Posted: June 5, 2019

Overcoming Barriers to Treatment of Opioid Use Disorder in Primary Care

Background: Primary care providers are experts in the treatment of other chronic diseases however have yet to embrace treatment for the chronic disease of OUD with MAT options such as buprenorphine. One study polled 108 family physicians and found that 80% regularly saw patients with OUD and 73% felt it was their role to treat these patients however only 10 % were buprenorphine providers (1). The most commonly cited barrier to becoming a prescriber was lack of training, both for the provider and for their staff (1). The Drug Addiction Treatment Act of 2000 mandates that physicians who wish to prescribe buprenorphine first complete an 8 hour training course and apply for a waiver from the Drug Enforcement Agency (DEA). In addition to certification requirements many doctors cite insecurity with treating these often complex patients as well as bias against addicted persons as reasons that they had not become buprenorphine providers (1). These barriers contribute to the fact that up to 80% of those with OUD do not receive MAT and that 60% of rural counties do not even have a provider with a DEA waiver to prescribe buprenorphine (2,3). Even clinicians with waivers often discontinue prescribing citing barriers including time constraints, resistance from practice partners, lack of specialty backup for complex problems, and attraction of drug users to their practice (3). These findings emphasize the need for improved methods of training and clinical support in order to improve the primary care response to the OUD crisis.

Approach: The overarching goal of this curriculum package is to improve access to high quality treatment for opioid use disorder with buprenorphine in the primary care setting using the following processes: 1. Increasing the number of primary care clinicians who are not just waivered but who begin to actively prescribe buprenorphine 2. Facilitating active prescribing by providing in-person technical assistance with a Credentialed Alcoholism and Substance Abuse Counselor (CASAC) consultation to ease set-up and implementation of OUD treatment in primary care 3. Provide easy access to primary care based addiction medicine experts via phone, text and electronic health record for any questions or concerns 4. Include administrative and clinical support staff in offices as part of consultation so that they can understand what is being asked and expected of from the office and to overcome stigma and other barriers 5. Creating a community wide referral network to ease access for patients who need treatment in more intensive settings 6. Include primary care clinicians as part of the waiver training team and include information specific to primary care offices in the waiver training or as an addendum a. Key points that must be included are what inappropriate lab results look like and how to manage AND how to handle acute pain issues 7. Establishing treatment of OUD as an integral part of Family Medicine physician and nurse practitioner residency training. 

Implementation: We tailored existing buprenorphine waiver curriculum to address commonly cited primary care barriers to MAT including partner and staff support, time constraint concerns, and regulatory fears. Attendees were provided with note templates, step wise guidelines for managing relapse and resources to access higher levels of care and expert back-up. A substance use counselor was available to provide consultations for offices to help with administrative or clinical process questions. The waiver training was integrated into the curriculum for all physician and nurse practitioner family medicine residents. Waiver trainings utilized ASAM’s mixed training model of 4 hours of online training and 4 hours of live conference training. ASAM did not have a formal ‘train the trainer’ program in place for the waiver trainings so a model was developed with consultation from local addiction medicine specialist to develop new providers who could teach the waiver trainings. Waiver training courses were limited by the size of the conference room (ranging from 30 to 50) and open to any interested clinician regardless of specialty or institution. All waiver training attendees were contacted by the program’s CASAC after the training and offered follow up support including further clinician education, office staff education, and administrative protocols to establish buprenorphine treatment in the office. Given the known barriers of time constraints and lack of practice partner support we added information during the buprenorphine waiver trainings about our own successful experience with providing buprenorphine in a primary care setting. We offered educational sessions to office partners and staff that were given by the clinicians and CASAC to help overcome concerns about what treating patients with opioid use disorder looks like in practice. To overcome the barrier of lack of specialty back-up, we reached out to local chemical dependency treatment programs and were able to create a step-wise guide for how to manage relapse or complex patients and direct phone numbers that primary care clinicians could call to get easily access more intense chemical dependency programs if needed. 

Future: As of the last six months, we implemented a provider attitude survey. This will help us more formally evaluate knowledge and attitudes regarding treatment of opioid use disorder before and after attending our waiver trainings and/or receiving our consultation services. As we collect more data through these formal evaluations we do intend to develop a peer-review article with this data. We have given several regional and national presentations on this approach.

Supplemental Files:

  • Buprenorphine Related Note Templates.pdf
  • Guidelines for Managing Relapse.pdf
  • Intake Packet Family Medicine Buprenorphine Program.pdf
  • Removing Barriers to Treat OUD in Primary Care CME Curriculum.pdf

Keywords

Primary Care, Opioid Use Disorder, Medication Assisted Treatment

Authors

Holly Ann Russell, MD, MS, University of Rochester School of Medicine and Dentistry

Elizabeth Loomis, MD, University of Rochester School of Medicine and Dentistry

Kristin E Smith, DNP, FNP-C, Highland Family Medicine

Andrew Hayes, Stony Brook University, School of Medicine


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