Office-based Opioid Treatment Research Articles

780. Inpatient Addiction Medicine Consultations at the Urban/Rural Frontier: Improving Quality of Care and Linkage to Outpatient Services for Patients with Substance Use Disorder in Central Kentucky

BackgroundWhen persons with opioid use disorder (OUD) are hospitalized with medical complications (e,g. endocarditis, viral hepatitis) they frequently do not receive medications for the underlying OUD. In recent years, a number of hospitals have implemented addiction medicine consultation (AMC) services to help address this treatment gap, though these are all in large urban centers. AMCs provide comprehensive substance use disorder (SUD) assessments, manage SUDs, initiate pharmacotherapy for OUD, and arrange linkage to ongoing treatment. The aim of this study was to describe the initial implementation and outcomes of a new AMC at the University of Kentucky Hospital, a 945-bed tertiary referral center with a large rural catchment.MethodsThe Addiction Consultation and Education Service(ACES) began October, 2018 and was comprised of several physicians and an APRN. A patient navigator assisted with prior authorizations and outpatient linkage. ACES referred to a new bridge clinic at the University for ongoing office-based opioid treatment as well as to community programs and licensed opioid treatment programs. Patient demographics, SUD diagnoses, and comorbidities (including details of the injection-related infections) are collected from the electronic health record, as well as key process metrics including: time-to-consultation and medication initiation, length of stay(LOS), discharge against medical advice(AMA), and details of linkage to outpatient services.ResultsFrom October-December, 91 patients were seen, 73 met DSM-5 criteria for OUD, 82 had a medical complication of SUD, and 53 lived in rural counties (Rural-Urban Continuum Codes 4–9). Average LOS was 19.5 days. Among OUD patients, 71% underwent buprenorphine/naloxone induction, 9% were started on methadone. Less than 6% of patients started on buprenorphine or methadone left against medical advice.ConclusionAMCs are a key part of providing comprehensive care for persons hospitalized with infectious complications of substance use. Initiating medication for OUD likely decreases rates of discharge against medical advice. Compared with other AMCs, a greater percentage of patients seen by ACES resided in rural counties. Establishing a bridge clinic prior to starting an AMC is critical to ensure ongoing care.Disclosures All authors: No reported disclosures.

Perspectives on the HIV continuum of care among adult opioid users in New York City: a qualitative study

BackgroundEngagement in the HIV care continuum combined with office-based opioid treatment remains a cornerstone in addressing the intertwined epidemics of opioid use disorder (OUD) and HIV/AIDS. Factors influencing patient engagement with OUD and HIV care are complex and require further study.MethodsIn this qualitative study, in-depth interviews were conducted among 23 adult patients who use drugs (PWUD) in an inpatient detoxification program in New York City. The semi-structured interview guide elicited participant experiences with various phases of the HIV care continuum, including factors influencing access to HIV care, interactions with HIV and primary care providers, preferences around integrated care approaches for OUD and HIV, and barriers experienced beyond clinical settings which affected access to HIV care (e.g., insurance issues, transportation, cost, retrieving prescriptions from their pharmacy). Data collection and thematic analysis took place concurrently using an iterative process-based established qualitative research method.ResultsRespondents elicited high acceptability for integrated or co-located care for HIV and OUD in primary care. Factors influencing engagement in HIV care included (1) access to rapid point-of-care HIV testing and counseling services, (2) insurance coverage and costs related to HIV testing and receipt of antiretroviral therapy (ART), (3) primary care providers offering HIV care and buprenorphine, (4) illicit ART sales to pharmacies, (5) disruption in supplies of ART following admissions to inpatient detoxification or residential treatment programs, (6) in-person and telephone contact with peer support networks and clinic staff, (7) stigma, and (8) access to administrative support in primary care to facilitate reengagement with care following relapse, behavioral health services, transportation vouchers, and relocation from subsidized housing exposing patients to actively using peers.ConclusionThese findings suggest expanding clinical and administrative support in primary care for PWUDs with patient navigators, case managers, mobile health interventions, and peer support networks to promote linkage and retention in care.

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.

Expanding treatment for opioid use disorder in publicly funded primary care clinics: Exploratory evaluation of the NYC health + hospitals buprenorphine ECHO program

Project Extension for Community Healthcare Outcomes (Project ECHO) offers an innovative and low-cost approach to enhancing the management of complex conditions among primary care providers. The NYC Health + Hospitals Buprenorphine ECHO (H + H ECHO) program offers primary care providers (PCPs) training and support in managing opioid use disorder (OUD). This exploratory study assessed the feasibility of a 16-session video conferencing platform led by Addiction Medicine experts in improving addiction knowledge, perceived self-efficacy, and buprenorphine prescribing among PCPs located in 17 publicly-funded ambulatory care clinics. A pre- and post-training survey assessed changes in knowledge and self-efficacy. Buprenorphine prescribing patterns were also captured pre-post training. Training sessions consisted of a review of the agenda by the H + H ECHO hub team, 15–30 min didactic lectures led by specialists, followed by a patient case presentation. Participants attended an average of 9 lectures (range, 1–15 sessions) and 53% of trainees attended at least 10 of the 16 sessions. Perceived self-efficacy improved post-H + H ECHO (73.2%) versus pre-training survey results (58.1%). There were minimal increases in knowledge post-training (58.4%) versus pre-training (51.4%). Only three additional providers reported prescribing Buprenorphine post-training (n = 10) versus pre-training (n = 7). Suggestions for improving H + H ECHO included trainings addressing stigma, administrative support, improved referrals to office-based opioid treatment (OBOT), integration of non-physician staff (i.e., case management, social work), and combining multimodal learning strategies (i.e., podcasts, web-based modules) with videoconferencing. This study demonstrates the feasibility of H + H ECHO among PCPs in publicly-funded clinics and improvements in self-efficacy. Studies are needed to identify alternative strategies to improve knowledge and prescribing of buprenorphine post-H + H ECHO.

Patient perceptions of treatment with medication treatment for opioid use disorder (MOUD) in the Vermont hub-and-spoke system

In 2013, Vermont leaders implemented the “hub-and-spoke” (H & S) system to increase access to medication treatment for opioid use disorder (MOUD). “Hubs” are licensed specialty opioid treatment programs (OTPs) with the authority to dispense buprenorphine/naloxone and methadone. “Spokes” are primary care practices that provide office-based opioid treatment, primarily with buprenorphine/naloxone. This report describes the qualitative component of an evaluation of the H&S system, conducted in 2016. The qualitative data collection assessed patient perspectives about the positive and negative aspects of treatment in the H & S system. The data collected included 80 responses to five open-ended questions and 24 in-depth interviews. Five open-ended questions were completed with hub (n = 40) and spoke (n = 40) participants. In-depth qualitative interviews were conducted with different hub (n =12) and spoke (n =12) participants. Findings from both data collection approaches suggest positive perceptions about treatment overall by patients treated in both settings. Participants treated in spokes reported a positive treatment environment, minimal stigma, and few obstacles to treatment and a strong positive relationship with their prescriber. Hub patients valued the MOUD and expressed gratitude for having access to MOUD, but reported the treatment environment was somewhat challenging, with long lines and drug talk in the clinic, high staff turnover and “cookie cutter” treatment. There appear to be some differences in patient perceptions of MOUD treatment between patients treated in primary care settings and specialized OTP settings.

Integrated outpatient treatment of opioid use disorder and injection-related infections: A description of a new care model

Persons with opioid use disorder (OUD) hospitalized with severe, injection-related infections (SIRI) are frequently hospitalized for the duration of IV antibiotic treatment due to concerns regarding their eligibility for outpatient parenteral antimicrobial therapy (OPAT), which is the standard of care for prolonged IV antibiotic courses for patients without drug use. As part of a pilot study, a novel, integrated care model was developed where patients with OUD and SIRI receive addiction consultation and buprenorphine induction while hospitalized, followed by ongoing management in an outpatient clinic that combines office-based opioid treatment with buprenorphine pharmacotherapy and counseling services with OPAT. Through three illustrative case vignettes the outpatient model is described along with challenges, lessons learned and future directions.

Responding to the opioid and overdose crisis with innovative services: The recovery community center office-based opioid treatment (RCC-OBOT) model

Opioid use disorder (OUD) and opioid-related overdose mortality are major public health concerns in the United States. Recently, several community-based and professional innovations - including hybrid recovery community organizations, peer-based emergency department warm handoff programs, emergency department buprenorphine induction, and low-threshold OUD treatment programs - have emerged or expanded in an effort to address significant obstacles to providing patients the care needed for OUD and to reduce the risk of overdose. Additional innovations are needed to address the crisis. Building upon the foundational frameworks of each of these recent innovations, a new model of OUD pharmacotherapy is proposed and discussed: the Recovery Community Center Office-Based Opioid Treatment model. Additionally, two potential implementation scenarios, the overdose and non-overdose event protocols, are detailed for communities, peers, and practitioners interested in implementing the model. Potential barriers to implementation of the model include service reimbursement, licensing regulations, and organizational concerns. Future research should seek to validate the model and to identify actual implementation and sustainability barriers and best practices.

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.

Primary Care Residents Delivering Care: Integration of Office-Based Opioid Treatment into an Internal Medicine Residency Curriculum.

Primary Care Residents Delivering Care: Integration of Office-Based Opioid Treatment into an Internal Medicine Residency Curriculum.

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.

The role of social work in the opioid epidemic: office-based opioid treatment programs

ABSTRACTThe opioid epidemic is a national emergency in the United States. To meet the needs of individuals diagnosed with Opioid Use Disorder (OUD) office-based opioid treatment programs (OBOT) are quickly expanding. However, social workers roles in OBOT programs are not clearly described. This paper will emphasize three roles social workers may fulfill in OBOT programs to combat the opioid crisis.

Development and Implementation of Tennessee Nonresidential Buprenorphine Treatment Guidelines.

To describe the recent legislation in Tennessee and subsequent development and implementation of state-wide buprenorphine treatment guidelines. In 2016, Tennessee began licensing office-based opioid treatment (OBOT) clinics. Due to initial licensing criteria, not all providers were required to be licensed with the Department of Mental Health and Substance Abuse Services (TDMHSAS). The gap in licensing made it difficult to ensure an appropriate standard of care was being met by all addiction treatment providers. Therefore, the state developed legislation that allowed for the creation of best practice guidelines to encompass all providers of buprenorphine in the state of Tennessee, not just the licensed OBOT clinics. The guidelines define what the standard of care should entail while treating this vulnerable addiction population. Tennessee legislation granted the formation of a committee to create the Tennessee Nonresidential Buprenorphine Treatment Guidelines. The committee was comprised of physicians, pharmacists, lawyers, law enforcement, and state officials. The finalized guidelines were published and effective January 1, 2018, and adopted as policy by the boards of medical examiners, osteopathic examination, and pharmacy shortly thereafter. The guidelines are now enforceable by the boards and give them the ability to discipline physicians who practice outside the standard of care. Tennessee legislation provides a model for other states to take action in combating this opioid crisis by not only increasing access to addiction treatment, but increasing access to quality care.

Training in office-based opioid treatment with buprenorphine in US residency programs: A national survey of residency program directors

ABSTRACTBackground: The prevalence of opioid use disorder (OUD) has increased sharply. Office-based opioid treatment with buprenorphine (OBOT) is effective but often underutilized because of physicians' lack of experience prescribing this therapy. Little is known about US residency training programs' provision of OBOT and addiction medicine training. Methods: The authors conducted a survey of residency program directors (RPDs) at all US residency programs in internal medicine, family medicine, and psychiatry to assess the frequency with which their residents provide care for OUD, presence and features of curricula in OBOT and addiction medicine, RPDs' beliefs about OBOT, and potential barriers to providing OBOT training. Results: The response rate was 49.5% (476 of 962). Although 76.9% of RPDs reported that residents frequently manage patients with OUD, only 23.5% reported that their program dedicates 12 or more hours of curricular time to addiction medicine, 35.9% reported that their program encourages/requires training in OBOT, and 22.6% reported that their program encourages/requires obtaining a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine. Most RPDs believe that OBOT is an important treatment option for OUD (88.1%) and that increased residency training in OBOT would improve access to OBOT (73.7%). The authors also found that programs whose RPD had favorable views of OBOT were more likely to provide OBOT and addiction medicine training. Psychiatry programs were most likely to provide OBOT training and their RPDs most likely to have beliefs about OBOT that were positive. Commonly cited barriers to implementing OBOT training include a lack of waivered preceptors (76.9%), competing curricular priorities (64.1%), and a lack of support (social work and counseling) services (54.0%). Conclusions: Internal medicine, family medicine, and psychiatry residents often care for patients with OUD, and most RPDs believe that increased residency training in OBOT would increase access to this treatment. Yet, only a minority of programs offer training in OBOT.

MySafeRx: a mobile technology platform integrating motivational coaching, adherence monitoring, and electronic pill dispensing for enhancing buprenorphine/naloxone adherence during opioid use disorder treatment: a pilot study

BackgroundWhile buprenorphine/naloxone (B/N) is approved for opioid use disorder treatment, effective delivery of B/N comes with significant challenges. Most notably, many patients do not take medication daily as prescribed; this non-adherence worsens treatment outcomes, increases healthcare costs, and leads to persistent worries of diversion among providers and policymakers. The present study examines the feasibility, usability, and acceptability of MySafeRx—a mobile technology platform integrating motivational coaching, adherence monitoring, and electronic pill dispensing designed to address the challenges of office-based opioid treatment (OBOT) with B/N.MethodsThe MySafeRx platform integrates electronic pill dispensers, text-messaging, and videoconferencing to provide supervised self-administration of medication and daily motivational coaching through an Android app interface. High-risk early adults (18–39 years old) who were enrolled in OBOT with B/N and had documented illicit opioid use in the past month during opioid agonist therapy (n = 12) participated in a 28-day single-arm observational study of the MySafeRx platform in addition to standard care.ResultsTwo-thirds of participants who completed the study achieved an average of > 5 days per week of supervised B/N self-administration. Visual confirmation of medication adherence was demonstrated for an average of 72% of study days among all participants. All participants achieved platform technical proficiency within 60 min, reporting good levels of usability and acceptability. Illicit opioid abstinence rates confirmed by urine toxicology increased by 53% during MySafeRx but fell 43% within 3 weeks post-intervention.ConclusionThe MySafeRx medication adherence and remote coaching mobile platform is acceptable and can be feasibly implemented in real-world opioid use disorder treatment settings during high-risk periods (i.e., initial stabilization, after illicit opioid lapse), resulting in reduced illicit opioid use; however, the effect did not last after intervention completion, suggesting longer duration or extended taper of program may be needed.ClinicalTrials.Gov NCT02942199 10/24/16 https://clinicaltrials.gov/ct2/show/NCT02942199

Group-based treatment of opioid use disorder with buprenorphine: A systematic review

BackgroundOpioid use disorder (OUD) has become a public health crisis in the U.S., and there is a need to develop effective clinical treatment strategies. Coupling buprenorphine/naloxone (B/N) maintenance with counseling is encouraged as a best practice, yet the efficacy research on individual counseling in B/N-based Office-Based Opioid Treatment (OBOT) has been equivocal to date. In contrast, models for integrating B/N prescribing through group-based counseling could potentially have a differential impact, yet no systematic reviews have focused on examining the extent of the literature on group-based models of B/N delivery. MethodsWe conducted a systematic literature review to identify existing studies characterizing the different formats of Group-Based Opioid Treatment (GBOT), which we defined as the coupling of B/N prescribing with required office-based group counseling. Using this definition of GBOT, B/N prescribing could occur either concurrently during a medical visit with group counseling (i.e., Shared Medical Appointment) or asynchronously (i.e., Group Psychotherapy). We assessed for all available scientific literature reporting on the feasibility, acceptability and/or efficacy of these different forms of GBOT. The systematic review protocol used PRISMA standards. ResultsWe included 10 peer-reviewed, full-text articles and 5 conference abstracts of office-based opioid use disorder treatment that reported data on the feasibility, acceptability, and efficacy of Group-Based Opioid Treatment with B/N. Of the ten full-text articles we included 4 studies describing a shared medical appointment (SMA) model and 6 studies describing a group psychotherapy model. Of these studies, all were low in quality due to study design and only three were randomized controlled trials. No studies were appropriately designed to rigorously compare the efficacy of a GBOT approach (i.e., B/N prescribing with required group-based counseling) versus B/N prescribing with required individual counseling; nor were they designed for rigorous comparison with medication management alone. Nevertheless, most studies reported on the feasibility and acceptability of various models representative of a GBOT approach. ConclusionThe small number of studies and study design limited the conclusions that could be drawn about the feasibility, acceptability, and efficacy of group-based B/N treatment. More research is needed to determine whether benefits exist of GBOT with B/N.

Wichita Psychiatrist Assaulted, Murdered by Patient, Police Say

Wichita Psychiatrist Assaulted, Murdered by Patient, Police Say

High prevalence of urine tampering in an office-based opioid treatment practice detected by evaluating the norbuprenorphine to buprenorphine ratio

The prevalence of urine tampering within office-based opioid treatment (OBOT) is not currently known. This study was a cross-sectional analysis of an OBOT practice in New York City that experienced both a change in provider and a change in electronic medical record software. At that time, every patient in the practice received a urine drug test for “quantitative buprenorphine metabolites.” MethodsOutcomes of the first three urine drug tests were tabulated and analyzed with specific attention to the frequency of buprenorphine-positive (bup+), norbuprenorphine-negative (norbup−) samples, a pattern consistent with urine tampering. ResultsOn the first sample 6/33 (18%) of patients submitted bup+/norbup− samples, and an additional 3 patients submitted bup+/norbup− samples on subsequent urine tests. Retention to the end of the study period among patients with bup+/norbup− samples was 33%, while in those with bup+/norbup+samples it was 96%. A scatter plot of norbuprenorphine vs. buprenorphine levels estimated that a ratio of <0.2 indicated tampering. ConclusionTesting for buprenorphine metabolites yields valuable clinical information. The prevalence of a result pattern consistent with tampering by “urine spiking,” the addition of unconsumed buprenorphine into the urine sample, may be higher than previous estimates. Previous lower cutoffs of the norbuprenorphine:buprenorphine metabolic ratio may miss a substantial proportion of these likely tampered samples.

Experiences of three states implementing the Medicaid health home model to address opioid use disorder—Case studies in Maryland, Rhode Island, and Vermont

PurposeThe United States is facing an unprecedented opioid epidemic. The Affordable Care Act (ACA) included several provisions designed to increase care coordination in state Medicaid programs and improve outcomes for those with chronic conditions, including substance use disorders. Three states—Maryland, Rhode Island, and Vermont – adopted the ACA's optional Medicaid health home model for individuals with opioid use disorder. The model coordinates opioid use disorder treatment that features opioid agonist therapy provided at opioid treatment programs (OTPs) and Office-based Opioid Treatment (OBOT) with medical and behavioral health care and other services, including those addressing social determinants of health. This study examines state approaches to opioid health homes (OHH) and uses a retrospective analysis to identify facilitators and barriers to the program's implementation from the perspectives of multiple stakeholders. MethodsWe conducted 28 semi-structured discussions with 70 discussants across the three states, including representatives from state agencies, OHH providers (OTPs and OBOTs), Medicaid health plans, and provider associations. Discussions were recorded, transcribed, and analyzed using NVivo. In addition, we reviewed state health home applications, policies, regulatory guidance, reporting, and other available OHH materials. We adapted the Exploration, Preparation, Implementation, and Sustainment (EPIS) model as a guiding framework to examine the collected data, helping us to identify key factors affecting each stage of the OHH implementation. ResultsOverall, discussants reported that the OHH model was implemented successfully and was responsible for substantial improvements in patient care. Contextual factors at both the state level (e.g., legislation, funding, state leadership, program design) and provider level (OHH provider characteristics, leadership, adaptability) affected each stage of implementation of the OHH model. States took a variety of approaches in designing and implementing the model, with facilitators related to gathering stakeholder input, receiving guidance and technical assistance, and tailoring program design to build on the state's existing care coordination initiatives and provider infrastructure. The OHH model constituted a substantial change for almost all OHH providers in the study, who reported that facilitators to implementation included having goals and workplace culture that were compatible with the OHH model, and having technical support from the state or non-governmental organizations. Some of the main barriers to implementation reported by OHH providers include shortages of primary care providers, dentists, and other providers willing to accept referrals of patients with opioid use disorder; limited community resources to address social determinants of health; challenges related to state-specific program design, such as staffing requirements and reimbursement methodology; care coordination limitations due to confidentiality restrictions and technological barriers; and internal capacity of providers to adopt the new model of care. ConclusionsThe OHH model appears to have the potential to effectively address the complex needs of individuals with opioid use disorder by providing whole-person care that integrates medical care, behavioral health, and social services and supports. The experiences of Maryland, Rhode Island, and Vermont can guide development and implementation of similar OHH initiatives in other states.

Providing Office-Based Treatment of Opioid Use Disorder.

Office-Based Opioid Treatment (OBOT) with buprenorphine has been available since 2000; however, many barriers to OBOT within primary care exist, and only 3.6% of family medicine physicians are waivered to prescribe buprenorphine.1 We have successfully integrated OBOT into our primary care practice,

Very early disengagement and subsequent re-engagement in primary care Office Based Opioid Treatment (OBOT) with buprenorphine

IntroductionPatients with opioid use disorder often require multiple treatment attempts before achieving stable recovery. Rates of disengagement from buprenorphine are highest in the first month of treatment and termination of buprenorphine therapy results in return to use rates as high as 90%. To better characterize these at-risk patients, this study aims to describe: 1) the frequency and characteristics of patients with very early disengagement (≤1month) from Office Based Opioid Treatment (OBOT) with buprenorphine and 2) the frequency and characteristics of patients who re-engage in care at this same OBOT clinic within 2years, among the subset of very early disengagers. MethodsThis is a retrospective cohort study of adult patients enrolled in a large urban OBOT program. Descriptive statistics were used to characterize the sample and the proportion of patients with very early (≤1month) disengagement and their re-engagement. Multivariable logistic regression models were used to identify patient characteristics associated with the outcomes of very early disengagement and re-engagement. Potential predictors included: sex, age, race/ethnicity, education, employment, opioid use history, prior substance use treatments, urine drug testing, and psychiatric diagnoses. ResultsOverall, very early disengagement was unusual, with only 8.4% (104/1234) of patients disengaging within the first month. Among the subset of very early disengagers with 2years of follow-up, the proportion who re-engaged with this OBOT program in the subsequent 2years was 11.9% (10/84). Urine drug test positive for opiates within the first month (AOR: 2.01, 95% CI: 1.02–3.93) was associated with increased odds of very early disengagement. Transferring from another buprenorphine prescriber (AOR: 0.09, 95% CI: 0.01–0.70) was associated with decreased odds of very early disengagement. No characteristics were significantly associated with re-engagement. ConclusionsEarly disengagement is uncommon; however, continued opioid use appeared to be associated with higher odds of treatment disengagement and these patients may warrant additional support. Re-engagement was uncommon, suggesting the need for a more formal explicit system to encourage and facilitate re-engagement among patients who disengage.