“UNC Extension for Community Healthcare Outcomes for Rural Primary Care Medication-Assisted Treatment (UNC ECHO for MAT),” University of North Carolina at Chapel Hill.
Key Lessons Learned in Medication-Assisted Treatment Implementation
- MAT Experience: Barriers and Perceived Impact
- Several midlevel providers faced challenges or delays finding a doctor willing to supervise MAT.
- The role of and emphasis placed on the psychosocial support component of MAT varied considerably across clinics. For example, federally qualified health centers (FQHCs) commonly reported having integrated behavioral health services onsite, whereas clinicians in other settings provided referrals to community-based addiction counselors with varying degrees of success.
- Some providers across settings shared that the group counseling approach was effective for this population because patients receive counseling and peer support simultaneously.
- Prescribers shared the following conditions that made MAT more effective: higher patient motivation, family/friend support, access to transportation and proximity to provider, patient honesty.
- Prescribers identified the following conditions associated with lower effectiveness of MAT: polysubstance abuse (especially methamphetamine in certain methamphetamine hot spots) and environments that repeatedly expose the patient to substance-use temptations.
- Providers expressed more concerns and uncertainty around MAT induction than MAT maintenance. Several had not yet induced a patient.
- Providers consistently reported embracing the harm-reduction model, especially in the FQHC setting.
- Many providers were surprised that MAT patients were particularly inspiring to work with because they often demonstrated substantial improvements in their lives, both in physical health and socially (e.g., restoring family relationships). Primary care providers said they often do not get to see this result with other patients.
- Provider Experience: ECHO for MAT Intervention
- Several providers reported recently joining the ECHO clinics (in 2019) and subsequently attending frequently.
- Providers who participated in ECHO for MAT clinics consistently found them helpful and informative, also reporting satisfaction with the range of topics covered.
- Rural MAT providers found the ECHO virtual community a source of peer support, when they would otherwise feel isolated. They found it encouraging and comforting to know that providers of all levels of experience were struggling with similar challenges in treating opioid use disorder (OUD) patients.
- Some providers cited the mid-day timing of the ECHO clinics as a barrier, preferring an early morning option. UNC ECHO for MAT originally only had a once per week mid-day ECHO clinic. They now have four events at UNC, including at other times of the day, and have worked with Mountain Area Health Education Center to sponsor other ECHO clinics, including an early morning option.
- Provider awareness of the ECHO practice coaching and clinical mentorship options was limited in the beginning, but as they engage, their awareness and value of this service increases. Providers who use coaching support services reported being satisfied with the assistance provided.
- Barriers for Patients Seeking or Receiving Medication-Assisted Treatment as Reported by Practices and Practice Coaches:
- Payment concerns
- Pharmacy not stocking buprenorphine (also requiring documentation of pregnancy or allergy for the mono-product)
- Confidentiality (small community)
- Treatment visits or behavioral health requirements conflicting with work
- Urine toxicology screening (observed or unobserved)
- Medication reconciliation (required to return between visits)
- Expectation that tapering from the medication will occur after a specified timeframe
- Provider/pharmacy lock-in
- Patients needing integrated care for MAT and primary care
- Barriers for MAT Providers as Reported by Practice Coaches and Providers Enrolled:
- Advanced practice professional providers lacking available supervision
- Several hospital systems not supporting MAT
- Lack of behavioral health providers
- Bias/stigma in community/health systems/leadership
- Pharmacies not stocking buprenorphine (also requiring documentation of pregnancy or allergy for the mono-product)
- Difficulty with DATA 2000 paperwork
- Time constraints/too busy
- Reimbursement concerns
- Lack of specialty backup
- Diversion concerns
- Drug Enforcement Administration intrusion/concerns
- Providers getting waivers and then resigning
- Lack of referrals
- Grant dependence to treat patients needing MAT who do not have the means to cover costs of care/prescriptions
For the 44 counties supported by grantee:
- 201 enrolled
- 126 waivers completed (5 more completed ECHO waiver training but do not waiver)
- 81 prescribing
With North Carolina Department of Health and Human Services support to expand AHRQ model to reach 100 counties:
- 401 enrolled
- 204 waivers completed (6 more completed ECHO waiver training but do not have waiver)
- 84 prescribing
In the News
- Clinical Expert and ECHO Hub Team Member, Dr. Jana Burson’s blog (Available at https://janaburson.wordpress.com/)
- HealthPayer Intelligence – How Major Payers Provide Substance Abuse Care for Opioid Misuse (Available at https://healthpayerintelligence.com/news/how-major-payers-provide-substance-abuse-care-for-opioid-misuse)
- Becker’s Hospital Review – Telemedicine: A force multiplier in fighting the opioid epidemic (Available at https://www.beckershospitalreview.com/telehealth/telemedicine-a-force-multiplier-in-fighting-the-opioid-epidemic.html)
- North Caroline Medical Board – Getting Started With MAT
- North Carolina AHEC – NC AHEC Trainings Help Put Recovery Within Reach – Medication-Assisted Treatment Trainings Offered Across North Carolina
- ASAM e-Learning Center: Treatment of Opioid Use Disorder – Waiver Qualifying-8 Hours Online - UNCAHRQ
- UNC Chapel Hill – News From Carolina – UNC-Chapel Hill Initiative Will Combat Opioid Use Disorders and Overdose Deaths
- There have been 209 ECHO clinic sessions supported by UNC ECHO for MAT from June 21, 2017, to August 28, 2019.
- On average, nine spokes participated in each clinic.
- For AHRQ-supported services and counties, 124 providers, who serve patients from the 44 counties, attended ECHO clinics.
- With a State match, the grantee expanded its reach and number of clinics, and from all 100 counties, 248 providers attended ECHO clinics.
- Through the AHRQ grant, UNC ECHO for MAT started conversations at all levels in the State, including communities; various professions and professional groups; and local, county, and State-level stakeholders, about OUD and evidence-based care, including MAT.
- Team members have presented information on MAT, OUD, stigma, approaches to evidence-based care, and UNC ECHO for MAT at more than 207 conferences, professional meetings, regional healthcare events, county or regional opioid task force meetings, health network meetings, tribal events, community forums, and county, regional, and State summits.
- Through these multilayered, far-reaching efforts to provide information and encourage dialogue about OUD and MAT, the UNC ECHO for MAT team members have raised awareness about MAT and treatment options overall for people struggling with opioid use.
- Faculty and staff have provided group, practice-level, and one-to-one education and information to counter stigma and misinformation.
- The UNC ECHO for MAT clinic, coaching, education, and training model for provider support and the grantee’s approaches have been adopted by other North Carolina entities offering services.
- Some of the faculty engaged with UNC ECHO have started spinoff projects that support, link with, and expand reach of the AHRQ grant.
- Data and findings from interviews are being used by State partners and other community leaders in their own grant applications and policy work.
- Recent published State surveillance data suggest a decrease in the number of overdose deaths in North Carolina for the first time in 5 years. UNC ECHO has been one part of many intervention efforts in the State (https://www.newsobserver.com/news/politics-government/article234547277.html.
Conferences & Publications
|North Carolina Medical Board Digital Forum||August 2019||Raleigh, NC|
|International Health Economics Association Annual Meeting||July 2019||Basel, Switzerland|
|Mountain Area Health Education Center Drug Users Summit||May 2019||Asheville, NC|
|North Carolina Addiction Medicine Fall Conference||November 2018||Asheville, NC|
|American College of Healthcare Executives/GCHEG* F2F Event||November 2018||Charlotte, NC|
|American Public Health Association||November 2018||San Diego, CA|
|4th Annual Sickle Cell Symposium||October 2018||Concord, ND/td>|
|NC OPDAAC State Meeting†||September 2018||Raleigh, NC|
|North Carolina Addiction Medicine Conference||April 2018||Asheville, NC|
|Mecklenburg County Opioid Summit||March 2018||Charlotte, NC|
|North Carolina Opioid Misuse and Overdose Prevention Summit||June 2017||Raleigh, NC|
|Parents and Family Recovery Annual Meeting||April 2017||Newport Beach, CA|
|American Academy of Addiction Psychiatry||December 2017||San Diego, CA|
Oral Presentation Poster
* Greater Charlotte Health Executives Group.
† North Carolina Opioid and Prescription Drug Abuse Advisory Committee.
- Gertner AK, Rotter JS, Holly ME, Shea CM, Green SL, Domino ME. The Role of Primary Care in the Initiation of Opioid Use Disorder Treatment in Statewide Public and Private Insurance. Journal of Addiction Medicine. 2021 May 10.
- Cole ES, DiDomenico E, Green S, Heil SKR, Hilliard T, Mossburg SE, Sussman AL, Warwick J, Westfall JM, Zittleman L, Salvador JG. 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. Subst Abus. 2021;42(2):123-129. doi: 10.1080/08897077.2021.1891492. Epub 2021 Mar 9. PMID: 33689594.
- Shea CM, Gertner AK, Green SL. Barriers and perceived usefulness of an ECHO intervention for office-based buprenorphine treatment for opioid use disorder in North Carolina: a qualitative study. Substance abuse. 2019 Dec 6:1-1.