018.04.011.
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Competing Interests: None declared.
Published on: (11 March 2022)
Page navigation anchor for RE: Journal Club discussion on Increasing Capacity for Treatment of Opioid Use Disorder in Rural Primary Care Practices
RE: Journal Club discussion on Increasing Capacity for Treatment of Opioid Use Disorder in Rural Primary Care Practices
Abbey Zacharski, Medical Student, University of Illinois College of Medicine Rockford
Other Contributors:
Joseph Berei, Medical Student

Alison Gustafson, Medical Student

Jessie Kirk, Medical Student

Katherine Walka, Medical Student
The overall purpose of this study was to analyze the implementation of an intervention designed to improve awareness, adoption, and utilization of buprenorphine treatment of opioid use disorder (OUD). Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado (IT MATTTRs) is a practice-focused training program that covered the pharmacology of buprenorphine, epidemiology of OUD, neurobiology of addiction, and buprenorphine treatment steps. Training included members of the entire health care team, such as physicians, nurses, and office staff.

This program used components of the RE-AIM evaluation framework to examine outcomes at the patient, practice, and community levels. The study was conducted across 16 counties in eastern Colorado, many of which are federally qualified health centers. Implementation of IT MATTTRs was analyzed using an implementation checklist of items that support treatment using buprenorphine. There was also data from a practice report that collected practice-level data, including data on the number of new inductions and the number of patients prescribed buprenorphine. Population-based data was assessed using the Colorado Prescription Drug Monitoring Program.

When assessing the results, it was clear to the group that this program was effective at significantly increasing the proportion of patients prescribed buprenorphine and receiving treatment for 6 or more months. Many items measured using the implementat...
Show More

The overall purpose of this study was to analyze the implementation of an intervention designed to improve awareness, adoption, and utilization of buprenorphine treatment of opioid use disorder (OUD). Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado (IT MATTTRs) is a practice-focused training program that covered the pharmacology of buprenorphine, epidemiology of OUD, neurobiology of addiction, and buprenorphine treatment steps. Training included members of the entire health care team, such as physicians, nurses, and office staff.

This program used components of the RE-AIM evaluation framework to examine outcomes at the patient, practice, and community levels. The study was conducted across 16 counties in eastern Colorado, many of which are federally qualified health centers. Implementation of IT MATTTRs was analyzed using an implementation checklist of items that support treatment using buprenorphine. There was also data from a practice report that collected practice-level data, including data on the number of new inductions and the number of patients prescribed buprenorphine. Population-based data was assessed using the Colorado Prescription Drug Monitoring Program.

When assessing the results, it was clear to the group that this program was effective at significantly increasing the proportion of patients prescribed buprenorphine and receiving treatment for 6 or more months. Many items measured using the implementation checklist also significantly improved, adding to the evidence that the IT MATTTRs program was clinically effective. Results that were clinically significant included an increase in referrals to practices with a buprenorphine prescriber, as well as a significant increase in the number of opioid overdose prevention kits given to patients. Interestingly, the referrals for behavioral health were not significantly increased at the end of the intervention, despite the fact that referrals for psychosocial support and connection programs (12-step, faith communities) increased significantly. The group discussed that this could be due to limited availability of behavioral health providers in rural areas or that more emphasis should be placed on the behavioral health aspect of OUD in this program.

As an analysis on the implementation of a public health program like IT MATTTRs, this study thoroughly analyzed outcomes at both the individual practice and population levels. However, the main question left unanswered is the patient’s perspective on buprenorphine treatment. This would potentially include their reasons for initiating treatment, their motivation for staying in treatment, and how buprenorphine for their OUD impacted their quality of life overall. Additionally, assessing the provider’s perspective on the treatment. It is unclear at this point how this study affected the provider’s clinical practice.

One point of discussion of the results of this study was the finding that new OUD treatment inductions did not increase significantly, while patients in treatment for greater than 6 months did increase significantly. There is no clear explanation as to why this occurred. Authors hypothesized that perhaps an early pent-up demand for OUD treatment in these rural communities eventually leveled off as patients in need received treatment which was why inductions did not increase significantly over the course of the study. However, with qualitative data, perhaps additional social determinants of health could have been better analyzed.

By assessing this qualitative component and hearing some of the stories behind the data, it would also provide better information on how generalizable this study is to other populations. The implementation of this program showed clinically significant improvements in access and treatment uptake that could be beneficial across other populations, especially since OUD is such a widespread public health epidemic. Additional information that would be useful in assessing generalizability would be more information of the patient and provider characteristics themselves. What were the different cultures of the patient population? Were there language barriers? What was the socioeconomic status of the patient population? As it stands currently, readers are left asking how feasible it would be to implement such an effective program in their own clinical practice. With this information in hand, it would be clearer what the barriers to implementation were from the patient and from the provider perspective.

Future studies using the training framework could include expanding the program to other primary care practices and hospital systems outside of the study region in Colorado. It was mentioned that this has been delivered to health professionals in Colorado, Montana, California, and North Carolina, but a comparison analysis between some of these places would be interesting and add to the support that this approach to treating OUD is clinically significant and effective. Additionally, a prolonged analysis beyond 1 year would be beneficial to assess the long-term implications of maintaining this program in rural communities. This program made a difference in addressing OUD treatment in the community for which it was designed and in which it was implemented, however further investigation to determine broad applicability and long-term effectiveness is necessary.
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Competing Interests: None declared.
Published on: (16 February 2022)
Page navigation anchor for RE: Increasing Capacity for Treatment of Opioid Use Disorder in Rural Primary Care Practices
RE: Increasing Capacity for Treatment of Opioid Use Disorder in Rural Primary Care Practices
Neil Korsen, Physician Scientist, Maine Medical Center Research Institute
Thank you to Linda Zittleman and colleagues for this description of an excellent example of translational research and for your efforts to improve care for people with opioid use disorders. I am familiar with this project, having served on an advisory group for all grantees in this program and by working with some of the authors on community engagement.
This paper reminded me of some key principles of successful translation of research into practice - engaging the whole practice team, packaging the intervention in a way that facilitates adoption, and doing a community intervention in parallel to raise awareness and increase community acceptance of the intervention.
The authors also do a very good job of measuring the impact of their intervention at multiple levels. Combining practice level process measures with population level prescription data is interesting and suggests that the region achieved results beyond those in other parts of the state. It is impressive to see how much practice change was accomplished, given that there are always competing demands on clinician and practice time and attention.
Thanks to the authors for a well done study.

Competing Interests: I was an advisor to this project in my role on an expert panel working with AHRQ. I have also worked with some of the authors who have mentored me and other colleagues on community engaged research. I have no financial conflicts.