Multidisciplinary treatment of opioid use disorder in primary care using the collaborative care model.

Background: Treatment of opioid use disorder (OUD) is highly effective, but access is limited and care is often fragmented. Treatment in primary care can improve access to treatment and address psychiatric and physical co-morbidities in a holistic, efficient, and non-stigmatizing way. The Collaborative Care Model (CCM) of behavioral health integration into primary care has been widely disseminated and shown to improve outcomes and lower costs when studied for depression, but its use in treating substance use disorders has not been well documented. Methods: We used a mixed-methods approach to examine the impact of implementing multidisciplinary treatment of OUD in our health system's five primary care clinics using the framework of the CCM, with care shared between the primary care clinician (PCP), behavioral health clinician, and medical assistant. The implementation included staff education, creation of electronic health record tools, and implementation support, and was evaluated using data from the electronic health record, the medical staff office, and a clinician survey. Results: Over the last 2 years of implementation, the number of waivered providers increased from 11 to 35, providers prescribing for 5 or more patients increased from 2 to 18, and patients initiated on buprenorphine increased from 4/month to 18/month. 180-day treatment retention was 53%, and 81% of patients had consistently negative urine drug testing. Psychiatric and medical comorbidities were common, 70 and 44%, respectively. Although PCPs who prescribed buprenorphine found working in this model enjoyable and effective, the majority of non-waivered PCPs remained reluctant to participate. Conclusions: In our experience, treatment of OUD in primary care utilizing the CCM effectively addresses OUD and commonly comorbid anxiety and depression, and leads to an expansion of treatment. Successful implementation of OUD treatment requires addressing negative attitudes and perceptions.

Buprenorphine Induction in a Rural Maryland Detention Center During COVID-19: Implementation and Preliminary Outcomes of a Novel Telemedicine Treatment Program for Incarcerated Individuals With Opioid Use Disorder.

Over 10 million individuals pass through U.S. detention centers on an annual basis, with nearly two-thirds meeting criteria for drug dependence/abuse. Despite proven efficacy, treatment with medications for opioid use disorder (MOUD) is underutilized in jail settings-a gap that could be addressed using telemedicine. Here we describe a new program of telemedicine-based clinical provision of new/continuing buprenorphine treatment for individuals detained in a rural jail. Implementation objectives were completed between January and August 2020, and patient encounters were conducted between August 2020 and February 2021. We established (i) telemedicine hardware/software capability; (ii) a screening process; (iii) buprenorphine administration methods; (iv) necessary medical release procedures; (v) telemedicine encounter coordination and medication prescription procedures; and (vi) a research platform. Seven incarcerated patients have been treated, two of whom were referred from community treatment. Patients were mostly male (71%), non-Hispanic White (86%), and averaged 33 years old. All patients tested positive for an opioid upon intake and began/continued buprenorphine treatment in the jail. Average time to first MOUD appointment was 9 days and patients were maintained in treatment an average 21 days. Referrals for continuing community treatment were offered to all patients prior to discharge. We report successful implementation of telemedicine MOUD in a rural detention center, with treatment engagement and initiation occurring prior to the high-risk period of discharge. The fact that this program was launched during the height of the pandemic highlights the flexibility of telemedicine-based buprenorphine treatment. Challenges and obstacles to implementation of buprenorphine treatment in a correctional system are discussed.