Implementing Office-Based Opioid Treatment Models in Primary Care

E. Marshall Brooks, PhD; Sebastian Tong, MD, MPH

Disclosures

J Am Board Fam Med. 2020;33(4):512-520. 

In This Article

Abstract and Introduction

Abstract

Background: Primary care practices are ideal sites for integrating medication-assisted treatment (MAT) for opioid use disorder, but little is known about how practices have achieved this. Our study aimed to describe the implementation experiences and treatment models of practices implementing MAT.

Methods: We conducted a qualitative analysis of MAT integration at 26 practices across Virginia after the state implemented the Addiction and Recovery Treatment Services (ARTS) benefit in 2017. Data collection activities included interviews with clinic team members, including buprenorphine-waivered prescribers, behavioral health clinicians, care coordinators, and peer counselors. We used a template analysis approach to thematically analyze data.

Results: Our study identified various ways in which MAT can be implemented in primary care clinics and other ambulatory settings. Although state regulations and treatment guidelines suggest colocating behavioral health counseling and medication management, providing care coordination, and conducting regular urine drug screens, we found a wide spectrum of ways in which practices can adapt and innovate treatment models to fit local needs.

Discussion: As the fight against the opioid epidemic continues, we need to identify feasible and effective MAT treatment models and integration approaches for primary care.

Introduction

Drug overdose deaths involving opioids continue to rise in the United States, with 67,367 individuals fatally overdosing in 2018.[1] Yet, most of these individuals are not receiving treatment in the substance use treatment system.[2] Although integrating medication-assisted treatment (MAT) into primary care settings is proven to expand access to opioid use disorder (OUD) treatment, there has been limited diffusion and adoption of relatively new treatments (eg, buprenorphine and injectable naltrexone) that could easily be adapted to community-based settings.[3,4] The Drug Addiction Treatment Act, passed nearly 2 decades ago, allows office-based clinicians to prescribe buprenorphine; yet, there has been very little integration of OUD treatment in primary care practices.[5]

The atrophied state of addiction treatment—in addition to the fact that most family physicians receive no training in addiction[6]—has led to fewer than half of the 2.2 million people who need treatment for opioid addiction actually receiving it.[7] Also, despite that prescription opioids contribute to nearly 40% of overdose deaths, fewer than 4% of the 900,000 US physicians who can prescribe opioid painkillers have become licensed to prescribe buprenorphine to treat people with OUD.[8]

Despite a slow uptake, integrating MAT into primary care is seen as a paramount strategy for combating the opioid epidemic. Previous research shows that MAT in primary care can enhance access to treatment, reduce costs, improve patient experiences of care, and improve patient outcomes.[9] Primary care-based MAT may particularly benefit low-resource patients who often struggle to access and maintain successful engagement with the substance use treatment system. By integrating addiction treatment services into primary care, practices can better identify and address patients' substance use issues, as well as co-occurring physical and mental health issues.[10]

Although numerous resources are available to aid primary care physicians in getting buprenorphine waivers, there is little research on the ways in which primary care practices are integrating and operationalizing MAT models.[11–14] This article describes common goals related to integrating MAT at 26 outpatient clinics, strategies to operationalize those goals, and challenges related to integrating MAT for OUD into primary care.

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