Evaluation of a Program Designed to Support Implementation of Prescribing Medication for Treatment of Opioid Use Disorder in Primary Care Practices

INTRODUCTION

The age-adjusted death rate involving synthetic opioids increased more than 10-fold (from 1 to 11.4 per 100,000 deaths) from 2013 to 2019.¹ Only 21.5% of people with opioid use disorder (OUD) received medication (ie, buprenorphine, naltrexone, methadone) from 2009 to 2013,² and this decreased to 13% from 2013 to 2019.³ In Colorado, only about one-half of people with OUD received treatment with buprenorphine and more than one-fifth of counties lacked a clinician who actively prescribed buprenorphine in 2019.⁴ Waiver activity and removal of the X-waiver requirement have increased medication for OUD (MOUD) prescribers in the United States but a shortage remains.^5-7 Only 10% to 28% of primary care clinicians prescribe MOUD.^8,9 Barriers to providing addiction treatment in primary care include limited access to treatment resources (eg, psychosocial services), clinician stigma, perceived low patient demand, training, and lack of confidence in treating complex patients with OUD.^8,10

Existing MOUD models have not adequately addressed these barriers. Most US opioid treatment programs (OTP) or methadone clinics operate at 80% capacity or greater.¹¹ Federal regulations require extensive certification and audits for OTPs¹² and access can be challenging because patients must travel to the OTP site for daily supervised medication administration.¹³ Many areas, especially rural communities, do not have OTPs.¹⁴ Integrating MOUD into primary care settings can increase patient access to effective OUD treatment.¹⁴ The Agency for Healthcare Research and Quality outlined the following 4 elements of MOUD models in primary care: (1) MOUD pharmacotherapy, (2) clinician and community education, (3) coordination of treatment with other health and psychological needs, and (4) psychosocial services.¹⁴ Prescriber education may include continuing medical education, teleconferences, technical assistance, consultation, or mentoring.¹⁴ Addiction medicine consult services have emerged to address challenges in access to OUD treatment.^15-17 Benefits of these services include engagement with primary care; increase in treatment uptake; and decreases in substance use, disease severity, and hospital readmissions.^18,19 Adding addiction consult services to the practice can offer clinicians increased variety and may support clinician retention.²⁰ Embedded addiction medicine consult services have been implemented in ambulatory settings, but this can be difficult in medically underserved regions (eg, rural areas).^21,22

We describe a primary care office-based MOUD implementation and addiction consultation service model designed to support small, rural clinics called Integrated Support for MOUD. The intervention consists of care team education using a standardized MOUD curriculum, access to addiction medicine consultants, practice facilitation, and financial incentives. Practice facilitation has been used to effectively implement a variety of evidence-based interventions,²³ including training primary care teams to increase capacity to offer treatment for OUD.^24,25 We highlight findings that demonstrate how the Integrated Support for MOUD program addresses the gap between OUD treatment need and availability, guided by 2 aims: (1) compare the number of active buprenorphine prescriptions in participating practices at the beginning and end of the program; and (2) compare implementation ratings of MOUD milestones in participating practices at the beginning and end of the program.

METHODS

We describe evaluation results from a Colorado primary care practice intervention supporting MOUD implementation. This program was authorized by Senate Bill 21-137 (CRS § 23-21-808) and used federal American Rescue Plan Act dollars. The Colorado Multiple Institutional Review Board determined this was not human subjects research.

RESULTS

Practices represented varying organizational structures, though most were clinician-owned. Practices were primarily family medicine, rural, and small (1 or 2 clinicians). Practice facilitators most commonly interacted with practices by e-mail (mean = 21.9 e-mails per practice) or virtual, web-based meeting, or conference call (mean = 9.7 meetings per practice) (Table 2).

The mean number of active buprenorphine prescriptions in the preceding 3 months increased significantly from 2.1 (SD = 7.7) at baseline to 11.3 (SD = 11.2, P <.001) at 13 months. Mean completion of core aim 1 (build your team) grew significantly from 40% at baseline to a final score of 93% (P <.001). Mean completion of core aim 2 (engage and support patients) increased significantly from 23% to a final score of 84% (P <.001). Mean completion of core aim 3 (connect with recovery support services) expanded significantly from 28% to a final score of 93% (P <.001). Changes in completion scores for all core aims were significant between each individual time point (P <.001 for all) (Table 2).

Practices increased mean completion scores for all of the MOUD milestones by the end of the program (Table 3). Changes in completion scores for all core aims were significant (P <.001) between each individual time point (Table 4, Supplemental Figure 1, Supplemental Figure 2).

DISCUSSION

In this report we describe the implementation of MOUD prescribing in 15 Colorado primary care practices. Our model used monthly clinical education forums, practice facilitation with core aims, and access to an addiction medicine physician for clinical support to increase prescribing activity and organizational capacity. Practices demonstrated significant increases in MOUD prescribing after 13 months of program participation. Adding to previous research, we also noted that obtaining a X-waiver was not sufficient to increase buprenorphine prescriptions, but providing education for clinicians was helpful for increasing prescriptions.²⁹ Significant changes in implementation ratings for each core aim reflect practices’ progress on implementing workflows and policies related to MOUD.

Practices increased implementation scores for core aim 1 (build your team) from a mean of 40% at baseline to 93% upon program completion. This aim addressed practice infrastructure that supports the entire care team’s ability to provide MOUD through activities such as empowering both clinicians and staff to champion MOUD implementation, and ensuring that all are aware of policies that reflect evidence-based guidelines for MOUD. Development of capacity among clinical and non-clinical staff, in addition to physicians, is critical for primary care practices to implement MOUD. Multidisciplinary teams are a common element of MOUD models in primary care, and including non-prescriber staff can help to relieve physicians’ workload.³⁰

Mean implementation scores for core aim 2 (engage and support patients) also increased, from 23% at program start to 84% at program end. This reflects patient-related capacity such as active outreach to patients regarding the availability and benefits of MOUD, use of screening tools to identify patients who may benefit from MOUD, and prompt appointment access for MOUD induction and maintenance visits. Enhancing patient outreach and access are important for practices that offer MOUD because up to 87% of people with OUD do not receive evidence-based treatment.^2,3 Prescribers have highlighted the need to increase patients’ awareness of the availability of MOUD treatment.³¹ Universal screening for OUD in emergency department settings has resulted in increased MOUD prescribing,³² suggesting that widespread screening could help reach people with OUD who have not been reached by current models.

Also increased were the mean implementation scores for core aim 3 (connect with recovery support services) which rose from 28% to 93%, reflecting connections to community resources to address patients’ health care, behavioral health, and social needs. This is important because mental health diagnoses are fairly common among people with OUD,³³ making up the majority of patients in some treatment programs.³⁴ Despite this, people with mental health diagnoses are less likely to receive OUD treatment.³⁵ Additionally, people seeking treatment for OUD are commonly affected by social determinants of health related to transportation, unemployment, finances, and food insecurity,³⁶ emphasizing the need for mental health and psychosocial resources.

Practices’ ability to implement MOUD was supported by access to an external addiction medicine physician for consultation to supplement clinician and team education, a unique element of this model. Most models include clinicians with experience caring for patients with OUD and an educational component.¹⁴ Lack of prescriber knowledge and confidence managing OUD are barriers to offering MOUD among primary care physicians,²² even those who have obtained the X-waiver.^9,31 Having access to tailored consultation is a particularly important element of support for MOUD implementation among primary care prescribers with limited MOUD experience. Our findings demonstrate that integrated support for MOUD curriculum can help primary care practices implement measurable changes in capacity to identify patients for MOUD, build multidisciplinary teams to deliver MOUD, and connect patients to medical, behavioral, and psychosocial resources to support their treatment.

The extent to which financial incentives motivated practices to achieve observed improvements in MOUD implementation in this program is unclear. Primary care clinicians have highlighted financial incentives as a motivator for offering MOUD,³⁷ but the effectiveness of financial incentives varies across professional roles (advanced practice providers vs primary care clinicians) and organizational setting (community clinics vs medical centers).³⁸ Financial incentives may be particularly effective among prescribers with higher levels of stigma toward MOUD care,³⁹ but when compared with other potential incentives, primary care clinicians rate reduced workload, protected time, and clinical resources more highly than financial incentives.³⁸ Implementation programs that do not include financial incentives have been effective in increasing the capacity for MOUD care,⁴⁰ indicating that additional research is needed to understand the specific contribution of financial incentives to MOUD implementation. Sustainable funding strategies for financial incentives for practices and access to an external addiction medicine consultant need exploration.

CONCLUSION

This model supported a group of primary care practices doing little to no MOUD prescribing, to begin prescribing at significantly higher levels and build capacity in workflows and policies to support MOUD by the end of the 13-month program. Clinical teams need support beyond removal of the X-waiver requirement to feel confident serving this patient population, and this scalable model for addiction consultation in primary care settings illustrates how education and support to clinical teams, especially those with limited experience, can help practices make tangible changes.