Integrating Buprenorphine for Opioid Use Disorder into Rural, Primary Care Settings

A qualitative study of methods used by rural VA-owned primary care practices to implement buprenorphine treatment of patients with opioid use disorders.

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Background: Medications for opioid use disorder (MOUD) including buprenorphine are effective, but underutilized. Rural patients experience pronounced disparities in access. To reach rural patients, the US Department of Veterans Affairs (VA) has sought to expand buprenorphine prescribing beyond specialty settings and into primary care.

Objective: Although challenges remain, some rural VA health care systems have begun offering opioid use disorder (OUD) treatment with buprenorphine in primary care. We conducted interviews with clinicians, leaders, and staff within these systems to understand how this outcome had been achieved.

Design: Using administrative data from the VA Corporate Data Warehouse (CDW), we identified rural VA health care systems that had improved their rate of primary care-based buprenorphine prescribing over the period 2015-2020. We conducted qualitative interviews (n = 30) with staff involved in implementing or prescribing buprenorphine in these systems to understand the processes that had facilitated implementation.

Participants: Clinicians, staff, and leaders embedded within rural VA health care systems located in the Northwest, West, Midwest (2), South, and Northeast.

Approach: Qualitative interviews were analyzed using a mixed inductive/deductive approach.

Key results: Interviews revealed the processes through which buprenorphine was integrated into primary care, as well as processes insufficient to enact change. Implementation was often initially catalyzed through a targeted hire. Champions then engaged clinicians and leaders one-on-one to "pitch" the case, describe concordance between buprenorphine prescribing and existing goals, and delineate the supportive role that they could provide. Sites were prepared for implementation by developing new clinical teams and redesigning clinical processes. Each of these processes was made possible with the active, instrumental support of leadership.

Conclusions: Results suggest that rural systems seeking to improve buprenorphine accessibility in primary care may need to alter primary care structures to accommodate buprenorphine prescribing, whether through new hires, team development, or clinical redesign.

Author/s:

Jessica J Wyse, Alison Eckhardt, Summer Newell, Adam J Gordon, Benjamin J Morasco

Management of Posttraumatic Stress Disorder

Tracy Ashby — Thu, 20 Dec 2018 06:00:00 +0000

Date Added:

December 21, 2018

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

December 17, 2018

URL:

Management of Posttraumatic Stress Disorder

Type:

Meta-analyses, Reviews, and Guidelines, Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2018.19290

Keywords

post-traumatic stress disorder

veterans

psychotherapy

PMID (1):

30556838

MeSH

Stress Disorders

stress disorders, post-traumatic

diagnostic and statistical manual of mental disorders

United States Department of Veterans Affairs

veterans health

This Veterans Affairs/Dept. of Defense Guideline recommends referral for individual, manualized trauma-focused psychotherapy (TFP) as the first line treatment for PTSD. Patients unwilling to undergo that treatment may benefit from SSRIs.

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Summary of the Clinical Problem

Individuals who have been personally or indirectly exposed to actual or threatened death, serious injury, or sexual violence have a wide range of psychological responses, from transient, nondebilitating reactions to symptoms that meet the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria for acute stress disorder or PTSD. Between 6% and 7% of adults in the US general population are estimated to experience PTSD during their lifetime. The prevalence is higher in women than in men. In 2016, 10.6% of veterans receiving care in the Veterans Health Administration had a diagnosis of PTSD. Among veterans who served in Iraq and/or Afghanistan, 26.7% of those seeking care in the Veterans Health Administration receive a PTSD diagnosis.

Author/s:

Ostacher, Michael J., Cifu, Adam S.