Implementation of a rural emergency department-initiated buprenorphine program in the mountain west: a study protocol.

BACKGROUND: Opioid related overdose morbidity and mortality continue to significantly impact rural communities. Nationwide, emergency departments (EDs) have seen an increase in opioid use disorder (OUD)-related visits compared to other substance use disorders (SUD). ED-initiated buprenorphine is associated with increased treatment engagement at 30 days. However, few studies assess rural ED-initiated buprenorphine implementation, which has unique implementation barriers. This protocol outlines the rationale and methods of a rural ED-initiated buprenorphine program implementation study. METHODS: This is a two-year longitudinal implementation design with repeated qualitative and quantitative measures of an ED-initiated buprenorphine program in the rural Mountain West. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework outlines intervention assessments. The primary outcome is implementation measured by ED-initiated buprenorphine protocol core components. Reach, adoption, and maintenance are secondary outcomes. External facilitators from an academic institution with addiction medicine and prior program implementation expertise partnered with community hospital internal facilitators to form an implementation team. External facilitators provide ongoing support, recommendations, education, and academic detailing. The implementation team designed and implemented the rural ED-initiated buprenorphine program. The program includes OUD screening, low-threshold buprenorphine initiation, naloxone distribution and administration training, and patient navigator incorporation to provide warm hand off referrals for outpatient OUD management. To address rural based implementation barriers, we organized implementation strategies based on Expert Recommendations for Implementing Change (ERIC). Implementation strategies include ED workflow redesign, local needs assessments, ED staff education, hospital leadership and clinical champion involvement, as well as patient and community resources engagement. DISCUSSION: Most ED-initiated buprenorphine implementation studies have been conducted in urban settings, with few involving rural areas and none have been done in the rural Mountain West. Rural EDs face unique barriers, but tailored implementation strategies with external facilitation support may help address these. This protocol could help identify effective rural ED-initiated buprenorphine implementation strategies to integrate more accessible OUD treatment within rural communities to prevent further morbidity and mortality. TRIAL REGISTRATION: ClinicalTrials.gov National Clinical Trials, NCT06087991. Registered 11 October 2023 - Retrospectively registered, https://clinicaltrials.gov/study/NCT06087991 .

Evaluation of a Primary Care-Based Multidisciplinary Transition Clinic for Patients Newly Initiated on Buprenorphine in the Emergency Department.

BACKGROUND: Care transitions represent vulnerable events for patients newly initiating medications for opioid use disorder (MOUD). Multidisciplinary primary care-based transition clinics may improve care linkage and retention in MOUD treatment. Additionally, these interventions may help primary care clinicians (PCPs) overcome barriers to adopting MOUD into practice. In this evaluation, we assessed the impact of a primary care-based transition clinic for patients newly initiating buprenorphine for opioid use disorder (OUD) in the emergency department. METHODS: We conducted a retrospective program evaluation within a single academic health system involving adults who newly initiated buprenorphine for OUD through an emergency department-based program and were referred to follow up in either a dedicated multidisciplinary primary care-based transition clinic (SPARC) vs referral to usual primary care (UPC). We performed descriptive analyses comparing patient demographics, referral volume, linkage to care, treatment retention, and markers of high-quality care between the 2 groups. A log-rank test was used to determine the difference in probabilities of retention between SPARC and UPC over 6 months. RESULTS: Over 12 months, the number of referrals to SPARC was greater than to UPC (N = 64 vs N = 26). About 58% of patients referred to SPARC attended an initial visit vs 38% referred to UPC. Treatment retention was consistently greater in SPARC than UPC (1 m: 90% vs 60%; 3 m: 76% vs 40%; 6 m: 60% vs 30%). Markers of care quality including naloxone provision (100% vs 80%) and infectious screening (81% vs 40%) were greater in SPARC clinic. SPARC was associated with a statistically significant increased probability of retention in treatment as compared to UPC (P < .01). CONCLUSIONS: In this observational evaluation, a primary care-based multidisciplinary transition clinic for patients initiating buprenorphine MOUD was associated with expanded access to longitudinal OUD treatment and superior linkage to care, retention in care, and quality of care compared to referral to usual primary care. Further research using a more rigorous research design is required to further evaluate these findings.

Examining the Primary Care Experience of Patients With Opioid Use Disorder: A Qualitative Study.

OBJECTIVES: Despite substantial investment in expanding access to treatment for opioid use disorder (OUD), overdose deaths continue to increase. Primary care holds enormous potential to expand access to OUD treatment, but few patients receive medications for OUD (MOUD) in primary care. Understanding both patient and clinician experiences is critical to expanding access to patient-centered MOUD care, yet relatively little research has examined patient perspectives on primary care-based MOUD. We sought to examine the care experiences of patients with OUD receiving medication-based treatment in a primary care setting. METHODS: We conducted semistructured interviews with patients receiving MOUD at a single primary care site at the University of Utah. Interviews were performed and transcribed by qualitative researchers, who used rapid qualitative analysis using a grounded theory-based approach to identify key themes pertaining to patient experiences receiving medication-based OUD treatment in primary care. RESULTS: Twenty-one patients were screened, and 14 completed the interview. In general, participants had numerous medical and psychiatric comorbidities. The following key themes pertaining to primary care-based OUD treatment were identified: (1) overall health improvement, (2) team-based care, (3) comparing primary care to specialty addiction treatment, (4) access to medications for OUD, and (5) discrimination and stigma. CONCLUSIONS: Patients reported many advantages to receiving primary care-based MOUD treatment. In particular, the flexibility and added support of team-based care along with the convenience of receiving addiction treatment alongside regular medical care were highly valued. These findings can be used to develop patient-centered initiatives aimed at expanding OUD treatment within primary care.