Purpose
Care of patients with opioid use disorder (OUD) is a natural fit for primary care and its fundamental strengths: respect for the patient, long-term clinical relationships, non-stigmatizing support, a degree of comfort with uncertainty, and a focus on whole-person care.1,2,3,4
All that is missing is a prescription for buprenorphine.
But we know things are not that simple. In 2017, fewer than 10 percent of primary care clinicians prescribed buprenorphine for OUD.5,6,7 Many studies have examined the barriers clinicians face in providing treatment for patients with OUD. Clinicians frequently cite logistical issues, including lack of time and support from staff, concerns about insurance reimbursement, need for prior authorizations, and regulatory factors, as common barriers to providing care for patients with OUD.8,9,10,11 One regulatory barrier, obtaining an X waiver to prescribe buprenorphine for patients with OUD, has been legally removed as of December 2022.12,13
Thousands of people are dying for lack of treatment and yet providers say there is no demand for treatment.14 People with OUD are harmed every day even as they desperately try to access prescribed buprenorphine.15 Adjusted estimates suggest past-year OUD affected over 7.5 million individuals in the U.S., but only 13% received FDA-approved medications.16 How can this circumstance be seen as “lack of patient demand” in primary care? When asked about the drivers of the OUD treatment gap, patients frequently cited stigma, prior negative experiences with OUD treatment, high out-of-pocket costs, and logistical issues, including difficulty finding a buprenorphine provider, provider waiting lists, and delays in buprenorphine initiation.17,18,19 Patients anticipate being rejected and do not trust healthcare to work for them.20,21
Low-threshold treatment addresses those deeper barriers that remain. By keeping its focus on patient health and safety, low-threshold treatment emphasizes medication for opioid use disorder (MOUD) through the removal of barriers, which allows profound healing to happen in the primary care setting. To get started, we need patients who trust primary care to help, and clinicians who will do so.
This brief provides an overview of what constitutes low-threshold treatment for patients with OUD, the state of the evidence and patient perspectives on low-threshold OUD treatment, and key steps and strategies for providing low-threshold treatment for patients with OUD in primary care settings. Additionally, this brief outlines recommendations for how policymakers can improve and expand the provision of low-threshold treatment for patients with OUD in primary care settings.
Low-threshold treatment emphasizes removing the barriers common to conventional OUD treatment and ensuring equitable access to care and treatment. Low-threshold approaches prioritize a “medication first” approach to buprenorphine; harm reduction, according to the principles described below in Figure 1; individualized psychosocial support; and caring, long-term clinical relationships.
Low-threshold treatment is based on the principles of harm reduction, as shown in Figure 1. Putting this into practice, key components of low-threshold treatment programs for patients with OUD include:22,23,24,25,26
- Prompt (same-day) initiation of buprenorphine prior to lengthy assessments or treatment planning sessions.
- Maintenance buprenorphine delivery without arbitrary tapering or time limits.
- Offering—but never requiring—individualized psychosocial services.
- Buprenorphine continuation based solely on the patient's clinical circumstances; positive tests for illicit substances should not result in discontinuation of buprenorphine.
- Flexibility in dosing, protocols, policies, and workflows for initiating and maintaining buprenorphine therapy.
- Availability in settings that best meet patient needs, such as primary and ambulatory care, mobile treatment sites, syringe exchange programs, and telehealth.
Benefits of low-threshold programs for patients with OUD, as outlined in the final column of Figure 1, include greater access, improved retention, and reduced overdose rate, and are supported by substantial scientific evidence (see next section).
Treatment as usual for patients with OUD too often includes high-threshold practices and rigid protocols, processes, and workflows that decrease retention in care. These approaches have served as barriers to treatment initiation and led to high rates of treatment discontinuation. Over a decade of research on low-threshold treatment for patients with OUD has demonstrated how this approach to care can improve equity and access to buprenorphine, especially for people of color, justice-involved individuals, and people experiencing homelessness, and can have more successful outcomes:27,28,29,30,31
- Prompt (same-day) treatment initiation of buprenorphine improves enrollment rates compared to treatment as usual (i.e., delaying initiation of MOUD).32,33,34
- Removal of abstinence requirements in OUD treatment has produced similar outcomes to treatment as usual (i.e., discontinuing MOUD due to drug tests finding non-prescribed substances).35,36,37
- Increased flexibility in regulations related to the use of telehealth for buprenorphine prescribing (initiated in response to the COVID-19 pandemic) has increased access to buprenorphine and may have comparable retention rates and outcomes as face-to-face treatment.38,39,40,41,42,43
- Optional psychosocial services during buprenorphine therapy can have similar or better outcomes to treatment as usual (i.e., requiring counseling and other behavioral interventions).44,45
- Provision of buprenorphine therapy in non-traditional settings such as syringe exchange programs, mobile health clinics, shelters, and on the street can improve patient engagement in treatment and may have comparable retention rates and outcomes as treatment as usual (i.e., provision of buprenorphine therapy in office-based settings).46,47,48,49,50,51,52,53,54,55
- Compared with treatment as usual (i.e., primary care services with external referral to substance use treatment), buprenorphine treatment along with safer injection and wound care equipment kits, reduced mortality, extended life expectancy, and was cost-effective.56
Understanding patient perspectives and expectations is especially important with a stigmatized condition like OUD.57,58,59 Patient satisfaction with a given program is correlated with longer retention in care.60,61 Several studies have documented that patients appreciate low-threshold care, specifically the following aspects:
- Fast access to treatment (e.g., prompt (same-day))62
- Alternative options to standard transitions to buprenorphine (i.e., low dose and high dose)63
- Assistance with securing childcare, transportation, and treatment openings64
- Support with pharmacy provision of buprenorphine and limiting trips to pharmacy65
- Reduced burdensome intake procedures66
- Supporting patient goals, even if those goals do not include abstinence67
- An individualized, collaborative approach68
- Understanding unique patient goals and helping them succeed69
- Harm reduction through Naloxone provision70
- Financial coverage of services71
- A non-stigmatizing approach by the program72
- Peer support services73
1. If Nothing Else, Start Prescribing Buprenorphine
There is no reason that buprenorphine should not be a normal part of primary care practice. Buprenorphine is an effective medication that saves lives, reducing the likelihood of overdose death for people with OUD by 82 percent.74,75,76 While psychosocial and behavioral therapies can be beneficial in conjunction with buprenorphine treatment, good outcomes can also be achieved from buprenorphine treatment without them.77,78,79 Even with increased prescribing rates, misuse and diversion of buprenorphine remain low.80,81,82 Treating OUD the same as any other chronic medical condition with a proven effective treatment means prescribing buprenorphine; here is how to get started:
- Start prescribing buprenorphine - Buprenorphine no longer requires any special training or registration. Any clinician with a current controlled substance registration can prescribe buprenorphine for OUD for as many patients as desired.83 The removal of X-waiver requirements by Section 1263 of the 'Consolidated Appropriations Act of 2023' has made it easier for primary care clinicians to treat OUD.84
- Support the use of patient-centered buprenorphine treatment approaches - Taking a shared decision-making approach to starting buprenorphine can be helpful in getting patient buy-in, leveraging their own experience, and respecting their personal goals. It is important to note that low-threshold induction options for getting patients started on buprenorphine can be more challenging when transitioning patients from fentanyl use versus prescription opioid or heroin use—learn more in Considerations for Transitioning from Fentanyl to Buprenorphine, Practice-Based Guidelines: Buprenorphine in the Age of Fentanyl (PDF – 1,646 KB), and Practical Tools for Prescribing and Promoting Buprenorphine in Primary Care Settings (PDF – 25.2 MB). There is currently no “best option” for transitioning from fentanyl to buprenorphine. Options for starting buprenorphine include:
- Prescribing low-dose (also referred to as microdosing) buprenorphine, described in this systematic review of microdosing initiations, helps to support individualized treatment and reduces side effects and withdrawal symptoms.
- Prescribing high-dose (also referred to as macrodosing) buprenorphine, like in these California emergency departments, addresses withdrawal symptoms more rapidly, helps remove barriers to short-term medication access, and extends the duration of action of buprenorphine. Compared to conventional buprenorphine doses, higher doses of some buprenorphine/naloxone combination products and buprenorphine monoproducts appear to improve retention in treatment.85 However, be sure to check your state's regulations regarding buprenorphine monoproducts, as some states have restrictions on their use.86,87,88,89
- Implementing rapid induction on extended-release buprenorphine, like in this Massachusetts General bridge clinic and this clinic in rural Alaska, can reduce the need for daily dosing, enhances patient adherence and convenience, reduces some of the need for drug testing, and eliminates concerns of diversion. However, extended-release buprenorphine is costlier than the other buprenorphine types and is more difficult to access.90,91
- Remember to be flexible in dosing and to continue prescribing - Eliminating policies that discontinue buprenorphine treatment during pregnancy, ongoing substance use, and acute pain management or that place arbitrary limits on buprenorphine—as some patients may need doses up to 32mg (or in rare cases beyond 32mg) due to the level of tolerance to high-potency opioids people can develop—are other ways to help people access and stay on buprenorphine.
2. Then, Get Your Team to Prescribe Buprenorphine
- Encourage others on your team to prescribe buprenorphine - Clinician stigma and misconceptions get in the way of MOUD prescribing, and contribute to negative experiences for patients with OUD and other substance use disorder (SUD).92,93,94,95 Staff training and education are important tools for addressing common myths and concerns related to the diversion or misuse of buprenorphine, the need for concurrent psychosocial and behavioral therapies with MOUD, and the fear of triggering a federal investigation when prescribing buprenorphine. Providing motivation, education, and training for the entire care team—such as making stigma reduction a key part of a practice's mission, offering staff shadowing opportunities, and conducting anti-stigma educational training like REACH Medical—can address stigma and dispel myths. There are several training and educational resources available, including this organizational action plan (PDF – 60.6 KB), these interactive training modules, this conversation starter guide, and this addiction language guide (PDF – 1,114 KB). It is also vital that clinical and non-clinical staff, from the highest levels of practice leadership to the front desk and security staff, participate in these educational initiatives in order to assure ongoing and reliable support for low-threshold care.96
3. Then, Work on Making Your Practice More Welcoming for People with OUD
Start removing or amending high-threshold practices and rigid protocols, processes, and workflows that decrease initiation and retention in OUD treatment in favor of low-threshold options that improve enrollment and retention rates.97,98,99
- Create a trauma-informed environment - Exposure to trauma and its negative health effects is more prevalent among people with SUD. It is vital the entire care team (including support staff and practice leadership) have a working understanding of the principles of trauma-informed care (TIC). Applying these principles can enhance empathy, create a safer and more compassionate treatment environment, and avoid re-traumatizing experiences for patients with SUD. These conversation starters (PDF – 593 KB), this training tool (PDF – 287 KB), and this continuing education activity provide strategies, cases, and examples for implementing TIC for patients with OUD.
- Adapt workflows and build a robust team - Transitioning to low-threshold care requires a shift in workflow to engage new and existing patients, manage transitions between levels of care, and address barriers to accessing MOUD. Low-threshold care ultimately requires only a prescribing clinician and a patient—waiting for a perfect team will harm people who need care today. However, should it be possible, consider:
- Adding care managers, social workers, patient navigators, or community health workers into primary care settings, and designating care coordination and management roles—as described in this Duke University guide (PDF – 188 KB) and this Pew Charitable Trusts report—can help limit disruptions in workflow.
- Adding Peer Recovery Support Specialists—as in this Pennsylvania health system program and this Washington, DC clinic—can increase patient retention in primary care OUD treatment.
- Adding behavioral health consultants—as described in this MOUD playbook—can help address the underlying causes of OUD, co-occurring substance use disorders, and other comorbid mental health conditions.
- Adding pharmacists, either as part of the care team or as consultants—as described in this fact sheet (PDF – 757 KB)—can be invaluable for dispensing buprenorphine (especially extended-release buprenorphine), providing patient education and monitoring, and improving patient safety. The addition of pharmacists in the Minneapolis Veterans Affairs Health Care System and in some North Carolina clinics provide examples for implementation.
- Change your practice policies - Allowing same-day walk-in visits, providing direct phone access to the treatment team, designing workflows that enable prompt (same-day) buprenorphine when appropriate, removing counseling requirements, removing the insistence on point-of-care drug testing, and welcoming people who use multiple substances—as described in this article and this one-pager (PDF – 189 KB)—are useful steps in creating an environment that helps patients start and continue OUD treatment. Washington State's Community-Based Medication-First Program provides an example for implementation.
- Access support and assistance for this transition, if needed - Having support as you transition to low-threshold care—such as this virtual technical assistance (TA) network in Maine (PDF – 3.2 MB), the clinical consultation calls in this Washington State program, or this dedicated clinician TA hotline in Massachusetts—can help ensure successful implementation. Mentorship is available via national networks like the Provider Clinical Support System Mentoring Program.
4. Remember to Address Other Healthcare Needs Once Patients with OUD Stabilize
Harm-reduction principles emphasize preventing overdose and infectious disease transmission; improving physical, mental, and social wellbeing; and offering low-barrier options for accessing healthcare services. It also recognizes that there are many ways to provide treatment for patients with OUD that may not include or may go beyond MOUD. Providing treatment services that engage people along the spectrum of engagement in MOUD will provide valuable opportunities to address co-occurring health problems, build relationships, and provide community that may one day lead to starting MOUD.
- Diagnose, treat, and prevent transmissible infections - People who use substances, particularly those that inject substances, are at increased risk for human immunodeficiency virus (HIV), hepatitis B and C viruses, and superficial and deep tissue infections.100,101,102,103 Offering comprehensive and routine HIV, viral hepatitis, and bacterial sexually transmitted infections testing; vaccinating against hepatitis A and B; providing condoms and safer injection equipment; prescribing HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP); and performing basic wound care can reduce the impact of negative health outcomes for people with OUD. This article outlines relevant strategies and supplies for addressing infections.
- Diagnose and treat mental health disorders - Over 60 percent of people with OUD have had any mental illness in the past year, and 27 percent will have a serious mental illness.104 In addition, suicidal thoughts and behaviors are much more common in people with OUD.105 Common mental health disorders include depression, anxiety, post-traumatic stress disorder, and attention-deficit/hyperactivity disorder (ADHD).106 Screening for and addressing suicide, co-occurring mental health disorders, and ADHD in particular, can have an impact on both their mental health symptoms and engagement in OUD treatment.107,108,109,110
- Provide preventive and chronic disease care and contraception – The chronic conditions that are common among the general population (e.g., hypertension, hyperlipidemia, and diabetes) are also common among people with OUD, and people with OUD may be at an increased risk for hyperthyroidism, hypothyroidism, type 2-diabetes, and cardiovascular disease.111,112,113 Preventive and chronic disease care needs (e.g., cancer screenings) for people with OUD are often overlooked.114 It is important to provide comprehensive care for all patients, including those with OUD. Be intentional about providing all relevant preventive care services for patients with OUD. Access to full spectrum contraceptive care (including Long-Acting Reversible Contraception) is important for people with SUD.115,116,117
- Work with community organizations to fills gaps in care - Community organizations can provide assistance for transportation, childcare, food, clothing, hygiene and other barriers that often deter people with OUD from accessing treatment.118 Wraparound care referrals to local syringe exchanges and detox and treatment facilities, when available, can help primary care practices supply recovery and harm-reduction supplies and services. The National Harm Reduction Coalition's Naloxone Finder can help with locating local community organizations that provide overdose prevention supplies and services.
5. When Possible, Do What You Can to Promote Care in Other Settings
High social needs and complex healthcare needs can create additional barriers for people with OUD and necessitate the implementation of additional services and supports outside of the walls of primary care practices. Understanding this:
- Provide on-demand OUD treatment and support using telehealth - National survey data found that during COVID, people with OUD were far more likely to receive treatment through telehealth.119 Receiving MOUD via telehealth was associated with improved treatment retention and lower odds of medically treated overdose.120 Telehealth for patients with OUD treatment can be video or telephone-based, like with this telephone consultation service, this virtual bridge program, and the Veterans Health Administration's virtual delivery of buprenorphine. OUD treatment support can also be provided via smartphone and computer-based behavioral health apps. This telehealth toolkit (PDF – 2.8 MB) provides guidance for getting started with telehealth for OUD treatment. It is important to note that the full set of telemedicine flexibilities granted during the COVID pandemic only extends through November 2023.121
- Expand OUD treatment services into non-traditional settings - Offering OUD treatment in syringe exchange programs, mobile health clinics, shelters, and on the street – such as with Connecticut's drop-in centers (PDF – 370 KB), San Francisco's Street Medicine Team (PDF – 3.8 MB), Baltimore City's Spot mobile clinic, and these bridge clinics—can help meet people with OUD where they are and engage them in care.
- Primary care is well-suited for treating patients with OUD due to its patient-centered approach and the urgency of prescribing buprenorphine. Despite the removal of certain barriers, such as the X waiver requirement, perceived low patient demand and clinician reluctance to prescribe buprenorphine is contributing to thousands of deaths every year due to untreated OUD. Low-threshold OUD treatment in primary care settings can address the stigma, fear of rejection, and distrust of healthcare that prevent people with OUD from seeking and staying in treatment.
- The defining characteristics of low-threshold treatment for patients with OUD are access to care through prompt (same-day) buprenorphine initiation, flexible maintenance without arbitrary limits, psychosocial support that is available but not required, clinical decisions based on patient circumstances rather than drug tests, adaptable protocols, and accessibility across various healthcare settings.
- Low-threshold treatment approaches have demonstrated similar or improved enrollment, retention, and outcomes when compared to the high-threshold practices and inflexible protocols of treatment as usual for patients with OUD and have not resulted in misuse or diversion of buprenorphine.
- Patients appreciate the elements of low-threshold care, including reduced intake procedures, fast treatment access, and non-stigmatizing and individualized care that does not require abstinence.
- Working towards delivering low-threshold treatment for patients with OUD is best pursued after a clinic has already been offering buprenorphine for OUD. This will provide a framework for clinics to work from and the needed perspective to start to identify and address stigma and other barriers.
- Once primary care providers are prescribing buprenorphine, they can more easily shift from high- to low-threshold practices and policies that make primary care practices more welcoming for patients with OUD.
- After amending practices and policies, primary care clinicians are well-positioned to provide comprehensive care for patients with OUD, including addressing infections, chronic illness, mental health care, and general preventive care; overdose prevention support and tools; and linking to community-based assistance and support.
- Lastly, primary care clinicians can expand access to low-threshold treatment for patients with OUD even further by meeting people where they are in the community and by providing OUD treatment via telehealth.
Considering the positive health outcomes of low-threshold care and the substantial gap in available buprenorphine treatment for people with OUD, policy groups and researchers are urging federal and state policymakers to examine relevant existing rules and regulations and remove those that hinder access to life-saving medications. Policy groups and researchers recommend several changes, including:
- Increasing the number of states that prohibit all insurers from requiring prior authorization for initial MOUD prescriptions122,123
- Removing state requirements for concurrent counseling as a condition to receive MOUD124
- Increasing public and private insurance reimbursement rates for treating patients with OUD, including all formulations of buprenorphine, the monoproduct and the extended-release product, and the services (e.g., case management) that support patients in their OUD treatment125,126
- Amending 42 CFR Part 8 to allow methadone for OUD, with certain safeguards, to also be prescribed in physician offices as buprenorphine is now127
- Maintaining the COVID-19 telemedicine flexibilities in 42 CFR Part 12 that allow for prescribing buprenorphine without an in-person visit128,129
- Academy Medication Assisted Treatment Playbook - Delivering Effective, Low-Threshold Treatment
- Academy Topic Brief - Polysubstance Use and Integrated Behavioral Health
- Academy Topic Brief - Stimulant Use Disorders and Integrated Behavioral Health
- Academy Topic Brief - Behavioral Health Apps in Primary Care
- Camden Coalition - Office-based Addiction Treatment: Sublocade Access
- Centers for Disease Control and Prevention - Linking People with Opioid Use Disorder to Medication Treatment (PDF – 1,885 KB)
- The Council of State Governments - State Options to Expand Buprenorphine Treatment for Opioid Use Disorder
- Duke University - Low Barrier Medication for Opioid Use Disorder at Community Health Centers and Primary Care Clinics: Recommendations for Implementation (PDF – 188 KB)
- Michigan Opioid Collaborative – Resources for Low Threshold Treatment for Patients with OUD
- The Pew Charitable Trusts - States Can Reduce Barriers to Prescribing Buprenorphine for Opioid Use Disorder
- Providers Clinical Support System - Telehealth for Opioid Use Disorder Toolkit: Guidance to Support High-Quality Care (PDF – 2.8 MB)
- Substance Abuse and Mental Health Services Administration - Practical Tools for Prescribing and Promoting Buprenorphine in Primary Care Settings
- The White House - ICYMI: Dr. Gupta Op-Ed on Transforming Management of Opioid Use Disorder with Universal Treatment
References
[1] Hsu YJ, Marsteller JA, Kachur SG, Fingerhood MI. Integration of buprenorphine treatment with primary care: Comparative effectiveness on retention, utilization, and cost. Popul Health Manag. 2019 Aug;22(4):292-299. https://doi.org/10.1089/pop.2018.0163. Accessed September 18, 2023.
[2] Korthuis PT, McCarty D, Weimer M, Bougatsos C, Blazina I, Zakher B, Grusing S, Devine B, Chou R. Primary care-based models for the treatment of opioid use disorder: A scoping review. Ann Intern Med. 2017 Feb 21;166(4):268-278. https://doi.org/10.7326/m16-2149. Accessed September 18, 2023.
[3] Buresh M, Stern R, Rastegar D. Treatment of opioid use disorder in primary care. BMJ. 2021;373:n784. https://doi.org/10.1136/bmj.n784. Accessed September 18, 2023.
[4] Incze MA, Chen D, Galyean P, Kimball ER, Stolebarger L, Zickmund S, Gordon AJ. Examining the primary care experience of patients with opioid use disorder: A qualitative study. J Addict Med. 2023 Jul-Aug 01;17(4):401-406. https://doi.org/10.1097/adm.0000000000001140. Accessed September 18, 2023.
[5] Abraham R, Wilkinson E, Jabbarpour Y, Bazemore A. Family physicians play key role in bridging the gap in access to opioid use disorder treatment. Am Fam Physician. 2020 Jul 1;102(1):10. https://pubmed.ncbi.nlm.nih.gov/32603069/. Accessed September 18, 2023.
[6] McGinty EE, Stone EM, Kennedy-Hendricks A, Bachhuber MA, Barry CL. Medication for opioid use disorder: A national survey of primary care physicians. Ann Intern Med. 2020 Jul 21;173(2):160-162. https://doi.org/10.7326%2FM19-3975. Accessed September 18, 2023.
[7] McBain RK, Dick A, Sorbero M, Stein BD. Growth and distribution of buprenorphine-waivered providers in the United States, 2007-2017. Ann Intern Med. 2020 Apr 7;172(7):504-506. https://doi.org/10.7326%2FM19-2403. Accessed September 18, 2023.
[8] Mackey K, Veazie S, Anderson J, Bourne D, Peterson K. Barriers and facilitators to the use of medications for opioid use disorder: A rapid review. J Gen Intern Med. 2020 Dec;35(Suppl 3):954-963. https://doi.org/10.1007%2Fs11606-020-06257-4. Accessed September 18, 2023.
[9] Austin EJ, Chen J, Briggs ES, et al. Integrating opioid use disorder treatment into primary care settings. AMA Netw Open. 2023 Aug 1;6(8):e2328627. https://doi.org/10.1001%2Fjamanetworkopen.2023.28627. Accessed September 18, 2023.
[10] Tofighi B, Williams AR, Chemi C, Suhail-Sindhu S, Dickson V, Lee JD. Patient barriers and facilitators to medications for opioid use disorder in primary care. Subst Use Misuse. 2019;54(14):2409-2419. https://doi.org/10.1080/10826084.2019.1653324. Accessed September 18, 2023.
[11] Gordon AJ, Kenny M, Dungan M, Gustavson AM, Kelley AT, Jones AL, Hawkins E, Frank JW, Danner A, Liberto J, Hagedorn H. Are x-waiver trainings enough? Facilitators and barriers to buprenorphine prescribing after x-waiver trainings. Am J Addict. 2022 Mar;31(2):152-158. https://doi.org/10.1111/ajad.13260. Accessed September 18, 2023.
[12] Substance Abuse and Mental Health Services Administration. Waiver Elimination (MAT Act). https://www.samhsa.gov/medications-substance-use-disorders/waiver-elimination-mat-act. Accessed September 18, 2023.
[13] Gordon AJ, Kenny M, Dungan M, Gustavson AM, Kelley AT, Jones AL, Hawkins E, Frank JW, Danner A, Liberto J, Hagedorn H. Are x-waiver trainings enough? Facilitators and barriers to buprenorphine prescribing after x-waiver trainings. Am J Addict. 2022 Mar;31(2):152-158. https://doi.org/10.1111/ajad.13260. Accessed September 18, 2023.
[14] Jones CM, Olsen Y, Ali MM, Sherry TB, Mcaninch J, Creedon T, Juliana P, Jacobus-Kantor L, Baillieu R, Diallo MM, Thomas A, Gandotra N, Sokolowska M, Ling S, Compton W. Characteristics and prescribing patterns of clinicians waivered to prescribe buprenorphine for opioid use disorder before and after release of new practice guidelines. JAMA Health Forum. 2023 Jul 7;4(7):e231982. https://doi.org/10.1001%2Fjamahealthforum.2023.1982. Accessed September 18, 2023.
[15] Jones CM, Han B, Baldwin GT, Einstein EB, Compton WM. Use of medication for opioid use disorder among adults with past-year opioid use disorder in the US, 2021. JAMA Netw Open. 2023 Aug 1;6(8):e2327488. https://doi.org/10.1001%2Fjamanetworkopen.2023.27488. Accessed September 18, 2023.
[16] Krawczyk N, Rivera BD, Jent V, Keyes KM, Jones CM, Cerdá M. Has the treatment gap for opioid use disorder narrowed in the U.S.?: A yearly assessment from 2010 to 2019. Int J Drug Policy. 2022 Dec;110:103786. https://doi.org/10.1016/j.drugpo.2022.103786. Accessed September 18, 2023.
[17] Mackey K, Veazie S, Anderson J, Bourne D, Peterson K. Barriers and facilitators to the use of medications for opioid use disorder: A rapid review. J Gen Intern Med. 2020 Dec;35(Suppl 3):954-963. https://doi.org/10.1007%2Fs11606-020-06257-4. Accessed September 18, 2023.
[18] Austin EJ, Chen J, Briggs ES, et al. Integrating opioid use disorder treatment into primary care settings. AMA Netw Open. 2023 Aug 1;6(8):e2328627. https://doi.org/10.1001%2Fjamanetworkopen.2023.28627. Accessed September 18, 2023.
[19] Tofighi B, Williams AR, Chemi C, Suhail-Sindhu S, Dickson V, Lee JD. Patient barriers and facilitators to medications for opioid use disorder in primary care. Subst Use Misuse. 2019;54(14):2409-2419. https://doi.org/10.1080/10826084.2019.1653324. Accessed September 18, 2023.
[20] Carlberg-Racich S, Sherrod D, Swope K, Brown D, Afshar M, Salisbury-Afshar E. Perceptions and experiences with evidence-based treatments among people who use opioids. J Addict Med. 2023 Mar-Apr 01;17(2):169-173. https://doi.org/10.1097/adm.0000000000001064. Accessed September 18, 2023.
[21] Hooker SA, Sherman MD, Lonergan-Cullum M, Nissly T, Levy R. What is success in treatment for opioid use disorder? Perspectives of physicians and patients in primary care settings. J Subst Abuse Treat. 2022 Oct;141:108804. https://doi.org/10.1016/j.jsat.2022.108804. Accessed September 18, 2023.
[22] Missouri Opioid State Targeted Response. Medication First Model for the Treatment of Opioid Use Disorder. https://www.careinnovations.org/wp-content/uploads/MedicationFirstApproach_1pager-1-1.pdf (PDF - 189 KB). Accessed September 18, 2023.
[23] Jakubowski A, Fox A. Defining low-threshold buprenorphine treatment. J Addict Med. 2020 Mar/Apr;14(2):95-98. https://doi.org/10.1097%2FADM.0000000000000555. Accessed September 18, 2023.
[24] University of Pennsylvania Leonard Davis Institute of Health Economics. Lowering the Barriers to Medication Treatment for People with Opioid Use Disorder. https://ldi.upenn.edu/our-work/research-updates/lowering-the-barriers-to-medication-treatment-for-people-with-opioid-use-disorder/. Accessed September 18, 2023.
[25] Martin SA, Chiodo LM, Bosse JD, Wilson A. The next stage of buprenorphine care for opioid use disorder. Ann Intern Med. 2018 Nov 6;169(9):628-635. https://doi.org/10.7326/m18-1652. Accessed September 18, 2023.
[26] Grande LA, Cundiff D, Greenwald MK, Murray M, Wright TE, Martin SA. Evidence on buprenorphine dose limits: A review. J Addict Med. 2023 Jun 16. https://doi.org/10.1097/adm.0000000000001189. Accessed September 18, 2023.
[27] Bhatraju EP, Grossman E, Tofighi B, McNeely J, DiRocco D, Flannery M, Garment A, Goldfeld K, Gourevitch MN, Lee JD. Public sector low threshold office-based buprenorphine treatment: Outcomes at year 7. Addict Sci Clin Pract. 2017;12(1):7. https://doi.org/10.1186%2Fs13722-017-0072-2. Accessed September 18, 2023.
[28] Alford DP, LaBelle CT, Richardson JM, O'Connell JJ, Hohl CA, Cheng DM, Samet JH. Treating homeless opioid dependent patients with buprenorphine in an office-based setting. J Gen Intern Med. 2007;22(2):171-176. https://doi.org/10.1007%2Fs11606-006-0023-1. Accessed September 18, 2023.
[29] Lee CS, Rosales R, Stein MD, Nicholls M, O'Connor BM, Loukas Ryan V, Davis EA. Brief Report: Low-barrier buprenorphine initiation predicts treatment retention among Latinx and Non-Latinx primary care patients. Am J Addict. 2019 Sep;28(5):409-412. https://doi.org/10.1111/ajad.12925. Accessed September 28, 2023.
[30] Mutter R, Spencer D, McPheeters J. Outcomes associated with treatment with and without medications for opioid use disorder. J Behav Health Serv Res. 2023 Oct;50(4):524-539. https://doi.org/10.1007/s11414-023-09841-8. Accessed September 18, 2023.
[31] Krawczyk N, Buresh M, Gordon MS, Blue TR, Fingerhood MI, Agus D. Expanding low-threshold buprenorphine to justice-involved individuals through mobile treatment: Addressing a critical care gap. J Subst Abuse Treat. 2019 Aug;103:1-8. https://doi.org/10.1016/j.jsat.2019.05.002. Accessed September 18, 2023.
[32] Jakubowski A, Lu T, DiRenno F, Jadow B, Giovanniello A, Nahvi S, Cunningham C, Fox A. Same-day vs. delayed buprenorphine prescribing and patient retention in an office-based buprenorphine treatment program. J Subst Abuse Treat. 2020 Dec;119:108140. https://doi.org/10.1016/j.jsat.2020.108140. Accessed September 18, 2023.
[33] Roy PJ, Price R, Choi S, Weinstein ZM, Bernstein E, Cunningham CO, Walley AY. Shorter outpatient wait-times for buprenorphine are associated with linkage to care post-hospital discharge. Drug Alcohol Depend. 2021 Jul 1;224:108703. https://doi.org/10.1016%2Fj.drugalcdep.2021.108703. Accessed September 18, 2023.
[34] Simon CB, Tsui JI, Merrill JO, Adwell A, Tamru E, Klein JW. Linking patients with buprenorphine treatment in primary care: Predictors of engagement. Drug Alcohol Depend. 2017;181:58-62. https://doi.org/10.1016/j.drugalcdep.2017.09.017. Accessed September 18, 2023.
[35] Weinstein LC, Iqbal Q, Cunningham A, Debates R, Landistratis G, Doggett P, Silverio A. Retention of patients with multiple vulnerabilities in a federally qualified health center buprenorphine program: Pennsylvania, 2017-2018. Am J Public Health. 2020 Apr;110(4):580-586. https://doi.org/10.2105/AJPH.2019.305525. Accessed September 18, 2023.
[36] Cunningham CO, Giovanniello A, Kunins HV, Roose RJ, Fox AD, Sohler NL. Buprenorphine treatment outcomes among opioid-dependent cocaine users and non-users. Am J Addict. 2013 Jul-Aug;22(4):352-7. https://doi.org/10.1111/j.1521-0391.2013.12032.x. Accessed September 18, 2023.
[37] Kapadia SN, Griffin JL, Waldman J, Ziebarth NR, Schackman BR, Behrends CN. A harm reduction approach to treating opioid use disorder in an independent primary care practice: A qualitative study. J Gen Intern Med. 2021 Jul;36(7):1898-1905. https://doi.org/10.1007/s11606-020-06409-6. Accessed September 18, 2023.
[38] Aronowitz SV, Engel-Rebitzer E, Lowenstein M, Meisel Z, Anderson E, South E. "We have to be uncomfortable and creative": Reflections on the impacts of the COVID-19 pandemic on overdose prevention, harm reduction & homelessness advocacy in Philadelphia. SSM Qual Res Health. 2021 Dec;1:100013. https://doi.org/10.1016/j.ssmqr.2021.100013. Accessed September 18, 2023.
[39] Wang L, Weiss J, Ryan EB, Waldman J, Rubin S, Griffin JL. Telemedicine increases access to buprenorphine initiation during the COVID-19 pandemic. J Subst Abuse Treat. 2021 May;124:108272. https://doi.org/10.1016/j.jsat.2020.108272. Accessed September 18, 2023.
[40] Harris R, Rosecrans A, Zoltick M, Willman C, Saxton R, Cotterell M, Bell J, Blackwell I, Page KR. Utilizing telemedicine during COVID-19 pandemic for a low-threshold, street-based buprenorphine program. Drug Alcohol Depend. 2022 Jan 1;230:109187. https://doi.org/10.1016/j.drugalcdep.2021.109187. Accessed September 18, 2023.
[41] Nordeck CD, Buresh M, Krawczyk N, Fingerhood M, Agus D. Adapting a low-threshold buprenorphine program for vulnerable populations during the COVID-19 pandemic. J Addict Med. 2021 Sep-Oct 01;15(5):364-369. https://doi.org/10.1097/ADM.0000000000000774. Accessed September 18, 2023.
[42] Weintraub E, Greenblatt AD, Chang J, Welsh CJ, Berthiaume AP, Goodwin SR, Arnold R, Himelhoch SS, Bennett ME, Belcher AM. Outcomes for patients receiving telemedicine-delivered medication-based treatment for Opioid Use Disorder: A retrospective chart review. Heroin Addict Relat Clin Probl. 2021;23(2):5-12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7861202/. Accessed September 18, 2023.
[43] Bhatraju EP, Grossman E, Tofighi B, McNeely J, DiRocco D, Flannery M, Garment A, Goldfeld K, Gourevitch MN, Lee JD. Public sector low threshold office-based buprenorphine treatment: Outcomes at year 7. Addict Sci Clin Pract. 2017 Feb 28;12(1):7. https://doi.org/10.1186/s13722-017-0072-2. Accessed September 18, 2023.
[44] Carroll KM, Weiss RD. The role of behavioral interventions in buprenorphine maintenance treatment: A review. Am J Psychiatry. 2017 Aug 1;174(8):738-747. https://doi.org/10.1176/appi.ajp.2016.16070792. Accessed September 18, 2023.
[45] Mutter R, Spencer D, McPheeters J. Outcomes associated with treatment with and without medications for opioid use disorder. J Behav Health Serv Res. 2023 Oct;50(4):524-539. https://doi.org/10.1007/s11414-023-09841-8. Accessed September 18, 2023.
[46] D'Onofrio G, O'Connor PG, Pantalon MV, Chawarski MC, Busch SH, Owens PH, Bernstein SL, Fiellin DA. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015 Apr 28;313(16):1636-44. https://doi.org/10.1001/jama.2015.3474. Accessed September 18, 2023.
[47] Busch SH, Fiellin DA, Chawarski MC, Owens PH, Pantalon MV, Hawk K, Bernstein SL, O'Connor PG, D'Onofrio G. Cost-effectiveness of emergency department-initiated treatment for opioid dependence. Addiction. 2017 Nov;112(11):2002-2010. https://doi.org/10.1111/add.13900. Accessed September 18, 2023.
[48] D'Onofrio G, Chawarski MC, O'Connor PG, Pantalon MV, Busch SH, Owens PH, Hawk K, Bernstein SL, Fiellin DA. Emergency department-initiated buprenorphine for opioid dependence with continuation in primary care: Outcomes during and after intervention. J Gen Intern Med. 2017 Jun;32(6):660-666. https://doi.org/10.1007/s11606-017-3993-2. Accessed September 18, 2023.
[49] Lowenstein M, Perrone J, Xiong RA, Snider CK, O'Donnell N, Hermann D, Rosin R, Dees J, McFadden R, Khatri U, Meisel ZF, Mitra N, Delgado MK. Sustained implementation of a multicomponent strategy to increase emergency department-initiated interventions for opioid use disorder. Ann Emerg Med. 2022 Mar;79(3):237-248. https://doi.org/10.1016/j.annemergmed.2021.10.012. Accessed September 18, 2023.
[50] Bachhuber MA, Thompson C, Prybylowski A, Benitez J MSW, Mazzella S MA, Barclay D. Description and outcomes of a buprenorphine maintenance treatment program integrated within Prevention Point Philadelphia, an urban syringe exchange program. Subst Abus. 2018;39(2):167-172. https://doi.org/10.1080/08897077.2018.1443541. Accessed September 18, 2023.
[51] Hood JE, Banta-Green CJ, Duchin JS, Breuner J, Dell W, Finegood B, Glick SN, Hamblin M, Holcomb S, Mosse D, Oliphant-Wells T, Shim MM. Engaging an unstably housed population with low-barrier buprenorphine treatment at a syringe services program: Lessons learned from Seattle, Washington. Subst Abus. 2020;41(3):356-364. https://doi.org/10.1080/08897077.2019.1635557. Accessed September 18, 2023.
[52] Weintraub E, Seneviratne C, Anane J, Coble K, Magidson J, Kattakuzhy S, Greenblatt A, Welsh C, Pappas A, Ross TL, Belcher AM. Mobile telemedicine for buprenorphine treatment in rural populations with opioid use disorder. JAMA Netw Open. 2021 Aug 2;4(8):e2118487. https://doi.org/10.1001/jamanetworkopen.2021.18487. Accessed September 18, 2023.
[53] Krawczyk N, Buresh M, Gordon MS, Blue TR, Fingerhood MI, Agus D. Expanding low-threshold buprenorphine to justice-involved individuals through mobile treatment: Addressing a critical care gap. J Subst Abuse Treat. 2019 Aug;103:1-8. https://doi.org/10.1016/j.jsat.2019.05.002. Accessed September 18, 2023.
[54] Carter J, Zevin B, Lum PJ. Low barrier buprenorphine treatment for persons experiencing homelessness and injecting heroin in San Francisco. Addict Sci Clin Pract. 2019 May 6;14(1):20. https://doi.org/10.1186/s13722-019-0149-1. Accessed September 18, 2023.
[55] Pepin MD, Joseph JK, Chapman BP, McAuliffe C, O'Donnell LK, Marano RL, Carreiro SP, Garcia EJ, Silk H, Babu KM. A mobile addiction service for community-based overdose prevention. Front Public Health. 2023 Jul 19;11:1154813. https://doi.org/10.3389/fpubh.2023.1154813. Accessed September 18, 2023.
[56] Jawa R, Tin Y, Nall S, Calcaterra SL, Savinkina A, Marks LR, Kimmel SD, Linas BP, Barocas JA. Estimated clinical outcomes and cost-effectiveness associated with provision of addiction treatment in US primary care clinics. JAMA Netw Open. 2023 Apr 3;6(4):e237888. https://doi.org/10.1001/jamanetworkopen.2023.7888. Accessed September 18, 2023.
[57] Simon C, Brothers S, Strichartz K, Coulter A, Voyles N, Herdlein A, Vincent L. We are the researched, the researchers, and the discounted: The experiences of drug user activists as researchers. Int J Drug Policy. 2021 Dec;98:103364. https://doi.org/10.1016/j.drugpo.2021.103364. Accessed September 18, 2023.
[58] Friedrichs A, Spies M, Härter M, Buchholz A. Patient preferences and shared decision making in the treatment of substance use disorders: A systematic review of the literature. PLoS One. 2016 Jan 5;11(1):e0145817. https://doi.org/10.1371/journal.pone.0145817. Accessed September 18, 2023.
[59] Kelley AT, Incze MA, Baylis JD, Calder SG, Weiner SJ, Zickmund SL, Jones AL, Vanneman ME, Conroy MB, Gordon AJ, Bridges JFP. Patient-centered quality measurement for opioid use disorder: Development of a taxonomy to address gaps in research and practice. Subst Abus. 2022 Dec;43(1):1286-1299. https://doi.org/10.1080/08897077.2022.2095082. Accessed September 18, 2023.
[60] Mackay L, Kerr T, Fairbairn N, Grant C, Milloy MJ, Hayashi K. The relationship between opioid agonist therapy satisfaction and fentanyl exposure in a Canadian setting. Addict Sci Clin Pract. 2021;16(1):26. https://doi.org/10.1186/s13722-021-00234-w. Accessed September 18, 2023.
[61] Lowenstein M, Abrams MP, Crowe M, Shimamoto K, Mazzella S, Botcheos D, Bertocchi J, Westfahl S, Chertok J, Garcia KP, Truchil R, Holliday-Davis M, Aronowitz S. "Come try it out. Get your foot in the door:" Exploring patient perspectives on low-barrier treatment for opioid use disorder. Drug Alcohol Depend. 2023 Jul 1;248:109915. https://doi.org/10.1016/j.drugalcdep.2023.109915. Accessed September 18, 2023.
[62] Shatterproof. Shatterproof National Principles of Care. https://www.shatterproof.org/shatterproof-national-principles-care. Accessed September 18, 2023.
[63] Sue KL, Cohen S, Tilley J, Yocheved A. A plea from people who use drugs to clinicians: New ways to initiate buprenorphine are urgently needed in the fentanyl era. J Addict Med. 2022 Jul-Aug 01;16(4):389-391. https://doi.org/10.1097/adm.0000000000000952. Accessed September 18, 2023.
[64] Saini J, Johnson B, Qato DM. Self-reported treatment need and barriers to care for adults with opioid use disorder: The US National Survey on Drug Use and Health, 2015 to 2019. Am J Public Health. 2022 Feb;112(2):284-295. https://doi.org/10.2105/ajph.2021.306577. Accessed September 18, 2023.
[65] Saini J, Johnson B, Qato DM. Self-reported treatment need and barriers to care for adults with opioid use disorder: The US National Survey on Drug Use and Health, 2015 to 2019. Am J Public Health. 2022 Feb;112(2):284-295. https://doi.org/10.2105/ajph.2021.306577. Accessed September 18, 2023.
[66] Carlberg-Racich S, Sherrod D, Swope K, Brown D, Afshar M, Salisbury-Afshar E. Perceptions and experiences with evidence-based treatments among people who use opioids. J Addict Med. 2023 Mar-Apr 01;17(2):169-173. https://doi.org/10.1097/adm.0000000000001064. Accessed September 18, 2023.
[67] Carlberg-Racich S, Sherrod D, Swope K, Brown D, Afshar M, Salisbury-Afshar E. Perceptions and experiences with evidence-based treatments among people who use opioids. J Addict Med. 2023 Mar-Apr 01;17(2):169-173. https://doi.org/10.1097/adm.0000000000001064. Accessed September 18, 2023.
[68] Marchand K, Foreman J, MacDonald S, Harrison S, Schechter MT, Oviedo-Joekes E. Building healthcare provider relationships for patient-centered care: A qualitative study of the experiences of people receiving injectable opioid agonist treatment. Subst Abuse Treat Prev Policy. 2020;15(1):7. https://doi.org/10.1186/s13011-020-0253-y. Accessed September 18, 2023.
[69] Chai D, Rosic T, Panesar B, Sanger N, van Reekum EA, Marsh DC, Worster A, Thabane L, Samaan Z. Patient-reported goals of youths in canada receiving medication-assisted treatment for opioid use disorder. JAMA Netw Open. 2021 Aug 2;4(8):e2119600. https://doi.org/10.1001%2Fjamanetworkopen.2021.19600. Accessed September 18, 2023.
[70] Holloway K, Murray S, Buhociu M, Arthur A, Molinaro R, Chicken S, Thomas E, Courtney S, Spencer A, Wood R, Rees R, Walder S, Stait J. Lessons from the COVID-19 pandemic for substance misuse services: Findings from a peer-led study. Harm Reduct J. 2022 Dec 12;19(1):140. https://doi.org/10.1186/s12954-022-00713-6. Accessed September 18, 2023.
[71] Young GJ, Hasan MM, Young LD, Noor-E-Alam M. Treatment experiences for patients receiving buprenorphine/naloxone for opioid use disorder: A qualitative study of patients' perceptions and attitudes. Subst Use Misuse. 2023;58(4):512-519. https://doi.org/10.1080/10826084.2023.2177111. Accessed September 18, 2023.
[72] Denhov A, Topor A. The components of helping relationships with professionals in psychiatry: Users' perspective. Int J Soc Psychiatry. 2012;58(4):417-424. https://doi.org/10.1177/0020764011406811. Accessed September 18, 2023.
[73] Snow RL, Simon RE, Jack HE, Oller D, Kehoe L, Wakeman SE. Patient experiences with a transitional, low-threshold clinic for the treatment of substance use disorder: A qualitative study of a bridge clinic. J Subst Abuse Treat. 2019 Dec;107:1-7. https://doi.org/10.1016/j.jsat.2019.09.003. Accessed September 18, 2023.
[74] Krawczyk N, Mojtabai R, Stuart EA, Fingerhood M, Agus D, Lyons BC, Weiner JP, Saloner B. Opioid agonist treatment and fatal overdose risk in a state-wide US population receiving opioid use disorder services. Addiction. 2020 Sep;115(9):1683-1694. https://doi.org/10.1111/add.14991. Accessed September 18, 2023.
[75] Sordo L, Barrio G, Bravo MJ, Indave BI, Degenhardt L, Wiessing L, Ferri M, Pastor-Barriuso R. Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies. BMJ. 2017 Apr 26;357:j1550. https://doi.org/10.1136/bmj.j1550. Accessed September 18, 2023.
[76] Larochelle MR, Bernson D, Land T, Stopka TJ, Wang N, Xuan Z, Bagley SM, Liebschutz JM, Walley AY. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study. Ann Intern Med. 2018 Aug 7;169(3):137-145. https://doi.org/10.7326/m17-3107. Accessed September 18, 2023.
[77] Amato L, Minozzi S, Davoli M, Vecchi S. Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Database Syst Rev. 2011 Oct 5;(10):CD004147. https://doi.org/10.1002/14651858.cd004147.pub4. Accessed September 18, 2023.
[78] Dugosh K, Abraham A, Seymour B, McLoyd K, Chalk M, Festinger D. A systematic review on the use of psychosocial interventions in conjunction with medications for the treatment of opioid addiction. J Addict Med. 2016 Mar-Apr;10(2):93-103. https://doi.org/10.1097%2FADM.0000000000000193. Accessed September 18, 2023.
[79] Wyse JJ, Morasco BJ, Dougherty J, Edwards B, Kansagara D, Gordon AJ, Korthuis PT, Tuepker A, Lindner S, Mackey K, Williams B, Herreid-O'Neill A, Paynter R, Lovejoy TI. Adjunct interventions to standard medical management of buprenorphine in outpatient settings: A systematic review of the evidence. Drug Alcohol Depend. 2021 Nov 1;228:108923. https://doi.org/10.1016%2Fj.drugalcdep.2021.108923. Accessed September 18, 2023.
[80] The Risk of Misuse and Diversion of Buprenorphine for Opioid Use Disorder Appears to Be Low in Medicare Part D. Data in Brief. OEI-02-22-00160. Washington, DC: Office of Inspector General; May 2023. https://oig.hhs.gov/oei/reports/OEI-02-22-00160.asp. Accessed September 18, 2023.
[81] Han B, Jones CM, Einstein EB, Compton WM. Trends in and characteristics of buprenorphine misuse among adults in the US. JAMA Netw Open. 2021 Oct 1;4(10):e2129409. https://doi.org/10.1001/jamanetworkopen.2021.29409. Accessed September 18, 2023.
[82] Tanz LJ, Jones CM, Davis NL, Compton WM, Baldwin GT, Han B, Volkow ND. Trends and characteristics of buprenorphine-involved overdose deaths prior to and during the COVID-19 pandemic. JAMA Netw Open. 2023 Jan 3;6(1):e2251856. https://doi.org/10.1001%2Fjamanetworkopen.2022.51856. Accessed September 18, 2023.
[83] Substance Abuse and Mental Health Services Administration. Waiver Elimination (MAT Act). https://www.samhsa.gov/medications-substance-use-disorders/waiver-elimination-mat-act. Accessed September 18, 2023.
[84] Substance Abuse and Mental Health Services Administration. Waiver Elimination (MAT Act). https://www.samhsa.gov/medications-substance-use-disorders/waiver-elimination-mat-act. Accessed September 18, 2023.
[85] Chambers LC, Hallowell BD, Zullo AR, Paiva TJ, Berk J, Gaither R, Hampson AJ, Beaudoin FL, Wightman RS. Buprenorphine dose and time to discontinuation among patients with opioid use disorder in the era of fentanyl. JAMA Netw Open. 2023;6(9):e2334540. https://doi.org/10.1001/jamanetworkopen.2023.34540. Accessed September 19, 2023.
[86] Blazes CK, Morrow JD. Reconsidering the usefulness of adding naloxone to buprenorphine. Front Psychiatry. 2020 Sep 11;11:549272. https://doi.org/10.3389%2Ffpsyt.2020.549272. Accessed September 18, 2023.
[87] Gregg J, Hartley J, Lawrence D, Risser A, Blazes C. The naloxone component of buprenorphine/naloxone: Discouraging misuse, but at what cost? J Addict Med. 2023 Jan-Feb 01;17(1):7-9. https://doi.org/10.1097/adm.0000000000001030. Accessed September 18, 2023.
[88] Nguemeni Tiako MJ, Dolan A, Abrams M, Oyekanmi K, Meisel Z, Aronowitz SV. Thematic analysis of state medicaid buprenorphine prior authorization requirements. JAMA Netw Open. 2023 Jun 1;6(6):e2318487. https://doi.org/10.1001/jamanetworkopen.2023.18487. Accessed September 18, 2023.
[89] Legal Action Center. Spotlight on Legislation Limiting the Use of Prior Authorization for Substance Use Disorder Services and Medications. https://www.lac.org/resource/spotlight-on-legislation-limiting-the-use-of-prior-authorization-for-substance-use-disorder-services-and-medications. Accessed September 18, 2023.
[90] Mariani JJ, Mahony AL, Podell SC, Brooks DJ, Brezing C, Luo SX, Naqvi NH, Levin FR. Open-label trial of a single-day induction onto buprenorphine extended-release injection for users of heroin and fentanyl. Am J Addict. 2021 Sep;30(5):470-476. https://doi.org/10.1111/ajad.13193. Accessed September 18, 2023.
[91] Hassman H, Strafford S, Shinde SN, Heath A, Boyett B, Dobbins RL. Open-label, rapid initiation pilot study for extended-release buprenorphine subcutaneous injection. Am J Drug Alcohol Abuse. 2023 Jan 2;49(1):43-52. https://doi.org/10.1080/00952990.2022.2106574. Accessed September 18, 2023.
[92] Klusaritz H, Bilger A, Paterson E, Summers C, Barg FK, Cronholm PF, Saine ME, Sochalski J, Doubeni CA. Impact of stigma on clinician training for opioid use disorder care: A qualitative study in a primary care learning collaborative. Ann Fam Med. 2023 Feb;21(Suppl 2):S31-S38. https://doi.org/10.1370%2Fafm.2920. Accessed September 18, 2023.
[93] Sue KL, Chawarski M, Curry L, McNeil R, Coupet E Jr, Schwartz RP, Wilder C, Tsui JI, Hawk KF, D'Onofrio G, O'Connor PG, Fiellin DA, Edelman EJ. Perspectives of clinicians and staff at community-based opioid use disorder treatment settings on linkages with emergency department-initiated buprenorphine programs. JAMA Netw Open. 2023 May 1;6(5):e2312718. https://doi.org/10.1001/jamanetworkopen.2023.12718. Accessed September 18, 2023.
[94] Andrilla CHA, Coulthard C, Larson EH. Barriers Rural Physicians Face Prescribing Buprenorphine for Opioid Use Disorder. Ann Fam Med. 2017 Jul;15(4):359-362. https://doi.org/10.1370%2Fafm.2099. Accessed September 18, 2023.
[95] Sue KL, Chawarski M, Curry L, McNeil R, Coupet E Jr, Schwartz RP, Wilder C, Tsui JI, Hawk KF, D'Onofrio G, O'Connor PG, Fiellin DA, Edelman EJ. Perspectives of clinicians and staff at community-based opioid use disorder treatment settings on linkages with emergency department-initiated buprenorphine programs. JAMA Netw Open. 2023 May 1;6(5):e2312718. https://doi.org/10.1001/jamanetworkopen.2023.12718. Accessed September 18, 2023.
[96] Stigma of Addiction Summit: Innovation Abstracts. Washington, DC: National Academy Medicine Report; January 2023. https://nam.edu/wp-content/uploads/2021/06/Innovation-Abstract-Packet_final.pdf (PDF - 1,312 KB). Accessed September 18, 2023.
[97] Jakubowski A, Lu T, DiRenno F, Jadow B, Giovanniello A, Nahvi S, Cunningham C, Fox A. Same-day vs. delayed buprenorphine prescribing and patient retention in an office-based buprenorphine treatment program. J Subst Abuse Treat. 2020 Dec;119:108140. https://doi.org/10.1016/j.jsat.2020.108140. Accessed September 18, 2023.
[98] Roy PJ, Price R, Choi S, Weinstein ZM, Bernstein E, Cunningham CO, Walley AY. Shorter outpatient wait-times for buprenorphine are associated with linkage to care post-hospital discharge. Drug Alcohol Depend. 2021 Jul 1;224:108703. https://doi.org/10.1016/j.drugalcdep.2021.108703. Accessed September 18, 2023.
[99] Simon CB, Tsui JI, Merrill JO, Adwell A, Tamru E, Klein JW. Linking patients with buprenorphine treatment in primary care: Predictors of engagement. Drug Alcohol Depend. 2017 Dec 1;181:58-62. https://doi.org/10.1016/j.drugalcdep.2017.09.017. Accessed September 18, 2023.
[100] National Institute on Drug Abuse. Drug Use and Viral Infections (HIV, Hepatitis) DrugFacts. https://nida.nih.gov/publications/drugfacts/drug-use-viral-infections-hiv-hepatitis. Accessed September 18, 2023.
[101] Saldana CS, Vyas DA, Wurcel AG. Soft tissue, bone, and joint infections in people who inject drugs. Infect Dis Clin North Am. 2020 Sep;34(3):495-509. https://doi.org/10.1016%2Fj.idc.2020.06.007. Accessed September 18, 2023.
[102] Rich KM, Solomon DA. Medical complications of injection drug use - Part I. NEJM Evidence. 2023;2(2):EVIDra2200292. https://doi.org/10.1056/EVIDra2200292. Accessed September 18, 2023.
[103] Rich KM, Solomon DA. Medical complications of injection drug use - Part II. NEJM Evidence. 2023;2(3):EVIDra2300019. https://doi.org/10.1056/EVIDra2300019. Accessed September 18, 2023.
[104] Jones CM, McCance-Katz EF. Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug Alcohol Depend. 2019 Apr 1;197:78-82. https://doi.org/10.1016/j.drugalcdep.2018.12.030. Accessed September 18, 2023.
[105] Streck JM, Parker MA, Bearnot B, Kalagher K, Sigmon SC, Goodwin RD, Weinberger AH. National trends in suicide thoughts and behavior among US adults with opioid use disorder from 2015 to 2020. Subst Use Misuse. 2022;57(6):876-885. https://doi.org/10.1080/10826084.2022.2046102. Accessed September 18, 2023.
[106] Santo T Jr, Campbell G, Gisev N, Martino-Burke D, Wilson J, Colledge-Frisby S, Clark B, Tran LT, Degenhardt L. Prevalence of mental disorders among people with opioid use disorder: A systematic review and meta-analysis. Drug Alcohol Depend. 2022 Sep 1;238:109551. https://doi.org/10.1016/j.drugalcdep.2022.109551. Accessed September 18, 2023.
[107] Zhu Y, Mooney LJ, Yoo C, Evans EA, Kelleghan A, Saxon AJ, Curtis ME, Hser YI. Psychiatric comorbidity and treatment outcomes in patients with opioid use disorder: Results from a multisite trial of buprenorphine-naloxone and methadone. Drug Alcohol Depend. 2021 Nov 1;228:108996. https://doi.org/10.1016/j.drugalcdep.2021.108996. Accessed September 18, 2023.
[108] Rohner H, Gaspar N, Rosen H, Ebert T, Kilarski LL, Schrader F, Al Istwani M, Lenz AJ, Dilg C, Welskop A, Goldmann T, Schmidt U, Philipsen A. ADHD Prevalence among outpatients with severe opioid use disorder on daily intravenous diamorphine and/or oral opioid maintenance treatment. Int J Environ Res Public Health. 2023 Jan 31;20(3):2534. https://doi.org/10.3390%2Fijerph20032534. Accessed September 18, 2023.
[109] Levin FR, Evans SM, Vosburg SK, Horton T, Brooks D, Ng J. Impact of attention-deficit hyperactivity disorder and other psychopathology on treatment retention among cocaine abusers in a therapeutic community. Addict Behav. 2004 Dec;29(9):1875-82. https://doi.org/10.1016/j.addbeh.2004.03.041. Accessed September 18, 2023.
[110] Kast KA, Rao V, Wilens TE. Pharmacotherapy for attention-deficit/hyperactivity disorder and retention in outpatient substance use disorder treatment: A retrospective cohort study. J Clin Psychiatry. 2021 Feb 23;82(2):20m13598. https://doi.org/10.4088/jcp.20m13598. Accessed September 18, 2023.
[111] National Center for Chronic Disease Prevention and Health Promotion. Centers for Disease Control and Prevention. About Chronic Diseases. https://www.cdc.gov/chronic-disease/about/index.html. Accessed September 18, 2023.
[112] Pan Y, Xu R. Mining comorbidities of opioid use disorder from FDA adverse event reporting system and patient electronic health records. BMC Med Inform Decis Mak. 2022 Jun 16;22(Suppl 2):155. https://doi.org/10.1186/s12911-022-01869-8. Accessed September 18, 2023.
[113] Slawek DE, Lu TY, Hayes B, Fox AD. Caring for patients with opioid use disorder: What clinicians should know about comorbid medical conditions. Psychiatr Res Clin Pract. 2019 Apr 1;1(1):16-26. https://doi.org/10.1176/appi.prcp.20180005. Accessed September 18, 2023.
[114] Anderson KE, Alexander GC, Niles L, Scholle SH, Saloner B, Dy SM. Quality of preventive and chronic illness care for insured adults with opioid use disorder. JAMA Netw Open. 2021 Apr 1;4(4):e214925. https://doi.org/10.1001/jamanetworkopen.2021.4925. Accessed September 18, 2023.
[115] Heil SH, Melbostad HS, Matusiewicz AK, Rey CN, Badger GJ, Shepard DS, Sigmon SC, MacAfee LK, Higgins ST. Efficacy and cost-benefit of onsite contraceptive services with and without incentives among women with opioid use disorder at high risk for unintended pregnancy: A randomized clinical trial. JAMA Psychiatry. 2021 Oct 1;78(10):1071-1078. https://doi.org/10.1001/jamapsychiatry.2021.1715. Accessed September 18, 2023.
[116] Charron E, Kent-Marvick J, Gibson T, Taylor E, Bouwman K, Sani GM, Simonsen SE, Stone RH, Kaiser JE, McFarland MM. Barriers to and facilitators of hormonal and long-acting reversible contraception access and use in the US among reproductive-aged women who use opioids: A scoping review. Prev Med Rep. 2023 Jan 18;32:102111. https://doi.org/10.1016/j.pmedr.2023.102111. Accessed September 18, 2023.
[117] Hurley EA, Goggin K, Piña-Brugman K, Noel-MacDonnell JR, Allen A, Finocchario-Kessler S, Miller MK. Contraception use among individuals with substance use disorder increases tenfold with patient-centered, mobile services: a quasi-experimental study. Harm Reduct J. 2023 Mar 6;20(1):28. https://doi.org/10.1186/s12954-023-00760-7. Accessed September 18, 2023.
[118] Saini J, Johnson B, Qato DM. Self-reported treatment need and barriers to care for adults with opioid use disorder: The US National Survey on Drug Use and Health, 2015 to 2019. Am J Public Health. 2022 Feb;112(2):284-295. https://doi.org/10.2105/ajph.2021.306577. Accessed September 18, 2023.
[119] Jones CM, Han B, Baldwin GT, Einstein EB, Compton WM. Use of medication for opioid use disorder among adults with past-year opioid use disorder in the US, 2021. JAMA Netw Open. 2023 Aug 1;6(8):e2327488. https://doi.org/10.1001%2Fjamanetworkopen.2023.27488. Accessed September 18, 2023.
[120] Jones CM, Shoff C, Hodges K, Blanco C, Losby JL, Ling SM, Compton WM. Receipt of telehealth services, receipt and retention of medications for opioid use disorder, and medically treated overdose among Medicare beneficiaries before and during the COVID-19 pandemic. JAMA Psychiatry. 2022 Oct 1;79(10):981-992. https://doi.org/10.1001/jamapsychiatry.2022.2284. Accessed September 18, 2023.
[121] Rand Corporation. The Solution to Telemedicine Prescribing of Buprenorphine Seems Clear to Everyone but DEA. https://www.rand.org/blog/2023/09/the-solution-to-telemedicine-prescribing-of-buprenorphine.html. Accessed September 18, 2023.
[122] Andraka-Christou B, Golan O, Totaram R, Ohama M, Saloner B, Gordon AJ, Stein BD. Prior authorization restrictions on medications for opioid use disorder: Trends in state laws from 2005 to 2019. Ann Med. 2023 Dec;55(1):514-520. https://doi.org/10.1080%2F07853890.2023.2171107. Accessed September 18, 2023.
[123] The Pew Charitable Trusts. Policies Should Promote Access to Buprenorphine for Opioid Use Disorder: State and federal leaders can eliminate barriers, boost treatment. https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2021/05/policies-should-promote-access-to-buprenorphine-for-opioid-use-disorder. Accessed September 18, 2023.
[124] The Pew Charitable Trusts. Overview of Opioid Treatment Program Regulations by State. https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2022/09/overview-of-opioid-treatment-program-regulations-by-state. Accessed September 18, 2023.
[125] Orgera K, Tolbert J. The Opioid Epidemic and Medicaid's Role in Facilitating Access to Treatment. San Francisco, CA: Kaiser Family Foundation; May 2019. https://www.kff.org/medicaid/issue-brief/the-opioid-epidemic-and-medicaids-role-in-facilitating-access-to-treatment/. Accessed September 18, 2023.
[126] Clemans-Cope L, Lynch V, Payton M, Aarons J. Medicaid professional fees for treatment of opioid use disorder varied widely across states and were substantially below fees paid by Medicare in 2021. Subst Abuse Treat Prev Policy. 2022 Jul 6;17(1):49. https://doi.org/10.1186/s13011-022-00478-y. Accessed September 18, 2023.
[127] The Pew Charitable Trusts. Overview of Opioid Treatment Program Regulations by State. https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2022/09/overview-of-opioid-treatment-program-regulations-by-state. Accessed September 18, 2023.
[128] Rand Corporation. The Solution to Telemedicine Prescribing of Buprenorphine Seems Clear to Everyone but DEA. https://www.rand.org/blog/2023/09/the-solution-to-telemedicine-prescribing-of-buprenorphine.html. Accessed September 18, 2023.
[129] The Pew Charitable Trusts. Policies Should Promote Access to Buprenorphine for Opioid Use Disorder: State and federal leaders can eliminate barriers, boost treatment. https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2021/05/policies-should-promote-access-to-buprenorphine-for-opioid-use-disorder. Accessed September 18, 2023.
Authors
- Stephen A. Martin, MD - Professor, UMass Chan Medical School
- Monique Thornton, MPH - CEO, Let's Talk Public Health
- Garrett E. Moran, PhD - Principal, Moran Consulting
- Noah Nesin, MD, FAAFP - Medical Director, Research & Innovation - Community Care Partnership of Maine
Other Contributors
- Rebecca F. Noftsinger, BA - Senior Study Director, Westat
Acknowledgements
We thank reviewers and other contributors from the Agency of Healthcare Quality and Research (AHRQ), National Integration Academy Council (NIAC), and Westat for sharing their time and expertise to develop, improve, and publish this work
Suggested Citation
Martin SA, Thornton M, Moran GE, Nesin N. The Role of Low-Threshold Treatment for Patients with OUD in Primary Care. Rockville, MD: Agency for Healthcare Research and Quality; October 2023. https://integrationacademy.ahrq.gov/products/topic-briefs/oud-low-threshold-treatment.