The who, the what, and the how: A description of strategies and lessons learned to expand access to medications for opioid use disorder in rural America.

Access to treatment for opioid use disorder (OUD) in rural areas within the United States remains a challenge. Providers must complete 8-24 h of training to obtain the Drug Addiction Treatment Act (DATA) 2000 waiver to have the legal authority to prescribe buprenorphine for OUD. Over the last 4 years, we executed five dissemination and implementation grants funded by the Agency for Healthcare Research and Quality to study and address barriers to providing Medications for Opioid Use Disorder Treatment (MOUD), including psychosocial supports, in rural primary care practices in different states. We found that obtaining the DATA 2000 waiver is just one component of meaningful treatment using MOUD, and that the waiver provides a one-time benchmark that often does not address other significant barriers that providers face daily. In this commentary, we summarize our initiatives and the common lessons learned across our grants and offer recommendations on how primary care providers can be better supported to expand access to MOUD in rural America.

The Role of Primary Care in Improving Access to Medication-Assisted Treatment for Rural Medicaid Enrollees with Opioid Use Disorder.

BACKGROUND: The opioid epidemic has disproportionately affected rural areas, where a limited number of health care providers offer medication-assisted treatment (MAT), the mainstay of treatment for opioid use disorder (OUD). Rural residents with OUD may face multiple barriers to engagement in MAT including long travel distances. OBJECTIVE: To examine the degree to which rural residents with OUD are engaged with primary care providers (PCPs), describe the role of rural PCPs in MAT delivery, and estimate the association between enrollee distance to MAT prescribers and MAT utilization. DESIGN: Retrospective cohort study. PARTICIPANTS: Medicaid-enrolled adults diagnosed with OUD in 23 rural Pennsylvania counties. MAIN MEASURES: Primary care utilization, MAT utilization, distance to nearest possible MAT prescriber, mean distance traveled to actual MAT prescribers, and continuity of pharmacotherapy. KEY RESULTS: Of the 7930 Medicaid enrollees with a diagnosis of OUD, a minority (18.6%) received their diagnosis during a PCP visit even though enrollees with OUD had 4.1 visits to PCPs per person-year in 2015. Among enrollees with an OUD diagnosis recorded during a PCP visit, about half (751, 50.8%) received MAT, most of whom (508, 67.6%) received MAT from a PCP. Enrollees with OUD with at least one PCP visit were more likely than those without a PCP visit to receive MAT (32.7% vs. 25%; p < 0.001), and filled more buprenorphine and naltrexone prescriptions (mean = 11.1 vs. 9.3; p < 0.001). The median of the distances traveled to actual MAT prescribers was 48.8 miles, compared to a median of 4.2 miles to the nearest available MAT prescriber. Enrollees traveling a mean distance greater than 45 miles to MAT prescribers were less likely to receive continuity of pharmacotherapy (OR = 0.71, 95% CI = 0.56-0.91, p = 0.007). CONCLUSIONS: PCP utilization among rural Medicaid enrollees diagnosed with OUD is high, presenting a potential intervention point to treat OUD, particularly if the enrollee's PCP is located nearer than their MAT prescriber.

Provider and Patient-panel Characteristics Associated With Initial Adoption and Sustained Prescribing of Medication for Opioid Use Disorder.

OBJECTIVES: Limited information is available regarding provider- and patient panel-level factors associated with primary care provider (PCP) adoption/prescribing of medication for opioid use disorder (MOUD). METHODS: We assessed a retrospective cohort from 2015 to 2018 within the Pennsylvania Medicaid Program. Participants included PCPs who were Medicaid providers, with no history of MOUD provision, and who treated ≥10 Medicaid enrollees annually. We assessed initial MOUD adoption, defined as an index buprenorphine/buprenorphine-naloxone or oral/extended release naltrexone fill and sustained prescribing, defined as ≥1 MOUD prescription(s) for 3 consecutive quarters from the PCP. Independent variables included provider- and patient panel-level characteristics. RESULTS: We identified 113 rural and 782 urban PCPs who engaged in initial adoption and 36 rural and 288 urban PCPs who engaged in sustained prescribing. Rural/urban PCPs who issued increasingly larger numbers of antidepressant and antipsychotic medication prescriptions had greater odds of initial adoption and sustained prescribing (P < 0.05) compared to those that did not prescribe these medications. Further, each additional patient out of 100 with opioid use disorder diagnosed before MOUD adoption increased the adjusted odds for initial adoption 2% to 4% (95% confidence interval [CI] = 1.01-1.08) and sustained prescribing by 4% to 7% (95% CI = 1.01-1.08). New Medicaid providers in rural areas were 2.52 (95% CI = 1.04-6.11) and in urban areas were 2.66 (95% CI = 1.94, 3.64) more likely to engage in initial MOUD adoption compared to established PCPs. CONCLUSIONS: MOUD prescribing adoption was concentrated among PCPs prescribing mental health medications, caring for those with OUD, and new Medicaid providers. These results should be leveraged to test/implement interventions targeting MOUD adoption among PCPs.

Patterns of clinic switching and continuity of medication for opioid use disorder in a Medicaid-enrolled population.

BACKGROUND: Many persons with opioid use disorder (OUD) initiate medication for opioid use disorder (MOUD) with one clinic and switch to another clinic during their course of treatment. These switches may occur for referrals or for unplanned reasons. It is unknown, however, what effect switching MOUD clinics has on continuity of MOUD treatment or on overdoses. OBJECTIVE: To examine patterns of switching MOUD clinics and its association with the proportion of days covered (PDC) by MOUD, and opioid-related overdose. DESIGN: Cross-sectional retrospective analysis of Pennsylvania Medicaid claims data. MAIN MEASURES: MOUD clinic switches (i.e., filling a MOUD prescription from a prescriber located in a different clinic than the previous prescriber), PDC, and opioid-related overdose. RESULTS: Among 14,107 enrollees, 43.2 % switched clinics for MOUD at least once during the 270 day period. In multivariate regression results, enrollees who were Non-Hispanic black (IRR = 1.43; 95 % CI = 1.24-1.65; p < 0.001), had previous methadone use (IRR = 1.32; 95 % CI = 1.13-1.55; p < 0.001), and a higher total number of office visits (IRR = 1.01; CI = 1.01-1.01; p < 0.001) had more switches. The number of clinic switches was positively associated with PDC (OR = 1.12; 95 % CI = 1.10-1.13). In secondary analyses, we found that switches for only one MOUD fill were associated with lower PDC (OR = 0.97; 95 % CI = 0.95-0.99), while switches for more than one MOUD fill were associated with higher PDC (OR = 1.40; 95 % CI = 1.36-1.44). We did not observe a relationship between opioid-related overdose and clinic switches. CONCLUSIONS: Lack of prescriber continuity for receiving MOUD may not be problematic as it is for other conditions, insofar as it is related to overdose and PDC.

Rural access to MAT in Pennsylvania (RAMP): a hybrid implementation study protocol for medication assisted treatment adoption among rural primary care providers.

BACKGROUND: The continued escalation of opioid use disorder (OUD) calls for heightened vigilance to implement evidence-based care across the US. Rural care providers and patients have limited resources, and a number of barriers exist that can impede necessary OUD treatment services. This paper reports the design and protocol of an implementation study seeking to advance availability of medication assisted treatment (MAT) for OUD in rural Pennsylvania counties for patients insured by Medicaid in primary care settings. METHODS: This project was a hybrid implementation study. Within a chronic care model paradigm, we employed the Framework for Systems Transformation to implement the American Society for Addiction Medicine care model for the use of medications in the treatment of OUD. In partnership with state leadership, Medicaid managed care organizations, local care management professionals, the Universities of Pittsburgh and Utah, primary care providers (PCP), and patients; the project team worked within 23 rural Pennsylvania counties to engage, recruit, train, and collaborate to implement the OUD service model in PCP practices from 2016 to 2019. Formative measures included practice-level metrics to monitor project implementation, and outcome measures involved employing Medicaid claims and encounter data to assess changes in provider/patient-level OUD-related metrics, such as MAT provider supply, prevalence of OUD, and MAT utilization. Descriptive statistics and repeated measures regression analyses were used to assess changes across the study period. DISCUSSION: There is an urgent need in the US to expand access to high quality, evidence-based OUD treatment-particularly in rural areas where capacity is limited for service delivery in order to improve patient health and protect lives. Importantly, this project leverages multiple partners to implement a theory- and practice-driven model of care for OUD. Results of this study will provide needed evidence in the field for appropriate methods for implementing MAT among a large number of rural primary care providers.