Buprenorphine Receipt and Retention for Opioid Use Disorder following an Initiative to Increase Access in Primary Care.

OBJECTIVES: Buprenorphine, a medication for opioid use disorder (OUD), is underutilized in general medical settings. Further, it is inequitably received by racialized groups and persons with comorbidities. The Veterans Health Administration launched an initiative to increase buprenorphine receipt in primary care. The project's objective was to identify patient-related factors associated with buprenorphine receipt and retention in primary care clinics (n = 18) participating in the initiative. METHODS: Retrospective cohort quality improvement evaluation of patients 18 years or older with 2 or more primary care visits in a 1-year period and an OUD diagnosis in the year before the first primary care visit (index date). Buprenorphine receipt was the proportion of patients with OUD who received 1 or more buprenorphine prescriptions from primary care providers during the post-index year and retention the proportion who received buprenorphine for 180 days or longer. RESULTS: Of 2880 patients with OUD seen in primary care, 11.7% (95% confidence interval [CI], 10.6%-12.9%) received buprenorphine in primary care, 58.2% (95% CI, 52.8%-63.3%) of whom were retained on buprenorphine for 180 days or longer. Patients with alcohol use disorder (adjusted odds ratio [AOR], 0.39; 95% CI, 0.27-0.57), nonopioid drug use disorder (AOR, 0.64; 95% CI, 0.45-0.93), and serious mental illness (AOR, 0.60; 95% CI, 0.37-0.97) had lower buprenorphine receipt. Those with an anxiety disorder had higher buprenorphine receipt (AOR, 1.42; 95% CI, 1.04-1.95). Buprenorphine receipt (AOR, 0.55; 95% CI, 0.35-0.87) and 180-day retention (AOR, 0.40; 95% CI, 0.19-0.84) were less likely among non-Hispanic Black patients. CONCLUSIONS: Further integration of addiction services in primary care may be needed to enhance buprenorphine receipt for patients with comorbid substance use disorders, and interventions are needed to address disparities in receipt and retention among non-Hispanic Black patients.

"The Only Reason I Am Willing to Do It at All": Evaluation of VA's SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center.

OBJECTIVES: Medication treatment for opioid use disorder (MOUD) is effective and recommended for outpatient settings. We implemented and evaluated the SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center-a quality improvement partnership to implement stepped care for MOUD in 2 Veterans Health Administration (VA) primary care (PC) clinics. METHODS: SUPPORT provided a dedicated clinical team (nurse practitioner prescriber and social worker) and stepped care ([1] identification, assessment, referral; [2] MOUD induction; [3] stabilization; and [4] maintenance supporting PC providers [PCPs] to initiate and/or sustain treatment) coupled with ongoing internal facilitation (consultation, trainings, informatics support). Qualitative interviews with stakeholders (PCPs and patients) and meeting notes identified barriers and facilitators to implementation. Electronic health record and patient tracking data measured reach, adoption, and implementation outcomes descriptively. RESULTS: SUPPORT's implementation barriers included the need for an X-waiver, VA's opioid tapering policies, patient and PCP knowledge gaps and PCP discomfort, and logistical compatibility and sustainability challenges for clinics. SUPPORT's dedicated clinical staff, ongoing internal facilitation, and high patient and PCP satisfaction were key facilitators. SUPPORT (January 2019 to September 2021) trained 218 providers; 63 received X-waivers, and 23 provided MOUD (10.5% of those trained). SUPPORT provided care to 167 patients, initiated MOUD for 33, and provided education and naloxone to 72 (all = 0 in year before launch). CONCLUSIONS: SUPPORT reached many PCPs and patients and resulted in small increases in MOUD prescribing and high levels of stakeholder satisfaction. Dedicated clinical staff was key to observed successes. Although resource-intensive, SUPPORT offers a potential model for outpatient MOUD provision.

Clinician Perspectives on Delivering Medication Treatment for Opioid Use Disorder during the COVID-19 Pandemic: A Qualitative Evaluation.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic necessitated changes in opioid use disorder care. Little is known about COVID-19's impact on general healthcare clinicians' experiences providing medication treatment for opioid use disorder (MOUD). This qualitative evaluation assessed clinicians' beliefs about and experiences delivering MOUD in general healthcare clinics during COVID-19. METHODS: Individual semistructured interviews were conducted May through December 2020 with clinicians participating in a Department of Veterans Affairs initiative to implement MOUD in general healthcare clinics. Participants included 30 clinicians from 21 clinics (9 primary care, 10 pain, and 2 mental health). Interviews were analyzed using thematic analysis. RESULTS: The following 4 themes were identified: overall impact of the pandemic on MOUD care and patient well-being, features of MOUD care impacted, MOUD care delivery, and continuance of telehealth for MOUD care. Clinicians reported a rapid shift to telehealth care, resulting in few changes to patient assessments, MOUD initiations, and access to and quality of care. Although technological challenges were noted, clinicians highlighted positive experiences, including treatment destigmatization, more timely visits, and insight into patients' environments. Such changes resulted in more relaxed clinical interactions and improved clinic efficiency. Clinicians reported a preference for in-person and telehealth hybrid care models. CONCLUSIONS: After the quick shift to telehealth-based MOUD delivery, general healthcare clinicians reported few impacts on quality of care and highlighted several benefits that may address common barriers to MOUD care. Evaluations of in-person and telehealth hybrid care models, clinical outcomes, equity, and patient perspectives are needed to inform MOUD services moving forward.

U.S. veterans' experiences and factors associated with use of a smartphone application to self-manage unhealthy alcohol use.

Unhealthy alcohol use is common among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans, yet barriers discourage treatment-seeking. Mobile applications (apps) that deliver alcohol interventions have potential to address these barriers and increase treatment receipt. Few studies have qualitatively assessed users' experiences with apps to manage alcohol use. We assessed OEF/OIF veterans' experiences with Step Away, an app to reduce alcohol-related risks, to identify factors that may influence engagement. This single-arm pilot study recruited OEF/OIF veterans with positive alcohol screens nationwide using mail/telephone. Veterans aged 18-55 who exceeded drinking guidelines and owned an iPhone were eligible. Twenty-one (16 men, 5 women) of 55 participants completed interviews. Interviews were analyzed using thematic analysis. Participants found Step Away easy to use, although setup was time consuming. Participants reported increased awareness of alcohol use, highlighting daily assessment, weekly feedback, goal setting, and high-risk notification features as helpful and associated awareness with an intent to decrease use. Participants described Step Away as informative, with over half reporting they would use it outside of the study and most recommending it. Suggestions for improvement included greater personalization and control over features. Step Away features appear to influence engagement and increase users' awareness about alcohol consumed and factors associated with drinking, as well as intent to change. Assessment, feedback, and customization features of apps may facilitate app engagement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Accessibility to Medication for Opioid Use Disorder After Interventions to Improve Prescribing Among Nonaddiction Clinics in the US Veterans Health Care System.

Importance: With increasing rates of opioid use disorder (OUD) and overdose deaths in the US, increased access to medications for OUD (MOUD) is paramount. Rigorous effectiveness evaluations of large-scale implementation initiatives using quasi-experimental designs are needed to inform expansion efforts. Objective: To evaluate a US Department of Veterans Affairs (VA) initiative to increase MOUD use in nonaddiction clinics. Design, Setting, and Participants: This quality improvement initiative used interrupted time series design to compare trends in MOUD receipt. Primary care, pain, and mental health clinics in the VA health care system (n = 35) located at 18 intervention facilities and nonintervention comparison clinics (n = 35) were matched on preimplementation MOUD prescribing trends, clinic size, and facility complexity. The cohort of patients with OUD who received care in intervention or comparison clinics in the year after September 1, 2018, were evaluated. The preimplementation period extended from September 1, 2017, through August 31, 2018, and the postimplementation period from September 1, 2018, through August 31, 2019. Exposures: The multifaceted implementation intervention included education, external facilitation, and quarterly reports. Main Outcomes and Measures: The main outcomes were the proportion of patients receiving MOUD and the number of patients per clinician prescribing MOUD. Segmented logistic regression evaluated monthly proportions of MOUD receipt 1 year before and after initiative launch, adjusting for demographic and clinical covariates. Poisson regression models examined yearly changes in clinician prescribing over the same time frame. Results: Overall, 7488 patients were seen in intervention clinics (mean [SD] age, 53.3 [14.2] years; 6858 [91.6%] male; 1476 [19.7%] Black, 417 [5.6%] Hispanic; 5162 [68.9%] White; 239 [3.2%] other race [including American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and multiple races]; and 194 [2.6%] unknown) and 7558 in comparison clinics (mean [SD] age, 53.4 [14.0] years; 6943 [91.9%] male; 1463 [19.4%] Black; 405 [5.4%] Hispanic; 5196 [68.9%] White; 244 [3.2%] other race; 250 [3.3%] unknown). During the preimplementation year, the proportion of patients receiving MOUD in intervention clinics increased monthly by 5.0% (adjusted odds ratio [AOR], 1.05; 95% CI, 1.03-1.07). Accounting for this preimplementation trend, the proportion of patients receiving MOUD increased monthly by an additional 2.3% (AOR, 1.02; 95% CI, 1.00-1.04) during the implementation year. Comparison clinics increased by 2.6% monthly before implementation (AOR, 1.03; 95% CI, 1.01-1.04), with no changes detected after implementation. Although preimplementation-year trends in monthly MOUD receipt were similar in intervention and comparison clinics, greater increases were seen in intervention clinics after implementation (AOR, 1.04; 95% CI, 1.01-1.08). Patients treated with MOUD per clinician in intervention clinics saw greater increases from before to after implementation compared with comparison clinics (incidence rate ratio, 1.50; 95% CI, 1.28-1.77). Conclusions and Relevance: A multifaceted implementation initiative in nonaddiction clinics was associated with increased MOUD prescribing. Findings suggest that engagement of clinicians in general clinical settings may increase MOUD access.

Efficacy and acceptability of interventions for co-occurring PTSD and SUD: A meta-analysis.

Over the past 20 years, numerous treatments addressing comorbid Posttraumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD) have been developed and tested. The current meta-analysis examined the efficacy and acceptability of the two central treatment types- trauma-focused and non-trauma-focused - compared with all comparators and with cognitive-behavioral manualized SUD treatments immediately post-treatment and at longest follow-up. Twenty-eight randomized clinical trials (N = 3247) were included. There were small to large within-group effects for all forms of active treatment (gs = 0.30-1.11). Trauma-focused but not non-trauma-focused treatments outperformed all comparators on PTSD outcomes at post-treatment. Neither trauma-focused nor non-trauma-focused treatment outperformed all comparators on SUD outcomes at post-treatment. Neither trauma- nor non-trauma-focused treatment outperformed manualized SUD treatments on PTSD outcomes at either time point. Manualized SUD treatments outperformed trauma-focused treatments on SUD outcomes at post-treatment and non-trauma-focused treatments on PTSD outcomes at follow-up. Regarding treatment retention, neither trauma-focused nor non-trauma-focused treatments significantly differed from all comparators or from manualized SUD treatments. Between-group results were largely unchanged in trim-and-fill analyses, but were not robust to fail-safe N. Few moderators were detected. Taken together, results suggest that trauma-focused, non-trauma-focused, and manualized SUD interventions are sound options for individuals with comorbid PTSD/SUD.

Clinical leaders and providers' perspectives on delivering medications for the treatment of opioid use disorder in Veteran Affairs' facilities.

BACKGROUND: Improving access to medication treatment of opioid use disorder (MOUD) is a national priority, yet common modifiable barriers (e.g., limited provider knowledge, negative beliefs about MOUD) often challenge implementation of MOUD delivery. To address these barriers, the VA launched a multifaceted implementation intervention focused on planning and educational strategies to increase MOUD delivery in 18 medical facilities. The purpose of this investigation was to determine if a multifaceted intervention approach to increase MOUD delivery changed providers' perceptions about MOUD over the first year of implementation. METHODS: Cross-disciplinary teams of clinic providers and leadership from primary care, pain, and mental health clinics at 18 VA medical facilities received invitations to complete an anonymous, electronic survey prior to intervention launch (baseline) and at 12- month follow-up. Responses were summarized using descriptive statistics, and changes over time were compared using regression models adjusted for gender and prescriber status, and clustered on facility. Responses to open-ended questions were thematically analyzed using a template analysis approach. RESULTS: Survey response rates at baseline and follow-up were 57.1% (56/98) and 50.4% (61/121), respectively. At both time points, most respondents agreed that MOUD delivery is important (94.7 vs. 86.9%), lifesaving (92.8 vs. 88.5%) and evidence-based (85.2 vs. 89.5%). Over one-third (37.5%) viewed MOUD delivery as time-consuming, and only 53.7% affirmed that clinic providers wanted to prescribe MOUD at baseline; similar responses were seen at follow-up (34.5 and 52.4%, respectively). Respondents rated their knowledge about OUD, comfort discussing opioid use with patients, job satisfaction, ability to help patients with OUD, and support from colleagues favorably at both time points. Respondents' ratings of MOUD delivery filling a gap in care were high but declined significantly from baseline to follow-up (85.7 vs. 73.7%, p < 0.04). Open-ended responses identified implementation barriers including lack of support to diagnose and treat OUD and lack of time. CONCLUSIONS: Although perceptions about MOUD generally were positive, targeted education and planning strategies did not improve providers' and clinical leaders' perceptions of MOUD over time. Strategies that improve leaders' prioritization and support of MOUD and address time constraints related to delivering MOUD may increase access to MOUD in non-substance use treatment clinics.

Usability and Acceptability of a Mobile App for the Self-Management of Alcohol Misuse Among Veterans (Step Away): Pilot Cohort Study.

BACKGROUND: Alcohol misuse is common among Operation Enduring Freedom and Operation Iraqi Freedom veterans, yet barriers limit treatment participation. Mobile apps hold promise as means to deliver alcohol interventions to veterans who prefer to remain anonymous, have little time for conventional treatments, or live too far away to attend treatment in person. OBJECTIVE: This pilot study evaluated the usability and acceptability of Step Away, a mobile app designed to reduce alcohol-related risks, and explored pre-post changes on alcohol use, psychological distress, and quality of life. METHODS: This single-arm pilot study recruited Operation Enduring Freedom and Operation Iraqi Freedom veterans aged 18 to 55 years who exceeded National Institute on Alcohol Abuse and Alcoholism drinking guidelines and owned an iPhone. Enrolled veterans (N=55) completed baseline and 1-, 3-, and 6-month assessments. The System Usability Scale (scaled 1-100, ≥70 indicating acceptable usability) assessed the effectiveness, efficiency, and satisfaction dimensions of usability, while a single item (scaled 1-9) measured the attractiveness of 10 screenshots. Learnability was assessed by app use during week 1. App engagement (proportion of participants using Step Away, episodes of use, and minutes per episode per week) over 6 months measured acceptability. Secondary outcomes included pre-post change on heavy drinking days (men: ≥5 drinks per day; women: ≥4 drinks per day) and Short Inventory of Problems-Revised, Kessler-10, and brief World Health Organization Quality of Life Questionnaire scores. RESULTS: Among the 55 veterans enrolled in the study, the mean age was 37.4 (SD 7.6), 16% (9/55) were women, 82% (45/55) were White, and 82% (45/55) had an alcohol use disorder. Step Away was used by 96% (53/55) of participants in week 1, 55% (30/55) in week 4, and 36% (20/55) in week 24. Step Away use averaged 55.1 minutes (SD 57.6) in week 1 and <15 minutes per week in weeks 2 through 24. Mean System Usability Scale scores were 69.3 (SD 19.7) and 71.9 (SD 15.8) at 1 and 3 months, respectively. Median attractiveness scores ranged from 5 to 8, with lower ratings for text-laden screens. Heavy drinking days decreased from 29.4% (95% CI 23.4%-35.4%) at baseline to 16.2% (95% CI 9.9%-22.4%) at 6 months (P<.001). Likewise, over 6 months, Short Inventory of Problems-Revised scores decreased from 6.3 (95% CI 5.1-7.5) to 3.6 (95% CI 2.4-4.9) (P<.001) and Kessler-10 scores decreased from 18.8 (95% CI 17.4-20.1) to 17.3 (95% CI 15.8-18.7) (P=.046). Changes were not detected on quality of life scores. CONCLUSIONS: Operation Enduring Freedom and Operation Iraqi Freedom veterans found the usability of Step Away to be acceptable and engaged in the app over the 6-month study. Reductions were seen in heavy drinking days, alcohol-related problems, and Kessler-10 scores. A larger randomized trial is warranted to confirm our findings.

Primary Care and Mental Health Prescribers, Key Clinical Leaders, and Clinical Pharmacist Specialists' Perspectives on Opioids and Benzodiazepines.

OBJECTIVE: Due to increased risks of overdose fatalities and injuries associated with coprescription of opioids and benzodiazepines, healthcare systems have prioritized deprescribing this combination. Although prior work has examined providers' perspectives on deprescribing each medication separately, perspectives on deprescribing patients with combined use is unclear. We examined providers' perspectives on coprescribed opioids and benzodiazepines and identified barriers and facilitators to deprescribing. DESIGN: Qualitative study using semistructured interviews. SETTING: One multisite Veterans Affairs (VA) healthcare system in the United States of America. SUBJECTS: Primary care and mental health prescribers, key clinical leaders, clinical pharmacist specialists (N = 39). METHODS: Interviews were audio-recorded, transcribed, and analyzed using thematic analysis. Themes were identified iteratively, through a multidisciplinary team-based process. RESULTS: Analyses identified four themes related to barriers and facilitators to deprescribing: inertia, prescriber self-efficacy, feasibility of deprescribing/tapering, and promoting deprescribing, as well as a fifth theme, consequences of deprescribing. Results highlighted the complexity of deprescribing when multiple prescribers are involved, a need for additional support and time, and concerns about patients' reluctance to discontinue these medications. Facilitators included agreement with the goal of deprescribing and fear of negative consequences if medications are continued. Providers spoke to how deprescribing efforts impaired patient-provider relationships and informed their decisions not to start patients on these medications. CONCLUSIONS: Although providers agree with the goal, prescribers' belief in a limited deprescribing role, challenges with coordination among prescribers, concerns about insufficient time and patients' resistance to discontinuing these medications need to be addressed for efforts to be successful.

Feasibility of a care management approach for complex substance use disorders and high acute services utilization.

Although care management approaches have potential to improve clinical outcomes and reduce healthcare costs, little is known about the feasibility of these interventions in patients with complex substance use disorders (SUDs), which are characterized by psychosocial, psychological and/or medical needs and high acute healthcare utilization. We assessed the feasibility of recruitment, treatment engagement, compliance with follow-up assessments, and patients' use of a care management model (CMM) at one medical center. This pilot study enrolled patients with complex SUDs and high healthcare utilization in a prospective, 1-year open trial of a CMM adapted for specific needs of this patient population. Patients completed baseline assessment, monthly assessments of treatment progress and follow-up assessments at 6- and 12-months. Patients' use of CMM services were abstracted from medical records. Of 33 eligible patients approached, 23 (69.6%) men enrolled in the study. Approximately 59.1% of patients attended a CMM visit in ≥8 of 12 months enrolled. Patients completed monthly assessments in 4.9 (SD = 3.1) of 12 months enrolled, and 68.2% and 41.0% completed 6- and 12-month follow-up assessments, respectively. The most common CMM service delivered was care coordination/case management, followed by supportive counseling, motivational interviewing, and medication management. Recruitment and engagement results suggest that use of CMM for complex SUDs and high healthcare utilization is feasible. More robust outreach services may be needed to increase engagement among those who did not engage or lost contact with the CMM team. Additional research is needed to evaluate if CMM enhances retention, improves outcomes and reduces acute healthcare utilization of patients with complex SUDs.

Patients' perspectives on care management services for complex substance use disorders.

Although care management approaches have potential to improve clinical outcomes and reduce high health care costs of patients with complex substance use disorders, characterized by high psychosocial, psychological, and/or medical needs and high acute health care utilization, little is known about patients' perspectives or experiences with these interventions. The objectives of this study were to identify barriers and facilitators to patient engagement in care management services for complex substance use disorders from patients' perspectives. This pilot study invited 22 men with complex substance use disorders and high health care utilization who were enrolled in a 1-year open trial of a Care Management Model to complete semi-structured interviews at 1- and 3-months post-baseline. Interviews were recorded, transcribed, and analyzed using template analysis. Five themes related to engagement were identified: barriers to conventional substance use disorder treatment, facilitators of care management services, patient-provider relationship, patient-related factors, and enhancements to a Care Management Model. Results highlighted the importance of the patient-provider relationship, individual visits with providers, flexible and personalized treatment, and a focus on recovery over abstinence in promoting patient engagement in care management services. Results also highlighted a need for increased outreach and assistance with housing and transit to treatment. Patients' perspectives support key elements of the care management services that are designed to facilitate patient engagement and suggest the need for additional outreach and assistance with obtaining shelter and transportation. Additional research is needed to evaluate if care management approaches enhance retention, improve outcomes, and reduce health care utilization of patients with complex and chronic substance use disorders.

Survey of Primary Care and Mental Health Prescribers' Perspectives on Reducing Opioid and Benzodiazepine Co-Prescribing Among Veterans.

Background: Due to the involvement of opioids and benzodiazepines in rising pharmaceutical overdoses, a reduction in coprescribing of these medications is a national priority, particularly among patients with substance use disorders and other high-risk conditions. However, little is known about primary care (PC) and mental health (MH) prescribers' perspectives on these medications and efforts being implemented to reduce coprescribing. Design: An anonymous survey. Setting: One multisite VA health care system. Subjects: Participants were 55 PC and 31 MH prescribers. Methods: Survey development was guided by the Promoting Action on Research Implementation in Health Services (PARIHS) conceptual framework. PC and MH prescribers of opioids or benzodiazepines were invited to complete an anonymous electronic survey. Responses were collapsed to highlight agreement, disagreement, and neutrality and summarized with means and percentages. Results: Over 80% of both prescriber groups reported concern about concurrent use and > 75% strongly agreed with clinical practice guidelines (CPG) that recommend caution in coprescribing among patients with high-risk conditions. More than 40% of both prescriber groups indicated that coprescribing continues because of beliefs that patients appear stable without adverse events and tapering/discontinuation is too difficult. Over 70% of prescribers rated strategies for addressing patients who refuse to discontinue, more time with patients, and identification of high-risk patients as helpful in reducing coprescribing. Conclusion: Despite strong agreement with CPGs, prescribers reported several barriers that contribute to coprescribing of opioids and benzodiazepines and challenge their ability to taper these medications. Multiple interventions are likely needed to reduce opioid and benzodiazepine coprescribing.