Addiction Treatment in Primary Care Expansion
| Status: | Recruiting |
|---|---|
| Conditions: | Chronic Pain, Chronic Pain |
| Therapuetic Areas: | Musculoskeletal |
| Healthy: | No |
| Age Range: | Any |
| Updated: | 11/18/2018 |
| Start Date: | May 1, 2018 |
| End Date: | April 30, 2019 |
| Contact: | Adam J Gordon, MD MPH |
| Email: | adam.gordon@va.gov |
| Phone: | (801) 582-1565 |
APEX- Addiction Treatment in Primary Care Expansion (PII 18-181)
The Veterans Health Administration (VA) is a national leader in addressing the twin epidemics
of chronic pain and opioid use, misuse, and opioid use disorder (OUD); but important
challenges remain. Both chronic pain and OUD are more common among Veterans compared to the
general population.1 As the VA transitions toward a greater emphasis on non-opioid chronic
pain treatments, improving access to OUD treatment will be critical for those Veterans with
new diagnoses of OUD in the context of long-term opioid therapy. Strong evidence supports the
treatment of OUD with medications, including naltrexone, buprenorphine, and methadone.2
Buprenorphine and naltrexone can be prescribed in primary care settings; OUD treatment in
primary care is associated with decreased opioid use, higher quality of care, and improved
quality of life.3-5 In partnership with VISN19 leadership, this project will address the
priority goal of improving access to medication-assisted therapy for OUD treatment. The
objective of the VISN Partnered Implementation Initiative startup phase (PHASE 1) is to
implement and evaluate the evidence-based, effective practice of medication treatment of
opioid use disorder in primary care settings. A subsequent PHASE 2 will study the
implementation of strategies from PHASE 1 across the entire VISN19. The investigators propose
two specific aims:
Aim 1: Evaluate the implementation and impact of a multifaceted provider support initiative
at two VA medical centers and four community-based clinics in VISN19 using the
integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS)
implementation framework. The multifaceted initiative will leverage existing VA and VISN
resources (including e-consults, telementoring and telehealth) to facilitate improved access
to OUD treatment in primary care.
Aim 2: Create an interactive implementation toolkit with guidance on facilitation and
incentive strategies and resources for broader dissemination across the VISN and VA.
of chronic pain and opioid use, misuse, and opioid use disorder (OUD); but important
challenges remain. Both chronic pain and OUD are more common among Veterans compared to the
general population.1 As the VA transitions toward a greater emphasis on non-opioid chronic
pain treatments, improving access to OUD treatment will be critical for those Veterans with
new diagnoses of OUD in the context of long-term opioid therapy. Strong evidence supports the
treatment of OUD with medications, including naltrexone, buprenorphine, and methadone.2
Buprenorphine and naltrexone can be prescribed in primary care settings; OUD treatment in
primary care is associated with decreased opioid use, higher quality of care, and improved
quality of life.3-5 In partnership with VISN19 leadership, this project will address the
priority goal of improving access to medication-assisted therapy for OUD treatment. The
objective of the VISN Partnered Implementation Initiative startup phase (PHASE 1) is to
implement and evaluate the evidence-based, effective practice of medication treatment of
opioid use disorder in primary care settings. A subsequent PHASE 2 will study the
implementation of strategies from PHASE 1 across the entire VISN19. The investigators propose
two specific aims:
Aim 1: Evaluate the implementation and impact of a multifaceted provider support initiative
at two VA medical centers and four community-based clinics in VISN19 using the
integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS)
implementation framework. The multifaceted initiative will leverage existing VA and VISN
resources (including e-consults, telementoring and telehealth) to facilitate improved access
to OUD treatment in primary care.
Aim 2: Create an interactive implementation toolkit with guidance on facilitation and
incentive strategies and resources for broader dissemination across the VISN and VA.
Among Veterans receiving healthcare from the Veterans Health Administration (VA), there has
been sharp rise in the number of veterans diagnosed with opioid use disorder (OUD). In 2013,
25,031 Veterans had OUD and in 2017, Veterans with OUD nearly tripled to 69,142.6 As the
largest direct provider of addiction treatment nationally, VA has taken steps to increase
access to medication treatment for OUD, which is recognized as an essential component of
evidence-based care.
The treatment of OUD involves several FDA-approved, VA formulary medications including
naltrexone, methadone, and buprenorphine/naloxone and buprenorphine (hereafter collectively
termed buprenorphine). Strong evidence supports the treatment of OUD with medications, and
they are the "gold standard" treatments for OUD. Medications for OUD have been shown to
substantially decrease risk for all-cause mortality and overdose mortality in people with
opioid use disorder. Unlike methadone, buprenorphine for OUD can be prescribed in
office-based settings such as primary care, and buprenorphine delivered in primary care is
associated with decreased opioid use, higher quality of care, and improved quality of life.
Medication treatment includes dispensation of methadone and buprenorphine in licensed opioid
treatment programs (OTPs) and prescriptions of buprenorphine and naltrexone in office-based
settings. Because there are only 32 licensed OTPs in the VA, buprenorphine and naltrexone
prescriptions are the means to improve access to medication treatment for Veterans with OUD.
Uptake of medication treatment, however, has been slow and uneven in the VA. In 2017, 35% of
Veterans diagnosed with OUD had received OUD medications.
In VISN19, rates of OUD and OUD treatment are low and heterogeneous across facilities and
compared with the national average (35%), fewer patients with OUD are on OUD medications
(21%) in VISN19. Multiple initiatives have been instituted to improve access to medication
treatment for Veterans with OUD, particularly in non-specialty office-based settings. In
2007, VA introduced the Buprenorphine in the VA Initiative (BIV; Director Gordon), a national
consult service, which aimed to improve care processes and patient outcomes associated with
buprenorphine. In 2010, VA unrolled Academic Detailing program in which pharmacy specialists
take on high-priority pharmaceutical education campaigns. An Academic Detailing campaign
specifically targeting the treatment of opioid use disorder was initiated in 2017. Further
improving access to evidence-based medication treatment of OUD remains a priority for VA and
VISN19.
been sharp rise in the number of veterans diagnosed with opioid use disorder (OUD). In 2013,
25,031 Veterans had OUD and in 2017, Veterans with OUD nearly tripled to 69,142.6 As the
largest direct provider of addiction treatment nationally, VA has taken steps to increase
access to medication treatment for OUD, which is recognized as an essential component of
evidence-based care.
The treatment of OUD involves several FDA-approved, VA formulary medications including
naltrexone, methadone, and buprenorphine/naloxone and buprenorphine (hereafter collectively
termed buprenorphine). Strong evidence supports the treatment of OUD with medications, and
they are the "gold standard" treatments for OUD. Medications for OUD have been shown to
substantially decrease risk for all-cause mortality and overdose mortality in people with
opioid use disorder. Unlike methadone, buprenorphine for OUD can be prescribed in
office-based settings such as primary care, and buprenorphine delivered in primary care is
associated with decreased opioid use, higher quality of care, and improved quality of life.
Medication treatment includes dispensation of methadone and buprenorphine in licensed opioid
treatment programs (OTPs) and prescriptions of buprenorphine and naltrexone in office-based
settings. Because there are only 32 licensed OTPs in the VA, buprenorphine and naltrexone
prescriptions are the means to improve access to medication treatment for Veterans with OUD.
Uptake of medication treatment, however, has been slow and uneven in the VA. In 2017, 35% of
Veterans diagnosed with OUD had received OUD medications.
In VISN19, rates of OUD and OUD treatment are low and heterogeneous across facilities and
compared with the national average (35%), fewer patients with OUD are on OUD medications
(21%) in VISN19. Multiple initiatives have been instituted to improve access to medication
treatment for Veterans with OUD, particularly in non-specialty office-based settings. In
2007, VA introduced the Buprenorphine in the VA Initiative (BIV; Director Gordon), a national
consult service, which aimed to improve care processes and patient outcomes associated with
buprenorphine. In 2010, VA unrolled Academic Detailing program in which pharmacy specialists
take on high-priority pharmaceutical education campaigns. An Academic Detailing campaign
specifically targeting the treatment of opioid use disorder was initiated in 2017. Further
improving access to evidence-based medication treatment of OUD remains a priority for VA and
VISN19.
Inclusion Criteria:
- Inclusion criteria include health care providers at 2 main VA facilities and four VA
community based outpatient clinics
Exclusion Criteria:
We found this trial at
2
sites
Salt Lake City, Utah 84148
Principal Investigator: Adam J. Gordon, MD MPH
Phone: 801-582-1565
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