Literature Collection

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.

BACKGROUND: Opioid use disorder (OUD), a chronic disease, is a major public health problem. Despite availability of effective treatment, too few people receive it and treatment retention is low. Understanding barriers and facilitators of treatment access and retention is needed to improve outcomes for people with OUD. OBJECTIVES: To assess 3-month outcomes pilot data from a patient-centered OUD treatment program in Iowa, USA, that utilized flexible treatment requirements and prioritized engagement over compliance. METHODS: Forty patients (62.5% female: mean age was 35.7 years, SD 9.5) receiving medication, either buprenorphine or naltrexone, to treat OUD were enrolled in an observational study. Patients could select or decline case management, counseling, and peer recovery groups. Substance use, risk and protective factors, and recovery capital were measured at intake and 3 months. RESULTS: Most participants reported increased recovery capital. The median Assessment of Recovery Capital (ARC) score went from 37 at enrollment to 43 (p < 0.01). Illegal drug use decreased, with the median days using illegal drugs in the past month dropping from 10 to 0 (p < 0.001). Cravings improved: 29.2% reported no cravings at intake and 58.3% reported no cravings at 3 months (p < 0.001). Retention rate was 92.5% at 3 months. Retention rate for participants who were not on probation/parole was higher (96.9%) than for those on probation/parole (62.5%, p = 0.021). CONCLUSION: This study shows preliminary evidence that a care model based on easy and flexible access and strategies to improve treatment retention improves recovery capital, reduces illegal drug use and cravings, and retains people in treatment.

OBJECTIVE: This study examined factors related to retention in buprenorphine treatment for opioid use disorder (OUD) among privately insured patients. METHODS: Patients with OUD who were newly started on buprenorphine during federal fiscal year (FY) 2011 were identified in a national private insurance claims database (MarketScan), and treatment retention (filled buprenorphine prescriptions) was evaluated through FY 2014. Proportional hazards models were used to examine demographic, clinical, and service use characteristics in FY 2011, including ongoing insurance coverage, associated with discontinuation of treatment. RESULTS: Of 16,190 patients with OUD newly started on buprenorphine in FY 2011, 45.0% were retained in treatment for more than one year, and 13.7% for more than three years (mean+/-SD duration of retention=1.23+/-1.16 years). During the first three years after buprenorphine initiation, 49.3% (N=7,988) disenrolled from their insurance plan. Cox proportional hazards models showed that for every 30 days of enrollment, the risk of discontinuation declined by 10% (hazard ratio [HR]=.90, 95% confidence interval [CI]=.90-.91). FY 2011 factors reducing discontinuation risk were age greater than the median (HR=.90, CI=.87-.93) and receipt of outpatient psychotherapy (HR=.90, CI=.86-.92); increased risk was associated with psychiatric hospitalization (HR=1.30, CI=1.24-1.36), emergency department visits (HR=1.07, CI=1.04-1.14), and additional substance use disorders (HR=1.05, CI=1.01-1.10). CONCLUSIONS: Buprenorphine treatment retention declined markedly in the first year and was substantially lower than in comparable studies from publicly funded health care systems, apparently largely due to disenrollment. The association of psychotherapy with greater retention suggests that it may be an important complement to opioid agonist treatment.

INTRODUCTION: Cigarette smoking rates among individuals with opioid use disorder (OUD) are notoriously high and may be improved by considering the timing of treatment integration for these two substances. The current study examined the feasibility of a method for assessing the timing of integrating smoking cessation pharmacotherapy within three different phases of outpatient treatment with medication for OUD (MOUD). METHODS: Seventy-four buprenorphine-maintained smokers were enrolled in a quasi-experimental study across three MOUD treatment phases: 0-90 (Phase 1), 91-365 (Phase 2), and > 365 days of MOUD treatment (Phase 3). During a 12-week varenicline-based intervention, the study assessed outcomes daily via text messages (cigarette smoking, varenicline adherence, side effects) or monthly at in-person visits (quit motivation and carbon monoxide levels). RESULTS: Thirty-five participants completed the study, with a lower retention rate in Phase 1 (37.5%) relative to Phases 2 (53.5%) or 3 (57.1%). A trend occurred for Phase 1 participants to report aversive side effects (e.g., abnormal dreams, gastrointestinal distress) on more study days. Among completers, adherence to text messaging and varenicline use was high and independent of MOUD treatment phase. Participants in all phases reported declines in cigarette smoking and increases in quit motivation over time; the study observed biochemically verified tobacco abstinence among only a few participants from Phases 2 or 3. CONCLUSIONS: This feasibility study demonstrates a method to evaluate the timing of treatment integration for cigarette smoking and MOUD. Method strengths include a study schedule that coincided with the MOUD clinic schedule and use of text messaging to encourage varenicline adherence and evaluate outcomes regularly.

Part 1: An introduction to medications for the treatment of opioid use disorder. The approach to OUD care -- Overview of medications for OUD -- Duration of treatment with OUD medication -- Treatment settings -- Challenges to expanding access to OUD medication -- Resources -- Notes -- Part 2: Addressing opioid use disorder in general medical settings. Scope of the Problem -- Screening -- Assessment -- Treatment planning or referral -- Resources -- Appendix -- Notes -- Part 3: Pharmacotherapy for opioid use disorder. Pharmacotherapy for opioid use disorder -- Overview of pharmacotherapy for opioid use disorder. Methadone -- Naltrexone -- Buprenorphine -- Medical management strategies for patients taking OUD medications in office-based settings -- Medical management of patients taking OUD medications in hospital settings -- PART 4: Partnering addiction treatment counselors with clients and healthcare professionals. Overview and context -- Quick guide to medications -- Counselor-prescriber communications -- Creation of a supportive counseling experience -- Other common counseling concerns -- Notes -- Part 5: Resources related to medications for opioid use disorder. General Resources -- Resources for counselors and peer providers -- Resources for clients and families -- Provider tools and sample forms -- Glossary of TIP terminology -- Notes

BACKGROUND: The prevalence of opioid use disorder (OUD) has increased sharply. Office-based opioid treatment with buprenorphine (OBOT) is effective but often underutilized because of physicians' lack of experience prescribing this therapy. Little is known about US residency training programs' provision of OBOT and addiction medicine training. METHODS: The authors conducted a survey of residency program directors (RPDs) at all US residency programs in internal medicine, family medicine, and psychiatry to assess the frequency with which their residents provide care for OUD, presence and features of curricula in OBOT and addiction medicine, RPDs' beliefs about OBOT, and potential barriers to providing OBOT training. RESULTS: The response rate was 49.5% (476 of 962). Although 76.9% of RPDs reported that residents frequently manage patients with OUD, only 23.5% reported that their program dedicates 12 or more hours of curricular time to addiction medicine, 35.9% reported that their program encourages/requires training in OBOT, and 22.6% reported that their program encourages/requires obtaining a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine. Most RPDs believe that OBOT is an important treatment option for OUD (88.1%) and that increased residency training in OBOT would improve access to OBOT (73.7%). The authors also found that programs whose RPD had favorable views of OBOT were more likely to provide OBOT and addiction medicine training. Psychiatry programs were most likely to provide OBOT training and their RPDs most likely to have beliefs about OBOT that were positive. Commonly cited barriers to implementing OBOT training include a lack of waivered preceptors (76.9%), competing curricular priorities (64.1%), and a lack of support (social work and counseling) services (54.0%). CONCLUSIONS: Internal medicine, family medicine, and psychiatry residents often care for patients with OUD, and most RPDs believe that increased residency training in OBOT would increase access to this treatment. Yet, only a minority of programs offer training in OBOT.