September 2018

In This Issue: Improving Opioid Safety
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Improving Implementation of Treatment for Veterans with Opioid Use Disorders in Low-Performing Facilities

Feature Article

Opioid use disorder is associated with increased morbidity and mortality, increased HIV and HCV (hepatitis C virus) infection rates, and increased criminal behavior. Opioid agonist therapy (OAT) has been shown to be effective in treating opioid use disorder and decreasing these negative consequences. While the efficacy of OAT has been established, the predominant problem is that of implementation: too few providers offer or provide OAT to patients with opioid use disorder due to patient, provider or system impediments. While the VA healthcare system has made great strides in implementing OAT over the past decade, national treatment rates remain low (only 30% of those Veterans eligible to receive OAT do), and several facilities continue to have very low prescribing rates.

The objective of this ongoing HSR&D study (2017–2021) is to increase the percentage of Veterans with opioid use disorder initiating and sustaining OAT in long-term treatment (minimum of three months) in facilities where the current percent of Veterans receiving medication for opioid use disorder is low (<20%). This project will not focus on establishing new methadone opioid treatment centers, but will focus on using intensive external facilitation to increase access to buprenorphine (relieves symptoms of opioid withdrawal) and – in cases where buprenorphine is contraindicated or not acceptable to the patient – naltrexone (blocks opiate receptors in the nervous system). Therefore, study investigators will work to:

• Implement intensive external facilitation at eight low-performing sites and compare the change in rate of OAT initiation and sustainment to the remaining low performing sites,
• Use formative evaluation methods to refine the intervention for further dissemination, and
• Assess the cost and budget impact of the intervention.

Eight low-performing VA sites will be selected for this study based on prescribing rates and the number of actionable patients (e.g., patients with opioid use disorder not currently receiving OAT) to receive the intervention. The remaining low-performing sites will continue to receive implementation as usual (e.g., VA Office of Mental Health and Suicide Prevention, and Academic Detailing interventions).  Administrative data will be used to monitor the proportion of Veterans with opioid use disorder that initiate and sustain OAT at all low-performing sites. The evaluation will include interviews with patients, substance use disorders clinic staff, and primary care and general mental health leadership to assess site-level barriers. Ongoing facilitation will consist of monthly conference calls with individual site teams and expert clinical consultation available via video conferencing.

Findings:

Pre-implementation interviews conducted at the first four intervention sites with leadership (Chief of Staff, Chief of Mental Health, Chief of Primary Care, Pharmacy Chief, and SUD Medical Director), as well as with providers in SUD, general mental health and primary care, indicate the following barriers:

• Time-consuming process to become waivered and locally credentialed,
• Difficulty engaging primary care and general mental health providers in prescribing,
• Misinformation about the time and resources needed for buprenorphine induction, and
• Fear and stigma related to treating patients with opioid use disorders.

Impact: Given the high prevalence and devastating consequences of opioid use disorder among Veterans, improving access to gold-standard treatment has the potential to improve the health of Veterans and, thereby, realize savings in healthcare costs by decreasing costly emergency room visits and hospitalizations associated with overdose and other complications. Increasing access to effective treatment also has the potential to reduce transmission of costly and life-threatening infectious diseases including HIV and HCV. This project also will provide important information regarding the intensity and cost of external facilitation required to promote adoption of OAT by low-performing facilities, thus providing a roadmap to best implement access to OAT at the additional low-performing sites. This information may also assist with designing and resourcing implementation strategies for sites that struggle to adopt other evidence based clinical practices.

Principal Investigator: Hildi Hagedorn, PhD, is part of HSR&D’s Center for Chronic Disease Outcomes Research (CCDOR) in Minneapolis, MN.

Additional Resources

• VHA Pain Management. Opioid Safety Initiative Toolkit.
• Veterans Crisis Line 1-800-273-8255 (press 1) or Text message to 838255.