Clinical leaders and providers’ perspectives on delivering medications for the treatment of opioid use disorder in Veteran Affairs’ facilities

Abstract

Background Improving access to medication treatment of opioid use disorder (MOUD) is a national priority, yet common modifiable barriers (e.g., limited provider knowledge, negative beliefs about MOUD) often challenge implementation of MOUD delivery. To address these barriers, the VA launched a multifaceted implementation intervention focused on planning and educational strategies to increase MOUD delivery in 18 medical facilities. The purpose of this investigation was to determine if a multifaceted intervention approach to increase MOUD delivery changed providers’ perceptions about MOUD over the first year of implementation. Methods Cross-disciplinary teams of clinic providers and leadership from primary care, pain, and mental health clinics at 18 VA medical facilities received invitations to complete an anonymous, electronic survey prior to intervention launch (baseline) and at 12- month follow-up. Responses were summarized using descriptive statistics, and changes over time were compared using regression models adjusted for gender and prescriber status, and clustered on facility. Responses to open-ended questions were thematically analyzed using a template analysis approach. Results Survey response rates at baseline and follow-up were 57.1% (56/98) and 50.4% (61/121), respectively. At both time points, most respondents agreed that MOUD delivery is important (94.7 vs. 86.9%), lifesaving (92.8 vs. 88.5%) and evidence-based (85.2 vs. 89.5%). Over one-third (37.5%) viewed MOUD delivery as time-consuming, and only 53.7% affirmed that clinic providers wanted to prescribe MOUD at baseline; similar responses were seen at follow-up (34.5 and 52.4%, respectively). Respondents rated their knowledge about OUD, comfort discussing opioid use with patients, job satisfaction, ability to help patients with OUD, and support from colleagues favorably at both time points. Respondents’ ratings of MOUD delivery filling a gap in care were high but declined significantly from baseline to follow-up (85.7 vs. 73.7%, p < 0.04). Open-ended responses identified implementation barriers including lack of support to diagnose and treat OUD and lack of time. Conclusions Although perceptions about MOUD generally were positive, targeted education and planning strategies did not improve providers’ and clinical leaders’ perceptions of MOUD over time. Strategies that improve leaders’ prioritization and support of MOUD and address time constraints related to delivering MOUD may increase access to MOUD in non-substance use treatment clinics.

Access to Medications for Opioid Use Disorder in Rural Versus Urban Veterans Health Administration Facilities

“…Barriers to providing MOUD that have been documented within VHA include perceived lack of time, lack of support to diagnose and treat OUD, and issues with credentialing and privileging waivered prescribers. 25 A recent VHA Notice addressed some of these barriers, including directing VA facilities to remove buprenorphine prescribing as a delineated privilege and recommending reduced caseload expectations for those providing medical management of OUD. 26 More generally, to ensure ongoing progress in MOUD accessibility, policy and systems-level changes that could increase the proportion of patients prescribed MOUD include addressing financial and regulatory barriers (e.g., eliminating the x-waiver to prescribe buprenorphine), and expanding access to MOUD in non-specialty clinical settings (primary care, emergency department) as well as criminal justice settings (prison, jail).…”

“…26 More generally, to ensure ongoing progress in MOUD accessibility, policy and systems-level changes that could increase the proportion of patients prescribed MOUD include addressing financial and regulatory barriers (e.g., eliminating the x-waiver to prescribe buprenorphine), and expanding access to MOUD in non-specialty clinical settings (primary care, emergency department) as well as criminal justice settings (prison, jail). 25 , 27 Finalizing the temporary regulatory changes enacted during the COVID-19 pandemic, such as relaxing methadone take-home policies and telemedicine requirements, and waiving the need for an in-person visit prior to prescribing buprenorphine, may also be considered. Notably, these policy changes substantially lowered the barriers for patients to receive MOUD and have thus far not been shown to have negatively impacted patient outcomes, including mortality.…”

Accessibility to Medication for Opioid Use Disorder After Interventions to Improve Prescribing Among Nonaddiction Clinics in the US Veterans Health Care System

“… 45 SCOUTT details have been previously reported. 30 , 46 Training before launch included 2 webinars, followed by an in-person 2-day meeting in August 2018. Trainings introduced SCOUTT and 2 evidenced-based MOUD models: physician-led medical management and nurse-led collaborative care.…”

Expanding access to medications for opioid use disorder through locally-initiated implementation

“…At the clinic and system level, primary barriers to increased MOUD prescribing include logistical issues such as lack of time, increased costs, regulatory barriers and issues relating to insurance, such as low rates of reimbursement and a need for prior authorization. Others have identified abstinence-only treatment philosophy, lack of support from leadership, inadequate mental health and psychosocial support and lack of education about MOUD as important barriers to prescribing at the provider and clinic level [ 15 – 21 ].…”