Office-based Opioid Treatment Program Research Articles

"I'm on the Right Path": Exploring 1-Month Retention in a Homeless-Tailored Outpatient-Based Opioid Treatment Program.

Homeless-tailored office-based opioid treatment (OBOT) programs have been developed to address the ongoing opioid overdose crisis, which disproportionately affects people experiencing homelessness. The objective of this study was to evaluate the facilitators of and barriers to retention in a homeless-tailored OBOT program. We performed in-depth qualitative interviews with 24 homeless-experienced adults who newly enrolled in Boston Health Care for the Homeless Program's OBOT program from January 6, 2022 through January 5, 2023. We purposively sampled participants based on whether they were retained at 1 month (n = 12) or not (n = 12). We used an abductive analytic process, applying codes to the interview transcripts from an a priori analytic framework based on the Behavioral Model for Vulnerable Populations and supplementing with emergent codes as needed. We compared themes by participants' 1-month retention status to explore facilitators of and barriers to retention in OBOT care. The average age was 41.9 years, 29.2% were female, 20.8% were Black, 58.3% were White, and 33.0% were Hispanic. Facilitators of retention common to many participants included the clinic experience, low-threshold model, clinic staff, and provision of comprehensive care. Among participants who were retained at 1-month, personal motivation, use of extended-release buprenorphine, and adequate buprenorphine efficacy were additional facilitators. Barriers to retention common to many participants included the clinic's surrounding environment, competing subsistence difficulties, and transportation difficulty. Among participants who were not retained at 1-month, opioid use severity, drug use in social networks, and inadequate buprenorphine efficacy represented additional barriers. We identified several common determinants of OBOT retention among our homeless-experienced participants as well as some facilitators and barriers that differed by 1-month retention status. These divergent factors represent potential points of intervention to promote retention in homeless-tailored OBOT programs.

COVID-19 and practice transformation: Building an office-based opioid treatment program in a family medicine residency practice.

This brief report describes how a family medicine residency practice (FMRP) leveraged a resident-led quality improvement project and a grant-funded Addiction Integrated Care Team (AICT) to initiate an office-based opioid treatment (OBOT) program to provide medications for opioid use disorder during the COVID-19 pandemic. In 2020, the practice experienced four disruptors that shifted motivation for practice development: (a) The COVID-19 pandemic demanded rapid change in primary care processes/staffing, including pivoting to telehealth/remote practice. (b) The practice's transition to a federally qualified community health center model meant a shift in organizational priorities that required offering OBOT services. (c) External grant resources became available through the AICT program to support practice core for OBOT, and 10 implementation strategies were utilized. (d) A resident champion implemented an OBOT quality improvement project. These efforts resulted in the practice offering the OBOT program and 18 patients receiving OBOT from January 2020 to February 2021, with 10 of 18 patients engaged for 12 months or longer. Further, the cumulative adoption and reach from January 2020 through September 2022 was 15 faculty and 14 residents becoming prescribers and 101 patients served within the OBOT program, respectively. FMRPs striving for significant practice transformation, such as implementing an OBOT program during a pandemic, may benefit from synergistic guidance and resources including established theory, strategies from the implementation science literature, and resident-led quality improvement efforts. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Patient-Centered Outcomes Associated With a Novel Office-Based Opioid Treatment Program in a District Health Department: Mixed Methods Pilot Study.

Granville and Vance counties have some of the highest opioid-related death rates in North Carolina, and have significant unmet needs with regard to opioid treatment. Medication for opioid use disorder (MOUD) is the most effective evidence-based approach to address opioid use disorder. Despite demonstrated efficacy and substantial need, access to MOUD is still insufficient in many parts of the United States. In order to connect patients with needed MOUD services, the district health department, Granville Vance Public Health (GVPH), established an office-based opioid treatment (OBOT) program. In this formative pilot study, we sought to describe patients' goals and outcomes in a program delivered at a rural local health department using an integrated care approach. We used a mixed methods concurrent nested research design. The primary method of investigation was one-on-one qualitative interviews with active OBOT patients (n=7) focused on patients' goals and perceived impacts of the program. Trained interviewers followed a semistructured interview guide developed iteratively by the study team. The secondary method was a descriptive quantitative analysis (79 patients; 1478 visits over 2.5 years) of treatment retention and patient-reported outcomes (anxiety and depression). Participants in the OBOT program were 39.6 years of age on average, and 25.3% (20/79) were uninsured. The average retention in the program was 18.4 months. The proportion of individuals in the program with moderate to severe depression (Patient Health Questionnaire-9 scores ≥10) decreased between program initiation (66%, 23/35) and at the most recent assessment (34%, 11/32). In qualitative interviews, participants credited the OBOT program for reducing or stopping the use of opioids and other substances (eg, marijuana, cocaine, and benzodiazepines). Many participants noted how the program helped them manage withdrawal symptoms and cravings, which helped them feel more in control of their use. Participants also attributed improvements in quality of life to the OBOT program, such as improved relationships with loved ones, improved mental and physical health, and improved financial stability. Initial data show promising patient outcomes for active GVPH OBOT participants, including reduction in opioid use and improvements in quality of life. As a pilot study, a limitation of this study is a lack of a comparison group. However, this formative project demonstrates promising patient-centered outcome improvements for GVPH OBOT participants.

Retention in Office-Based Opioid Treatment and Impact on Emergency Department Use in Adolescents and Young Adults With Opioid Use Disorder

PurposeLonger retention in medication treatment (MT) of addiction is associated with improved health outcomes among adults with opioid use disorder. MT remains underutilized among adolescents and young adults (AYA); factors associated with MT retention are not well-defined and effect of retention on treatment outcomes is unknown. This study examined patient characteristics associated with retention in an office-based opioid treatment program for AYA patients and determined the impact of retention time on emergency department (ED) utilization. MethodsThis was a retrospective study of AYA patients from January 1, 2009, to December 31, 2020. Retention time was the difference between first and last appointment, analyzing follow-up periods of one and two years. Linear regression assessed factors associated with retention. Negative binomial regression showed effect of retention on ED utilization. ResultsA total of 407 patients were included. Factors positively associated with retention were diagnosis of anxiety, depression, and nicotine use disorder, White race, private insurance, and Medicaid insurance; however, stimulant/cocaine use disorder was negatively associated (one-year follow-up, p ≤ .028; two-year follow-up, p ≤ .017). Longer retention was associated with reduced risk of ED utilization at one-year (incident rate ratio = 0.84, 95% confidence interval: 0.72–0.99; p = .03) and two-year follow-ups (incident rate ratio = 0.86 95% confidence interval: 0.77–0.96; p = .008). DiscussionDiagnosis of anxiety, depression, nicotine use disorder, and stimulant/cocaine use disorder, and insurance and race can influence retention in MT. Longer retention in MT was associated with lower ED visits, decreasing health care utilization. MT programs should evaluate various interventions to optimize opportunities for increasing retention among their patient cohorts.

Urine Drug Test Results Among Adolescents and Young Adults in an Outpatient Office-Based Opioid Treatment Program

PurposeUrine drug testing (UDT) is an important feature of outpatient treatment for opioid use disorder, but associations with patient characteristics among adolescent and young adult patients are unknown. This study assessed UDT results in office-based opioid treatment and characteristics associated with treatment compliance. MethodsThis was a retrospective study of adolescent and young adult patients enrolled in office-based opioid treatment between January 1, 2009, and December 31, 2020. UDT results were described as positive results or expected and unexpected results. Expected results were negative UDTs for opioids, marijuana (THC [tetrahydrocannabinol]), or cocaine/methamphetamine, or a positive UDT for buprenorphine. Unexpected results were positive UDTs for opioids, THC, or cocaine/methamphetamine, or a negative UDT for buprenorphine. Treatment compliance was defined as ≥75% of UDTs provided being expected results. Counts and percentages described UDT results. Regressions evaluated associations between patient characteristics (retention time, age, sex, race/ethnicity, insurance, and comorbid mental health diagnoses) with treatment compliance, and assessed change of positivity rates for UDTs over time. ResultsA total of 407 patients were included. Overall, 305 patients (74.9%) demonstrated treatment compliance. Rates of expected UDT results increased with longer retention time (p <.001), except for methamphetamine. Buprenorphine expected results ranged from 77.0% to 96.5%. Diagnosis of stimulant use disorder was associated with decreased compliance (p = .04), while diagnoses of depression, anxiety, nicotine use disorder, and post-traumatic stress disorder were associated with increased compliance (p ≤.04). DiscussionProportion of expected UDT results increased with retention time. Diagnosis of specific mental health conditions affected treatment compliance. Further research regarding long-term health outcomes is needed.

Nurse-Sensitive Indicators in the Care of Individuals With Opioid Use Disorder.

Patients with opioid use disorder (OUD) seek care in primary care settings where nurses support the provision of medication-assisted treatment. Office-based opioid treatment (OBOT) that includes buprenorphine hydrochloride administration under the supervision of a nurse for stabilization and maintenance therapy has the potential to improve outcomes for patients with OUD in primary care settings. However, the first step is to determine if OBOT nurses provide nurse-sensitive care, which consists of activities that have been shown to make a difference in patient outcomes. Content analysis of 368 nursing notes from 100 patients enrolled in an OBOT program in an urban hospital-based primary care clinic was conducted. Data were analyzed descriptively according to quantity and qualitatively according to the content. Entries indicative of care coordination and transition management were extracted. Seven content categories within care coordination were identified, including harm reduction, medication management, symptom management, communication between providers, promoting adherence, self-management goal setting, and patient education. Four areas within transition management were identified including supporting connections to resources, referrals for care, medication reconciliation, and communication with other facilities. Care coordination was documented more frequently than transition management. The presence of nurse-sensitive indicators provides evidence for and distinguishes the role of the nurse in OUD care.

Non–prescribed buprenorphine preceding treatment intake and clinical outcomes for opioid use disorder

ObjectiveSuccessful retention on buprenorphine improves outcomes for opioid use disorder (OUD); however, we know little about associations between use of non–prescribed buprenorphine (NPB) preceding treatment intake and clinical outcomes. MethodsThe study conducted observational retrospective analysis of abstracted electronic health record (EHR) data from a multi-state nationwide office-based opioid treatment program. The study observed a random sample of 1000 newly admitted patients with OUD for buprenorphine maintenance (2015–2018) for up to 12 months following intake. We measured use of NPB by mandatory intake drug testing and manual EHR coding. Outcomes included hazards of treatment discontinuation and rates of opioid use. ResultsCompared to patients testing negative for buprenorphine at intake, those testing positive (59.6%) had lower hazards of treatment discontinuation (HR = 0.52, 95% CI: 0.44, 0.60, p < 0.01). Results were little changed following adjustment for baseline opioid use and other patient characteristics (aHR: 0.60, 95% CI: 0.51, 0.70, p < 0.01). Risk of discontinuation did not significantly differ between patients by buprenorphine source: prescribed v. NPB (reference) at admission (HR = 1.15, 95% CI: 0.90, 1.46). Opioid use was lower in the buprenorphine positive group at admission (25.0% vs. 53.1%, p < 0.0001) and throughout early months of treatment but converged after 7 months for those remaining in care (17.1% vs. 16.5%, p = 0.89). ConclusionNPB preceding treatment intake was associated with decreased hazards of treatment discontinuation and lower opioid use. These findings suggest use of NPB may be a marker of treatment readiness and that buprenorphine testing at intake may have predictive value for clinical assessments regarding risk of early treatment discontinuation.

Primary care and medication management characteristics among patients receiving office-based opioid treatment with buprenorphine.

Office-based opioid treatment (OBOT) is an evidence-based treatment model for opioid use disorder (OUD) offered by both addiction and general primary care providers (PCPs). Calls exist for more PCPs to offer OBOT. Few studies have been conducted on the primary care characteristics of OBOT patients. To characterize medical conditions, medications, and treatment outcomes among patients receiving OBOT with buprenorphine for OUD, and to describe differences among patients by age and by time in care. This study is a retrospective review of medical records on or before 4/29/2019 at an outpatient primary care clinic within a nonprofit addiction treatment setting. Inclusion criterion was all clinic patients actively enrolled in the OBOT program. Patients not prescribed buprenorphine or with no OBOT visits were excluded. Of 355 patients, 42.0% had another PCP. Common comorbid conditions included chronic pain and psychiatric diagnosis. Few patients had chronic viral hepatitis or HIV. Patients reported a median of 4 medications. Common medications were cardiovascular, antidepressant, and nonopioid pain agents. Older patients had a higher median number of medications. There was no significant difference in positive opioid urine toxicology (UT) based on age, chronic pain status, or psychoactive medications. Patients retained >1 year were less likely to have positive opioid UT. Clinical needs of many patients receiving OBOT are similar to those of the general population, supporting calls for PCPs to provide OBOT.

Hepatitis C Treatment Among People Who Use Drugs in an Office-Based Opioid Treatment Program Versus a Syringe Exchange Program: A Real-World Prospective Clinical Trial

Background: Hepatitis C Virus (HCV) treatment in people who inject drugs (PWID) is a key component of elimination models but PWID face substantial barriers to treatment access. Despite data showing treatment outcomes among PWID on medications for opioid use disorder (MOUD) are similar to non-PWID outcomes, few studies examine PWID treatment outcomes with only syringe services support. Objectives: To evaluate the effect of recruitment for HCV treatment with elbasvir/grazoprevir (E/G) in a syringe services program (SSP) as compared to an MOUD program for people with opioid use disorder. Methods: This real-world, multi-site prospective open-label pilot study compares treatment of PWID with aspartate aminotransferase to platelet ratio (APRI) &lt; 0.7 and genotype 1a, 1b, and 4 HCV with E/G, engaged in MOUD (n = 25) or an SSP (n = 25). The MOUD arm was enrolled through a federally qualified community health center and SSP arm through a nearby SSP. Prospective arms were compared to an academic hepatology clinic group (n = 50). Sustained virologic response at 12 weeks (SVR12), medication adherence, and treatment discontinuation were evaluated. Results: In the MOUD vs SSP arms, substance use throughout treatment was found in 36% (9/25) vs 100% (25/25); good adherence (&gt; 90% pills taken) in 100% (25/25) vs 68% (17/25); treatment completion 100% (25/25) vs 64% (16/25); and SVR12 rates were 96% (24/25) vs 60% (15/25). In the community standard comparison group, SVR12 was achieved in 94% (47/50). There were two virologic failures or re-infections in the SSP group; all other non-responders were due to missing SVR12 data. Conclusions: While recruitment and follow-up are challenging in SSPs, preliminary data suggests adherence, treatment completion, and SVR12 are high in PWID treated with E/G engaging in SSP or MOUD. All metrics are comparable to community standards for non-PWID for treatment of HCV with direct-antiviral drugs.

"I'm a Survivor": Perceptions of Chronic Disease and Survivorship Among Individuals in Long-Term Remission from Opioid Use Disorder.

BackgroundWhile opioid use disorder (OUD) is prevalent, little is known about what patients with OUD in sustained remission think about the chronic disease model of OUD and their perspectives of the cause, course, and ongoing treatment needs of their OUD.ObjectiveTo (1) examine patient perceptions of the chronic disease model of addiction and disease identity and (2) use an explanatory model framework to explore how these perceptions inform ongoing treatment needs and help maintain abstinence.DesignQualitative study of a cross-sectional cohort of patients with OUD in long-term sustained remission currently receiving methadone or buprenorphine. Participants completed a single in-depth, semi-structured individual interview.ParticipantsTwenty adults were recruited from two opioid treatment programs and two office-based opioid treatment programs in Baltimore, MD. Half of the participants were Black, had a median (IQR) age of 46.5 (43–52) years and the median (IQR) time since the last non-prescribed opioid was 12 (8–15) years.ApproachHybrid deductive-inductive thematic analysis of the transcribed interviews.Key ResultsSome participants described a chronic OUD disease identity where they continue to live with OUD. Participants who maintain an OUD identity describe inherent traits or predetermination of developing OUD. Maintaining a disease identity helps them remain vigilant against returning to drug use. Others described a post-OUD/survivor identity where they no longer felt they had OUD, but the experience remains. Each perspective informed attitudes about continued treatment with methadone or buprenorphine and strategies to remain in remission.ConclusionsThe identity that people with OUD in sustained remission maintain was the lens through which they viewed other aspects of their OUD including cause and ongoing treatment needs. An alternative, post-OUD/survivorship model emerged or was accepted by participants who did not identify as currently having OUD. Understanding patient perspectives of OUD identity might improve patient-centered care and improve outcomes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06925-z.

Staff Attitudes toward Buprenorphine before and after Implementation of an Office-Based Opioid Treatment Program in an Urban Teaching Clinic

Purpose Improving access to buprenorphine treatment is necessary to address the national opioid use disorder (OUD) crisis. This study investigates attitudes about buprenorphine prescribing among staff at a primary care clinic and compares attitudes before and after implementation of an office-based opioid treatment (OBOT) program. Methods Providers and staff in an academic primary care clinic were surveyed prior to and one year following implementation of an OBOT program. Descriptive statistics, Pearson’s Chi-2 tests and logistic regression models were used to compare staff and provider attitudes about use of buprenorphine for OUD and to compare attitudes before and after OBOT implementation. Results At baseline, 20% of staff indicated strong belief that buprenorphine is an effective treatment for OUD and 16% indicated strong belief that primary care providers should prescribe it. Staff appeared less likely than providers to believe strongly that buprenorphine is effective (OR 0.24, 95% CI= 0.08-.78, p = 0.02; aOR 0.28, 95% CI=.08-1.0, p = 0.05 adjusted for age, race and gender). Following implementation of an OBOT program, the percentage of staff who believed strongly in the effectiveness of buprenorphine for OUD increased from 20% to 40% (p = 0.31), and the percentage who believed that primary care providers (PCPs) should prescribe it increased from 16% to 30% (p = 0.52). Conclusions Staff in a primary care clinic were less likely than providers to believe in the effectiveness of buprenorphine treatment or that PCPs should prescribe it for OUD. That their beliefs substantially changed after implementation of an OBOT program suggests that direct experience impacts attitudes.

Designing and Evaluating COVID-19 Protocols for an Office-Based Opioid Treatment Program in an Urban Underserved Setting

Despite changing federal regulations for providing telehealth services and provision of controlled substances during the COVID-19 pandemic, there is little guidance available for office-based opioid treatment (OBOT) programs integrated into primary care settings. (1) Develop disaster-preparedness protocols specific to the COVID-19 pandemic for an urban OBOT program, and (2) evaluate the impacts of the protocol and telehealth on care. Disaster-preparedness protocols specific to the COVID-19 pandemic were developed for an urban OBOT program, implemented on March 16, 2020. Retrospective chart review compared patients from January 1, 2020 to March 13, 2020, to patients from March 16, 2020 to April 30, 2020, abstracting patient demographics and comparing show and no-show rates between studied groups. The disaster-preparedness protocol was developed under a deliberative process to address social issues of the urban underserved population. Of 852 visits conducted between Jan 1, 2020, and April 30, 2020, a 91.7% show rate (n = 166/181) was documented for telemedicine visits after protocol implementation compared with a 74.1% show rate (n = 497/671) for routine in-person care (P = .06) without significant differences between the study populations. The no-show rate was significantly lower after protocol implementation (8.3% vs 25.9%; P <0.05). OBOTs require organized workflows to continue to provide services during the COVID-19 pandemic. Telemedicine, in the face of relaxed federal regulations, has the opportunity to enhance addiction care, creating a more convenient as well as an equally effective mechanism for OBOTs to deliver care that should inform future policy.

Systematic content analysis of patient evaluations of START NOW psychotherapy reveals practical strategies for improving the treatment of opioid use disorder

BackgroundClinical trials provide consistent evidence for buprenorphine’s efficacy in treating opioid use disorder (OUD). While the Drug Addiction Treatment Act of 2000 requires physicians to combine medication-assisted treatment (MAT) with behavioral intervention, there is no clear evidence for what form or elements of psychotherapy are most effective when coupled with MAT to treat OUD. This investigation involves focus groups designed to collect patient opinions about a specific psychotherapy, called START NOW, as well as general beliefs about various elements of psychotherapy for treating OUD. Our analysis reveals trends about patient preferences and strategies for improving OUD treatment.MethodsSubjects included patients enrolled in buprenorphine/naloxone MAT at our institution’s office-based opioid treatment program. All subjects participated in a single START NOW group session, which was led by a provider (physician or nurse practitioner trained and standardized in delivering START NOW). Consented subjects participated in satisfaction surveys and audio-recorded focus groups assessing individual beliefs about various elements of psychotherapy for treating OUD.ResultsOverall, 38 different focus groups, 92 participation events, and 44 unique subjects participated in 1-to-6 different START NOW session/audio-recorded focus group sessions led by a certified moderator. Demographic data from 36/44 subjects was collected. Seventy-five percent (33/44) completed the START NOW Assessment Protocol, which revealed self-reported behavioral trends. Analysis of all 92 START NOW Satisfaction Questionnaire results suggests that subjects’ opinions about START NOW improved with increased participation. Our analysis of audio-recorded focus groups is divided into three subsections: content strategies for new psychotherapies, implementation strategies, and other observations. For example, participants request psychotherapies to target impulsivity and to teach future planning and build positive relationships.ConclusionsThe results of this study may guide implementation of psychotherapy and improve the treatment of OUD, especially as it relates to improving the modified START NOW program for treating OUD. Our study also reveals a favorable outlook of START NOW with increased participation, suggesting that any initial reticence to this program can be overcome to allow for effective implementation.

Buprenorphine Dosage and Urine Quantitative Buprenorphine, Norbuprenorphine, and Creatinine Levels in an Office-Based Opioid Treatment Program.

Background:Treatment progress is routinely monitored by urine testing in patients with opioid use disorder (OUD) undergoing buprenorphine medication-assisted treatment (MAT). However, interpretation of urine test results could be challenging. This retrospective study aims to examine the results of quantitative buprenorphine, norbuprenorphine, and creatinine levels in urine testing in relation to sublingual buprenorphine dosage to facilitate an accurate interpretation of urine testing results.Methods:We reviewed the medical charts of 41 consecutive patients, who were residing in halfway houses where their medication intake was closely monitored and who had enrolled in an office-based MAT program at an urban clinic between July 2018 and June 2019. The patients’ urine testing results were reviewed, and demographic variables were recorded. We focused on the patients treated with 8-, 12-, or 16-mg/day of buprenorphine, examining their urine buprenorphine, norbuprenorphine, and creatinine levels. Analysis of variance tested the statistical association between the dosage and urine testing results on the norbuprenorphine-to-creatinine ratio.Results:A total of 240 urine samples from 41 patients were included for this study. The 41 patients received a mean buprenorphine dose of 10.5 ± 3.7 mg/day (range, 4-20 mg/day). Then, this study examined the distribution of the 240 urine samples and then focused on 184 urine samples that came from the 33 patients who were treated with 8-, 12-, and 16-mg/day of buprenorphine, the 3 most common dosages. All of the 184 urine samples had a creatinine level of >20 mg/dL and buprenorphine-to-norbuprenorphine ratio <50:1. The average norbuprenorphine-to-creatinine ratio in the 8 mg/day dosage group was 3.85 ± 2.24 × 10−4 (n = 66; range, 0.44-11.12). The respective ratios in the 12- and 16-mg dosage groups were 5.64 ± 3.40 × 10−4 (n = 83; range, 1.55-22.72) and 6.23 ± 4.92 × 10−4 (n = 35; range, 1.37-27.12). The 3 dosage groups differed significantly in the mean ratios (P < .01), except when the 12- and 16-mg dosage groups were compared (P = .58). The results of this study thus suggest that prescribers should pay attention to the following features: (1) unexpected substance(s) in urine testing, (2) creatinine level under 20 mg/dL, (3) buprenorphine-to-creatinine ratio over 50:1, (4) buprenorphine dosage over 24 mg/day, and (5) norbuprenorphine-to-creatinine ratio consistently under 0.5 × 10−4 in patients treated with 8 mg/day or 1.5 × 10−4 in patients treated with 12 mg/day or more.Conclusion:This study suggested parameters for interpreting quantitative urine test results in relation to buprenorphine intake dose in office-based opioid treatment programs.

Establishing a Telehealth Program in Primary Care for the Treatment of Opioid Use Disorder.

More than 130 Americans die from opioid overdose each day. To address the opioid epidemic, opioid treatment programs are in place to treat substance use disorder. These programs have seen an influx of patients and are not able to accommodate the number of patients. Primary care practices can help with the crisis by providing an office-based opioid treatment (OBOT) program. To describe the necessary steps and considerations to put in place for implementing a telehealth OBOT program. Establishing a telehealth program for patients controlled on medication-assisted treatment can improve access to care, improve patient compliance, and redirect the workflow of the family practice. After a literature review of established OBOT programs, state and federal laws, Medicare and reimbursement policies, a telehealth opioid treatment program was designed for private primary care practice. Primary care practices can should implement an office based opioid treatment program via telehealth to improve workflow and accessibility to care. To offer improved access to care for patients with opioid addiction and seamless workflow in the office-based setting, primary care practices should consider establishing their telehealth OBOT program based on the following recommendations.

Video directly observed therapy intervention using a mobile health application among opioid use disorder patients receiving office-based buprenorphine treatment: protocol for a pilot randomized controlled trial

BackgroundOffice-based buprenorphine treatment of opioid use disorder (OUD) does not typically include in-person directly observed therapy (DOT), potentially leading to non-adherence. Video DOT technologies may safeguard against this issue and thus enhance likelihood of treatment success. We describe the rationale and protocol for the Trial of Adherence Application for Buprenorphine treatment (TAAB) study, a pilot randomized controlled trial (RCT) to evaluate the effects of video DOT delivered via a smartphone app on office-based buprenorphine treatment outcomes, namely illicit opioid use and retention.MethodsParticipants will be recruited from office-based opioid addiction treatment programs in outpatient clinics at two urban medical centers and randomized to either video DOT (intervention) delivered via a HIPAA-compliant, asynchronous, mobile health (mHealth) technology platform, or treatment-as-usual (control). Eligibility criteria are: 18 years or older, prescribed sublingual buprenorphine for a cumulative total of 28 days or less from the office-based opioid treatment program, and able to read and understand English. Patients will be considered ineligible if they are unable or unwilling to use the intervention, provide consent, or complete weekly study visits. All participants will complete 13 in-person weekly visits and be followed via electronic health record data capture at 12- and 24-weeks post-randomization. Data gathered include the following: demographics; current and previous treatment for OUD; self-reported diversion of prescribed buprenorphine; status of their mental and physical health; and self-reported lifetime and past 30-day illicit substance use. Participants provide urine samples at each weekly visit to test for illicit drugs and buprenorphine. The primary outcome is percentage of weekly urines that are negative for opioids over the 12-weeks. The secondary outcome is engagement in treatment at week 12.DiscussionVideo DOT delivered through mHealth technology platform offers possibility of improving patients’ buprenorphine adherence by providing additional structure and accountability. The TAAB study will provide important preliminary estimates of the impact of this mHealth technology for patients initiating buprenorphine, as well as the feasibility of study procedures, thus paving the way for further research to assess feasibility and generate preliminary data for design of a future Phase III trial.Trial Registration ClinicalTrails.gov, NCT03779997, Registered on December 19, 2018.

Outcomes of a novel office-based opioid treatment program in an internal medicine resident continuity practice

BackgroundThe integration of opioid use disorder (OUD) care and competencies in graduate medical education training is needed. Previous research shows improvements in knowledge, attitudes, and practices after exposure to OUD care. Few studies report outcomes for patients with OUD in resident physician continuity practices.MethodsA novel internal office-based opioid treatment (OBOT) program was initiated in a resident continuity clinic. Surveys of resident and staff knowledge and attitudes of OBOT were administered at baseline and 4 months. A retrospective chart review of the 15-month OBOT clinic obtained patient characteristics and outcomes.ResultsTwelve patients with OUD were seen in the OBOT clinic. Seven patients (58%) were retained in care at the end of the study period for a range of 9–15 months. Eight patients demonstrated a good clinical response. Surveys of residents and staff at 4 months were unchanged from baseline showing persistent lack of comfort in caring for patients with OUD.ConclusionsOBOT can be successfully integrated into resident continuity practices with positive patient outcomes. Improvement in resident and staff attitudes toward OBOT were not observed and likely require direct and frequent exposure to OUD care to increase acceptance.

Patient Barriers and Facilitators to Medications for Opioid Use Disorder in Primary Care

Introduction: This study explored factors influencing patient access to medications for opioid use disorder (OUD), particularly for individuals eligible but historically suboptimal follow-up with in-house referrals to office-based opioid treatment (OBOT). Objectives: In-depth qualitative interviews among a mostly underserved sample of adults with OUD elicited: 1) knowledge and experiences across the OUD treatment cascade; and 2) more nuanced elements of patient-centered care, including shared decision making with providers, experiences in OBOT versus specialty addiction treatment, transitioning from methadone to buprenorphine or extended-release naltrexone (XR-NTX), and voluntary discontinuation of medications for OUD. Methods: We conducted semi-structured qualitative interviews between January and February of 2018 among adult inpatient detoxification program patients with OUD (n = 23). Preliminary analysis of interviews yielded key themes and ideas that were coded from a grounded theory approach. Results: Willingness to engage with OBOT was influenced by a complex array of practical considerations, including access to patient-centered care in OBOT settings, positive experiences with illicitly obtained buprenorphine, and differential experiences pertaining to OBOT versus specialty addiction treatment. Responses were generally favorable towards OBOT with buprenorphine, yet knowledge regarding extended-release naltrexone was limited. Respondents were often frustrated by clinicians when requesting to transition from methadone to buprenorphine or XR-NTX. Lastly, participants elucidated limited access to OBOT programs in underserved neighborhoods and suburban settings. Conclusion: Limited access to patient-centered care in OBOT with buprenorphine and extended-release naltrexone may exacerbate challenges to retention and/or reengagement with OUD care.

In Case You Haven't Heard…

Remember the MAT‐PDOA (Medication Assisted Treatment–Prescription Drug and Opioid Addiction) grant program from the Substance Abuse and Mental Health Services Administration? It ended last September. Robert Ashford, a recovery advocate who is managing editor of the new Journal of Recovery Science, came in after the first year and headed up technical assistance (TA) for it. There were so many challenges to getting people educated about treatment. Twenty‐eight single state authorities (SSAs) received the funding. Some SSAs opted to make opioid treatment programs (OTPs) subrecipients under statewide grants, and many office‐based opioid treatment (OBOT) programs received funding. Ashford recalled that 60 to 80 percent of the training was on enhancing psychosocial reports, with the additional training on best practices for prescribing and induction. In some states, patients were titrated off their buprenorphine or methadone if they took benzodiazepines, and in some, they were refused induction altogether. “This wasn't always coming from the SSA; it was coming from individual lower‐level providers,” he said. Punishing people for using drugs by reducing their take‐home doses of methadone or buprenorphine is bad, he said. “But kicking people out of treatment is worse,” he said. The worst culprits were not the OTPs — they were the OBOT programs, or the Federally Qualified Health Centers (FQHCs) who contracted with them, he said. “There was a lot more sense that clients could be removed from the FQHC programs for noncompliance,” he said. “Sometimes, they would be discharged to a higher level of care. It wasn't a regulation, but many providers were doing it.” This raises questions about the kind of TA that is going to STR and SOR grantees and subrecipients. MAT‐PDOA grants were minuscule by comparison — $25,000. Some states, like Missouri, spent down their STR money quickly, with medication‐first, mainly buprenorphine. Missouri got a lot of patients into treatment by not requiring counseling. “As soon as you require, say, nine hours of clinical engagement, and they want to get reimbursed for it…,” he said, trailing off. “We have a lot of people who aren't getting the medication they need.” This is the purpose of TA: educating providers. But it doesn't always work. “We can educate all day long, but some of these philosophies are too deeply rooted,” he said.

Provider and patient perspectives on barriers to buprenorphine adherence and the acceptability of video directly observed therapy to enhance adherence

BackgroundBuprenorphine effectively reduces opioid craving and illicit opioid use. However, some patients may not take their medication as prescribed and thus experience suboptimal outcomes. The study aim was to qualitatively explore buprenorphine adherence and the acceptability of utilizing video directly observed therapy (VDOT) among patients and their providers in an office-based program.MethodsClinical providers (physicians and staff; n = 9) as well as patients (n = 11) were recruited from an office-based opioid treatment program at an urban academic medical center in the northwestern United States. Using a semi-structured guide, interviewers conducted individual interviews and focus group discussions. Interviews were digitally recorded and transcribed verbatim. Transcripts were independently coded to identify key themes related to non-adherence and then jointly reviewed in an iterative fashion to develop a set of content codes.ResultsAmong providers and patients, perceived reasons for buprenorphine non-adherence generally fell into several thematic categories: social and structural factors that prevented patients from consistently accessing medications or taking them reliably (e.g., homelessness, transportation difficulties, chaotic lifestyles, and mental illness); refraining from taking medication in order to use illicit drugs or divert; and forgetting to take medication, especially in the setting of taking split-doses. Some participants perceived non-adherence to be less of a problem for buprenorphine than for other medications. VDOT was viewed as potentially enhancing patient accountability, leading to more trust from providers who are concerned about diversion. On the other hand, some participants expressed concern that VDOT would place undue burden on patients, which could have the opposite effect of eroding patient-provider trust. Others questioned the clinical indication.ConclusionsFindings suggest potential arenas for enhancing buprenorphine adherence, although structural barriers will likely be most challenging to ameliorate. Providers as well as patients indicated mixed attitudes toward VDOT, suggesting it would need to be thoughtfully implemented.