Expanding Access to Medications for Opioid Use Disorder: Program and Policy Approaches from Outside the Veterans Health Administration

Abstract

To mitigate morbidity and mortality of the drug-related overdose crisis, the Veterans Health Administration (VHA) can increase access to treatments that save lives—medications for opioid use disorder (MOUD). Despite an increasing need, MOUD continues to be underutilized due to multifaceted barriers that exist within broader macro- and microenvironments. To promote MOUD utilization, policymakers and healthcare leaders should (1) identify and implement person-centered MOUD delivery systems (e.g., the Medication First Model, community-informed design); (2) recognize and address MOUD delivery gaps (e.g., the Best-Practice in Oral Opioid Agonist Collaborative); (3) broaden the definition of the MOUD delivery system (e.g., access to MOUD in non-clinical settings); and (4) expand MOUD options (e.g., injectable opioid agonist therapy). Increasing access to MOUD is not a singular fix to the overdose-related crisis. It is, however, a possible first step to mitigate harm, and save lives.

Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis

“…Clinicians have also begun to call for incorporation of addiction medicine specialists into multidisciplinary endocarditis care teams [ 8 , 47 , 48 ]. Improving access to OAT in general medical settings requires changes in several areas, including improved education for health professionals, prioritizing access to medications on-demand, enabling multiple medication treatment options, and decreasing patients’ out-of-pocket costs [ 31 , 49 ]. Many patients at both hospital sites also reported injecting stimulants; managing stimulant use disorder requires other addiction treatment and harm reduction strategies beyond OAT, including psychosocial interventions and access to sterile injecting equipment [ 7 , 11 ], which could also be facilitated by specialized inpatient addiction medicine consultation services.…”

Opioid agonist treatment and risk of death or rehospitalization following injection drug use–associated bacterial and fungal infections: A cohort study in New South Wales, Australia

“…Published rates of OAT engagement as part of discharge planning following hospitalization with injecting-related infections vary widely, including 8% in Boston, Massachusetts, US [ 31 ] and 81% in Saint John, New Brunswick, Canada [ 29 ]. Improving access to OAT requires clinical and regulatory changes, including improved education for health professionals, increasing the number of points of access and availability on-demand, facilitating multiple medication options, and decreasing out-of-pocket patient costs [ 59 ]. Infectious disease specialists should consider integrating OAT into their care of patients with injecting-related infections [ 29 , 60 ].…”

The introduction of a novel formulation of buprenorphine into organized health systems

“…Our findings also suggest that relatively few VHA patients receive BUP-XR, despite efforts in facilitating the extensive provision of MOUD and policies requiring it to be available ( Gordon et al., 2020 ) and despite encouraging results supporting the use of BUP-XR as a useful treatment option for complex treatment-resistant veterans with significant medical and psychosocial co-morbidities ( Cotton et al., 2021 ). System-level barriers that may reduce the prescribing of MOUD within the VHA include differences in policies and protocols compared with other local and state healthcare institutions—VHA systems operate locally but are under federal as opposed to state guidelines ( Priest et al., 2020 ). To facilitate the sharing of best practices and increase education, the VHA has invested in several nationwide initiatives to help improve access to MOUD, such as the Buprenorphine in the VA Initiative, the Medication Addiction Treatment Initiative, and the Stepped Care for Opioid Use Disorder Train the Trainer Initiative ( Gordon et al., 2020 ).…”