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BackgroundIn the US, emergency room visits and overdoses related to prescription opioids have soared and the rates of illicit opioid use, including heroin and fentanyl, are increasing. Opioid use disorder (OUD) is associated with higher morbidity and mortality, higher HIV and HCV infection rates, and criminal behavior. Opioid agonist therapy (OAT; methadone and buprenorphine) is proven to be effective in treating OUD and decreasing its negative consequences. While the efficacy of OAT has been established, too few providers prescribe OAT to patients with OUD due to patient, provider, or system factors. While the Veterans Health Administration (VHA) has made great strides in OAT implementation, national treatment rates remain low (35% of patients with OUD) and several facilities continue to have much lower prescribing rates.MethodsEight VA sites with low baseline prescribing rates (lowest quartile, < 21%) were randomly selected from the 35 low prescribing sites to receive an intensive external facilitation implementation intervention to increase OAT prescribing rates. The intervention includes a site-specific developmental evaluation, a kick-off site visit, and 12 months of ongoing facilitation. The developmental evaluation includes qualitative interviews with patients, substance use disorders clinic staff, and primary care and general mental health leadership to assess site-level barriers. The site visit includes: (1) a review of site-specific barriers and potential implementation strategies; (2) instruction on using available dashboards to track prescribing rates and identify actionable patients; and (3) education on OAT, including, if requested, buprenorphine certification training for prescribers. On-going facilitation consists of monthly conference calls with individual site teams and expert clinical consultation. The primary outcomes is the proportion of Veterans with OUD initiating and sustaining OAT, with intervention sites expected to have larger increases in prescribing compared to control sites. Final qualitative interviews and a cost assessment will inform future implementation efforts.DiscussionThis project will examine and respond to barriers encountered in low prescribing VHA clinics allowing refinement of an intervention to enhance access to medication treatment for OUD in additional facilities.

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Background Identifying effective strategies to improve access to medication treatments for opioid use disorder (MOUD) is imperative. Within the Veterans Health Administration (VHA), provision of MOUD varies significantly, requiring development and testing of implementation strategies that target facilities with low provision of MOUD. Objective Determine the effectiveness of external facilitation in increasing the provision of MOUD among VHA facilities with low baseline provision of MOUD compared to matched controls. Design Pre-post, block randomized study designed to compare facility-level outcomes in a stratified sample of eligible facilities. Four blocks (two intervention facilities in each) were defined by median splits of both the ratio of patients with OUD receiving MOUD and number of patients with OUD not currently receiving MOUD (i.e., number of actionable patients). Intervention facilities participated in a 12-month implementation intervention. Participants VHA facilities in the lowest quartile of MOUD provision (35 facilities), eight of which were randomly assigned to participate in the intervention (two per block) with twenty-seven serving as matched controls by block. Intervention External facilitation included assessment of local barriers/facilitators, formation of a local implementation team, a site visit for action planning and training/education, cross-facility quarterly calls, monthly coaching calls, and consultation. Main Measures Pre- to post-change in the facility-level ratio of patients with an OUD diagnosis receiving MOUD compared to control facilities. Key Results Intervention facilities significantly increased the ratio of patients with OUD receiving MOUD from an average of 18% at baseline to 30% 1 year later, with an absolute difference of 12% (95% confidence interval [CI]: 6.6%, 17.0%). The difference in differences between intervention and control facilities was 3.0% (95% CI: − 0.2%. 6.7%). The impact of the intervention varied by block, with smaller, less complex facilities more likely to outperform matched controls. Conclusions Intensive external facilitation improved the adoption of MOUD in most low-performing facilities and may enhance adoption beyond other interventions less tailored to individual facility contexts.