Evidence-Based Interventions to Improve Opioid Prescribing in Primary Care: a Qualitative Assessment of Implementation in Two Studies.

BACKGROUND: The TOPCARE and TEACH randomized controlled trials demonstrated the efficacy of a multi-faceted intervention to promote guideline-adherent long-term opioid therapy (LTOT) in primary care settings. Intervention components included a full-time Nurse Care Manager (NCM), an electronic registry, and academic detailing sessions. OBJECTIVE: This study sought to identify barriers, facilitators, and other issues germane to the wider implementation of this intervention. DESIGN: We conducted a nested, qualitative study at 4 primary care clinics (TOPCARE) and 2 HIV primary care clinics (TEACH), where the trials had been conducted. APPROACH: We purposively sampled primary care physicians and advanced practice providers (hereafter: PCPs) who had received the intervention. Semi-structured interviews explored perceptions of the intervention to identify unanticipated barriers to and facilitators of implementation. Interview transcripts were analyzed through iterative deductive and inductive coding exercises. KEY RESULTS: We interviewed 32 intervention participants, 30 physicians and 2 advanced practice providers, who were majority White (66%) and female (63%). Acceptability of the intervention was high, with most PCPs valuing didactic and team-based intervention elements, especially co-management of LTOT patients with the NCM. Adoption of new prescribing practices was facilitated by proximity to expertise, available behavioral health care, and the NCM's support. Most participants were enthusiastic about the intervention, though a minority voiced concerns about the appropriateness in their particular clinical environments, threats to the patient-provider relationship, or long-term sustainability. CONCLUSION: TOPCARE/TEACH participants found the intervention generally acceptable, appropriate, and easy to adopt in a variety of primary care environments, though some challenges were identified. Careful attention to the practical challenges of implementation and the professional relationships affected by the intervention may facilitate implementation and sustainability.

Adapting low-dose buprenorphine induction to meet patient needs: A pilot study.

Introduction: Low-dose buprenorphine induction (LDBI) has been proposed to initiate buprenorphine in patients who are taking full opioid agonists in order to limit the risk of precipitated withdrawal. The objective of this study was to understand how real-world patient-specific adjustments in LDBI protocols impacted success rates in buprenorphine conversion. Methods: This case series identified patients seen by the Addiction Medicine Consult Service at UPMC Presbyterian Hospital who were started on LDBI with transdermal buprenorphine followed by sublingual buprenorphine-naloxone between April 20, 2021, and July 20, 2021. The primary outcome was successful induction of sublingual buprenorphine. Characteristics of interest included total morphine milligram equivalents (MME) in the 24 hours prior to induction, MME during each day of induction, total time of induction, and final daily maintenance buprenorphine dose. Results: Of the 21 patients included for analysis, 19 (91%) successfully completed LDBI and converted to a maintenance buprenorphine dose. Median (IQR) opioid analgesia utilization in the 24 hours prior to induction was 113 MME (63-166 MME) in the converted group and 83 MME (75-92 MME) in the group that did not convert. Conclusions: Transdermal buprenorphine patch followed by sublingual buprenorphine-naloxone resulted in a high success rate for LDBI. Patient-specific adjustments may be considered in order to effect a high success rate of conversion.

Shorter outpatient wait-times for buprenorphine are associated with linkage to care post-hospital discharge.

BACKGROUND: Inpatient addiction consult services (ACS) lower barriers to accessing medications for opioid use disorder (MOUD), however not every patient recommended for MOUD links to outpatient care. We hypothesized that fewer days between discharge date and outpatient appointment date was associated with improved linkage to buprenorphine treatment among patients evaluated by an ACS. METHODS: We extracted appointment and demographic data from electronic medical records and conducted retrospective chart review of adults diagnosed with opioid use disorder (OUD) evaluated by an ACS in Boston, MA between July 2015 and August 2017. These patients were initiated on or recommended buprenorphine treatment on discharge and provided follow-up appointment at our hospital post-discharge. Multivariable logistic regression assessed whether arrival to the appointment post-discharge was associated with shorter wait-times (0-1 vs. 2+ days). RESULTS: In total, 142 patients were included. Among patients who had wait-times of 0-1 day, 63 % arrived to their appointment compared to wait-times of 2 or more days (42 %). There were no significant differences between groups based on age, gender, distance of residence from the hospital, insurance status, co-occurring alcohol use disorder diagnosis, or discharge with buprenorphine prescription. After adjusting for covariates, patients with 0-1 day of wait-time had 2.6 times the odds of arriving to their appointment [95 % CI 1.3-5.5] compared to patients who had 2+ days of wait-time. CONCLUSION: For hospitalized patients with OUD evaluated for initiating MOUD, same- and next-day appointments are associated with increased odds of linkage to outpatient MOUD care post-discharge compared to waiting two or more days.

Pain management in patients with chronic kidney disease and end-stage kidney disease.

PURPOSE OF REVIEW: This review evaluates current recommendations for pain management in chronic kidney disease (CKD) and end-stage kidney disease (ESKD) with a specific focus on evidence for opioid analgesia, including the partial agonist, buprenorphine. RECENT FINDINGS: Recent evidence supports the use of physical activity and other nonpharmacologic therapies, either alone or with pharmacological therapies, for pain management. Nonopioid analgesics, including acetaminophen, topical analgesics, gabapentinoids, serotonin-norepinephrine reuptake inhibitors, and TCA may be considered based on pain cause and type, with careful dose considerations in kidney disease. NSAIDs may be used in CKD and ESKD for short durations with careful monitoring. Opioid use should be minimized and reserved for patients who have failed other therapies. Opioids have been associated with increased adverse events in this population, and thus should be used cautiously after risk/benefit discussion with the patient. Opioids that are safer to use in kidney disease include oxycodone, hydromorphone, fentanyl, methadone, and buprenorphine. Buprenorphine appears to be a promising and safer option due to its partial agonism at the mu opioid receptor. SUMMARY: Pain is poorly managed in patients with kidney disease. Nonpharmacological and nonopioid analgesics should be first-line approaches for pain management. Opioid use should be minimized with careful monitoring and dose adjustment.