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BACKGROUND/RATIONALE:
Veterans are known to have high prevalence of addiction to heroin and prescription opiates with 23,241 VA patients being given a diagnosis of opioid dependence in FY05. Opioid agonist therapy (OAT), an evidenced-based treatment for opioid dependence, has traditionally been restricted to use in highly regulated licensed Opioid Agonist Treatment Programs (OTPs), mainly in the form of methadone. OTPs in the VA, however, have been able to accommodate only a small proportion of the total number of opioid-dependent patients who would benefit from OAT; approximately 65% of veterans diagnosed with opioid dependence do not receive OAT.
In an effort to expand access to OAT beyond highly regulated OTP’s, Congress made an amendment to the Drug Abuse Treatment Act (DATA 2000), which allows physicians to prescribe OAT in office-based practices to enhance availability of effective opioid addiction treatment and to provide new treatment options for opioid-dependent patients. Sublingual buprenorphine (Subutex) and buprenorphine/naloxone (Suboxone), both Schedule III, were approved for use by the FDA under DATA 2000. In 2003, the VA approved Subutex and Suboxone for non-formulary use within the VA. National formulary status is pending revision of the criteria for use by Pharmacy Benefits Management (PBM).
Despite the overwhelming need for treatment of opioid-dependent veterans, VA utilization of Subutex and Suboxone has been poor. In FY05, only 719 veterans received sublingual buprenorphine prescriptions. It is unclear what barriers prevent more veterans from receiving appropriate buprenorphine treatment. For example, it may be that there exists a lack of education regarding buprenorphine, outpatient practices are not equipped to handle OAT therapy, or providers believe OAT treatment is inappropriate outside of OTPs.
OBJECTIVE(S):
The purpose of this study is to identify both barriers to and facilitators of the implementation of sublingual buprenorphine therapy for the treatment of opioid dependence within the VA. Factors affecting the implementation of sublingual buprenorphine treatment will be examined at the provider-, facility-, and system-levels, both at sites that have had success implementing and sites that have had difficulty implementing sublingual buprenorphine therapy.
METHODS:
All VA facilities selected as participating sites will have a high prevalence of opioid addiction (defined as having 100+ patients diagnosed and treated for opioid dependence at the facility in the last fiscal year); none of them will have a VA OTP or a contract for an OTP in the community. Using NPCD and PBM data, two groups of sites will be selected from facilities meeting these criteria: 10 sites with no/unsuccessful implementation of buprenorphine (sublingual buprenorphine prescriptions filled by < 5 unique patients in FY05); and at least 5 sites in which there has been successful implementation of buprenorphine treatment (sublingual buprenorphine prescriptions filled by 40+ unique patients in FY05).
Key Informant Interviews at selected sites: At each site, we will select 5+ staff members to interview via telephone. Individuals will be selected on the basis of discussions with the Facility Director and/or the Facility Chief of Staff, but will include at a minimum the substance abuse treatment program director, the director of Primary Care or Infectious disease, an addiction treatment physician, a non-physician front-line addiction treatment provider, and a pharmacist. Additional interviews will be sought as needed with staff that have clinical or administrative roles in non-mental health/ addiction services and will be added based on the organizational structure of particular sites. The interviews will last less than 60 minutes, will be conducted by a Research Psychologist with pre-interview guidance from the PIs, and will follow a semi-structured format. All interviews will be audiotaped for later review and coding.
Questions will include several ice-breakers to elicit descriptive information (e.g., organization of specialty SUD treatment programs, patient load in primary care and infectious disease clinics). More targeted question will tap a number of conceptual domains (e.g., philosophy toward the treatment of addicted patients; administration support; pharmacy attitudes towards buprenorphine; lessons learned from adopting buprenorphine use, including facilitators and how barriers were overcome).
Qualitative Analyses and Summative Evaluation: Audiotapes will be transcribed, and the two co-investigators will carefully review the key informant interviews and use consensus discussions to reliably list responses within each of the conceptual domains outlined above. Each investigator will read the transcript independently, attempting to identify important responses to the guiding global question “what are the major barriers to the adoption of buprenorphine use in VA?”. Any disagreements will be resolved through consensus discussion. Data will be analyzed to identify facilitators, barriers and characteristics that differentiate the sites that have adopted buprenorphine from those that have not. Information from the analyses will be presented to the SUD QUERI Buprenorphine Work Group and used to target future interventions seeking to facilitate buprenorphine implementation in VA aimed at narrowing the OAT treatment gap for veterans with opioid dependence.
FINDINGS/RESULTS:
JIT has been completed. Project is about to start.
IMPACT:
Findings from this study will inform the design of future implementation initiatives for sublingual buprenorphine treatment aimed at circumventing identified barriers and capitalizing on identified facilitators. Short-term goals include the identification of specific recommendations to the SUD QUERI Buprenorphine Work Group with regard to strategies that will maximize future efforts to implement buprenorphine use within the VA. Longer-term goals include the dissemination within the VA community of a body of information regarding the barriers to adopting buprenorphine, as well as the facilitators to utilizing buprenorphine therapy, that will improve the treatment of opioid dependent veterans, some of our most vulnerable patients.
PUBLICATIONS:
None at this time.
DRA:
Substance Abuse, Addictive Disorders
DRE:
Quality of Care
Keywords:
none
MeSH Terms:
none
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