Primary CareBased Models for the Treatment of Opioid Use Disorder
Published Feb 21, 2017 · P. Korthuis, D. McCarty, M. Weimer
Annals of Internal Medicine
152
Citations
1
Influential Citations
Abstract
Opioid use disorder (OUD) is a national crisis in the United States (1). In 2014, approximately 1.9 million Americans aged 12 years or older were estimated to have an OUD related to prescription opioids, and nearly 600000 used heroin (2). In 2013, an estimated 16000 persons died as a result of prescription opioid overdose, and approximately 8000 died of heroin overdose (3). Medication-assisted treatment (MAT) for OUD, also referred to as pharmacotherapy, decreases illicit opioid use, prevents relapse, improves health, and reduces the risk for death from OUD (4). Medications approved by the U.S. Food and Drug Administration include a full agonist (methadone), partial opioid agonists (buprenorphine, buprenorphinenaloxone, and implantable buprenorphine), and opioid antagonists (oral and extended-release naltrexone). These medications block the euphoric and sedating effects of opioids, reduce craving for opioids, and mitigate opioid withdrawal symptoms. Medication-assisted treatment more effectively reduces opioid use than behavioral treatment alone (5, 6). Behavioral therapy addresses the psychosocial contributors to OUD and may augment retention in treatment. The Office of National Drug Control Policy and the U.S. Department of Health and Human Services recently prioritized increasing access to MAT (1, 7). Integrating MAT into primary care settings expands access to OUD treatment (8). The Drug Addiction Treatment Act of 2000 enabled physicians to prescribe buprenorphine for treatment of OUD, but its use remains limited (3, 9, 10). Understanding the most effective and promising models of care is critical for optimizing initiatives to expand access to MAT (1). Because not all MAT models are published and outcomes of different MAT models have not been compared, the Agency for Healthcare Research and Quality (AHRQ) commissioned a scoping review to develop a taxonomy of MAT models of care for OUD, with a focus on primary care settings. Methods Scope of the Review The review protocol and methods are detailed in the full report (11) (www.effectivehealthcare.ahrq.gov/reports/final.cfm). The review describes representative MAT models of care in primary care settings and does not provide an exhaustive list of models for MAT integration. Representative models were selected on the basis of their influence on current clinical practice, their innovativeness, or their focus on MAT for specific primary care populations or settings. Eleven key informants (8 nonfederal and 3 federal) with experience implementing MAT for OUD in primary care settings were interviewed between March and June 2016 (Table 1). We facilitated small group telephone discussions using a semistructured guide (Appendix Table 1), asking participants to identify MAT models used in primary care (regardless of whether they were published) and to specify key model components. Calls were recorded, summarized, and shared with the group for clarification and additional input. On the basis of key informant input, we developed a framework categorizing key components of MAT models to provide a structure for future research and discussion. We then integrated input from the key informants with the available literature. Table 1. Key Informants (n= 11) Appendix Table 1. Sample Questions for Key Informants We searched for literature describing MAT models in primary care settings or their effectiveness from 1995 through June 2016 using Ovid MEDLINE, PsycINFO, the Cochrane Library, SocINDEX, and CINAHL (Appendix Table 2); reviewed reference lists; and solicited additional references from key informants. We also searched gray literature sources (ClinicalTrials.gov, Health Services Research Projects in Progress, Google Scholar, NIH RePORTER, and Web sites of government agencies with MAT initiatives) and e-mailed stakeholders about the opportunity to submit scientific information packets for ongoing or unpublished research. The literature review provided descriptive and contextual information on the models to supplement key informant interviews. The search identified 5892 abstracts; we reviewed 475 full-text articles (27 of which informed descriptions of MAT models of care) and 14 gray literature citations (Table 2). Appendix Table 2. Search Strategies Table 2. Sources for MAT Models of Care Role of the Funding Source This topic was selected by the AHRQ for systematic review by an Evidence-based Practice Center. A representative from the AHRQ who served as a Contracting Officer's Technical Representative provided technical assistance during the conduct of the full evidence review and provided comments on draft versions of the full evidence report. The AHRQ did not directly participate in the literature search; determination of study eligibility criteria; data analysis or interpretation; or preparation, review, or approval of the manuscript for publication. Results Key informants consistently noted 4 key components of MAT models in primary care: pharmacotherapy with buprenorphine or naltrexone, provider and community educational interventions (such as in-person, Web-based, and telehealth provider continuing medical education [CME] activities; community-based advertising campaigns; and stakeholder conferences), coordination and integration of OUD treatment with other medical and psychological needs, and psychosocial services (such as counseling on-site or by referral). Models varied in the degree of component implementation. Table 3 summarizes 12 representative models of MAT care and how the 4 key components are addressed. We included models that contained all 4 key components and that met criteria for effectiveness, innovation, and addressing special populations (for example, rural settings, patients with HIV, and prenatal care). Ten models were described by key informants, 6 were described in the published literature, and 7 were described in gray literature sources (Table 2). We categorized 4 models as primarily practice-based and 8 as systems-based, though most have elements of both. For each model, we discuss clinician-, practice-, and system-level factors, including financing, evidence of effectiveness, challenges, and situations in which the model is most likely to be feasible and effective. Table 3. Overview of MAT Models of Care for OUD in the Primary Care Setting* Practice-Based Models Office-Based Opioid Treatment In office-based opioid treatment (OBOT), physicians who complete 8 hours of training and receive a Drug Enforcement Administration waiver number may prescribe buprenorphinenaloxone in the context of primary care (12, 13). Although many providers offer OBOT without staff assistance, some practices designate a clinic staff member (often a nurse or social worker) to coordinate buprenorphine prescribing (1416). Psychosocial services include brief counseling provided on-site by the physician or other staff and off-site referrals. Office-based opioid treatment is financed through provider reimbursement of billable visits. Medicare and many state Medicaid programs cover buprenorphine, though prior authorization is frequently required. The Providers' Clinical Support System for MAT (http://pcssmat.org), funded by the Substance Abuse and Mental Health Services Administration, is a free systems-level resource that supports OBOT implementation nationally with provider education and mentoring. Retention in treatment and opioid use outcomes with OBOT are similar to those in methadone treatment programs, with 38% retention at 2 years and 91% of urine toxicology screens negative for opioids among those retained in 1 long-term cohort study (14). Office-based opioid treatment may be particularly advantageous for reaching persons with OUD who are already engaged in primary care and offers an alternative for patients who cannot access methadone treatment programs. Challenges include a variable scope of psychosocial services and structure required for management of complex patients. Also, nurse practitioners and physician assistantsimportant providers of primary care in rural areasare currently not eligible to prescribe buprenorphine. Buprenorphine HIV Evaluation and Support Collaborative Model The Buprenorphine HIV Evaluation and Support (BHIVES) Collaborative model adapted the OBOT framework to integrate buprenorphine treatment into primary care for HIV-infected patients (1726). Primary care providers in 9 HIV clinics provided buprenorphine, facilitated by a nonphysician coordinator and variable on-site psychosocial services. The BHIVES cohort of 303 participants receiving buprenorphine showed 49% treatment retention at 12 months, and opioid use in the previous 30 days decreased from 84% at baseline to 42% at 12 months (18). The BHIVES model is recommended as the standard of care for engaging HIV-infected patients with OUD in treatment (2729). Buprenorphine and HIV care are typically covered by patient insurance. Funding from the Ryan White Comprehensive AIDS Resources Emergency Act (30) supplements medication coverage, care coordination, and counseling services in some states. An advantage of the BHIVES model is that it addresses MAT, HIV care, and primary care within a single setting (31). Challenges include limited financial support for on-site counseling in clinics without designated Ryan White funding. The Providers' Clinical Support System for MAT includes physician mentors with expertise in HIV care. One-Stop Shop Model The one-stop shop model was developed in response to an outbreak of HIV infection in rural Indiana that was due to sharing infected syringes (32) where there were no existing OUD or HIV treatment services. Based in an existing mental health clinic, the model provides integrated care for HIV and hepatitis C virus infection, MAT, mental health, primary care, and syringe exchange (33). A primary care provider embedded in the mental health clinic prescribes extended-release naltrexone and antiretroviral therapy. Financing is from a combination of existing Medi