“MAT Expansion in Rural Oklahoma,” American Institutes for Research (AIR) in partnership with the State of Oklahoma.
Key Lessons Learned in Medication-Assisted Treatment Implementation
- Provider Recruitment: While recruitment was anticipated to be a challenge, it was more challenging and took longer than anticipated to identify and engage interested clinicians. Sometimes seeds laid with clinicians and practices about obtaining a waiver and using medication to treat patients with OUD take months of exposure to take root and yield interest. Ongoing periodic follow-up with providers who express interest but experience delays in pursuing or obtaining the waiver ensures that support is waiting for the provider when they are ready to proceed.
- DEA Waivers: Federal regulations implemented just prior to the start of the grant opened the ability to obtain a waiver to a larger body of clinicians. However, parties who want to implement MAT need to understand State or local policies or requirements (e.g., exclusionary formularies, supervisory requirements for nurse practitioners or physician assistants). In some cases, these may present barriers to clinicians’ ability to prescribe medications for OUD.
- High Staff Turnover: The high amount of clinician turnover is a challenge to retaining qualified providers in practices that are already stretched thin.
- Engagement: Engagement is highly variable. Ongoing outreach/contact may be needed to ensure training is progressing and clinicians are moving toward treating patients.
- Change May Be Small Scale, but Still Locally Important: The yield of patients served in some cases is not high; in rural primary care, some OklahomaMAT participating providers obtained the 30 person waiver and were not interested in expanding beyond that limit. While many implementation projects foster large scale change, the changes may be smaller scale in rural primary care expansion of MAT/MOUD, but equally as relevant to the practice and local community served.
- Mentorship: Mentorship is a rich strength of this kind of program; providers value it but don’t always know to ask for it or feel comfortable asking. Proactive outreach by mentors helps build trust and openness to make the most of this resource.
- Seventy-seven participants enrolled, with 49 still participating at the end of the grant (“active participants”). Among active participants, 38 completed training and 33 obtained the waiver required to prescribe buprenorphine-based medications to treat patients with OUD. Four additional providers completed training and obtained a waiver, but subsequently withdrew from the program. The project also further supported the required waiver-qualifying training for approximately 20 additional Oklahoma clinicians who were not Oklahoma MAT participants, but lived in proximity to in-person trainings sponsored by the project Oklahoma.
- Among the 33 waivered OklahomaMAT providers still participating at the end of the grant, 22 (67%) reported actively treating patients. With the exclusion of one outlier who was treating 96 patients at the end of the grant, the 22 treating providers were treating, on average, 10.9 patients.
- At least 324 patients with OUD were being treated by OklahomaMAT providers by the end of the grant. Further, there is capacity to treat as many as 1,360 patients if the 22 waivered providers who are already seeing patients treated to the capacity of their respective waiver limits.
- More than 40 percent of the 82 patients consenting to share medical records had a co-morbid pain diagnosis. This is perhaps reflective of the impact of years of high opioid pain prescribing in the State so severe that the State’s litigation against the pharmaceutical industry served as a contextual backdrop for most of the grant period.
- Patients appear to be meeting the goals of retention in treatment, relapse prevention, and maintenance of recovery. Among those for whom we have medical records, half of the patients began seeing their MAT provider 6 months or more prior to medical record extraction, and among these, 73 percent remained in treatment for at least 6 months. Patients are adhering to treatment; 92 percent of completed Urine drug screens (UDSs) that tested for buprenorphine or norbuprenorphine showed a positive result. Further, only 15 percent of UDSs were positive for opiates, indicating that most patients are not continuing to use opioids.
- Provider engagement in the OklahomaMAT program was positively associated with provider self-efficacy and belief in the evidence base for MAT.
- Providers in single-site practices with a singular focus on primary care were the least likely to have been waivered by the end of the study, as well as the least likely among waivered providers to have started treating patients. Of 16 providers in single-site, primary-care-only practices, 44 percent completed the waiver. Among the 33 providers in practices of other size and specialty combinations, 78 percent completed the waiver. Similarly, 43 percent of waivered providers in single-site, primary-care-only practices were treating patients by the end of the study, and 73 percent of all other waivered providers were treating patients.
- Demonstrating evidence of provider commitment to MAT and its sustainability in the local community, 11 of the 22 providers who were treating patients by the end of the grant had expanded their waiver capacity limit.
In the News
- Modern Healthcare – Building a Lifeline for Rural Addicts (Available at https://www.modernhealthcare.com/article/20161001/MAGAZINE/310019940/building-a-lifeline-for-rural-addicts)
- KOCO-TV – State of Addiction: Grant to Help Treat Opioid Addiction in Rural Oklahoma (Available at https://www.koco.com/article/state-of-addiction-grant-to-help-treat-opioid-addiction-in-rural-oklahoma/9601721)
- Capitol Hill Briefing – Using Data to Drive Community-based Approaches to the Opioid Crisis
- The OklahomaMAT program has contributed to a 400% increase in the number of providers in our counties of focus who are waivered to treat OUD using buprenorphine-based medications. Although we are not the only initiative contributing to this increase, Oklahoma MAT providers account for about 28% of the increase in waivered providers since the program began. In six of our counties of focus, an Oklahoma MAT provider is the only waivered provider in the county.
- The OklahomaMAT grant has laid a foundation for AIR CARES staff to work with other states and entities in expanding access to MAT, including: 1) MAT training and technical assistance for the Nevada Primary Care Association’s contributions to Nevada’s State Opioid Response (SOR) grant, expanding MAT capacity in Federally Qualified Health Centers; and 2) an Office Based Opioid Treatment (OBOT) Fellowship Program component of a SUPPORT Act planning grant to the State of Delaware’s Division of Medicaid and Medical Assistance.
Conferences & Publications
|Rx Drug Abuse & Heroin Summit||April 8, 2021||Online|
|AcademyHealth Annual Research Meeting||July 28 - August 6, 2020||Online|
|AcademyHealth National Health Policy Conference||February 10, 2020||Washington, DC|
|North American Primary Care Research Group (NAPCRG) Annual Meeting||November 18, 2019||Toronto, CA|
|AcademyHealth Medicaid Medical Directors Network Annual Fall Meeting||September 17, 2019||Washington, DC|
|AcademyHealth Annual Research Meeting||June 24, 2018||Seattle, WA|
|CMS Quality Conference||February 13, 2018||Baltimore, MD|
|APHA Annual Meeting||November 5, 2017||Atlanta, GA|
Oral Presentation Poster
- 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.