Opioid Agonist Therapy

Goal 2B. Implementing Opioid Agonist Therapy

Buprenorphine

Background

Opioid dependence (Raisch et al., 2002) is a chronic, relapsing, medical disorder that afflicts several million individuals in the United States, including 26,818 veterans enrolled in the Veterans Health Administration (VA) (Dalton et al., 2005; Mark et al., 2001; McKellar & Saweikis, 2005). Untreated or ineffectively treated opioid dependence contributes to premature mortality and increased utilization of healthcare and social services (Marsch, 1998). Illicit opioid use also contributes to increased use of other drugs and alcohol, criminal activity, and morbidity from medical disorders, including infections with human immunodeficiency virus (HIV) and hepatitis C (HCV). Opioid agonist therapy (OAT) is an effective, evidenced-based, standard of care treatment for opioid dependence (Kivlahan et al., 2007; Krantz & Mehler, 2004; Mattick, et al., 2003). Historically, OAT was restricted to methadone treatment delivered exclusively in licensed OAT Programs (OATPs). Unfortunately, only 40 VA OATP programs exist and as many as 70% of veterans with opioid dependence did not receive any OATP care over a one year time frame (Dalton et al. 2005; Mark et al., 2001).

Recently, in an effort to expand access to OAT beyond OATPs, Congress passed legislation which allows qualified physicians to prescribe and dispense approved sublingual buprenorphine (Subutex) and buprenorphine/naloxone (Suboxone) tablets (hereafter collectively termed buprenorphine [O'Connor & Fiellin; 2000]), in office-based practices for the treatment of opioid dependence (Fiellin et al., 2001; Fiellin & O'Connor, 2002; Fiellin et al., 2006).  Buprenorphine has been shown to be a safe and effective treatment of opioid dependence in non-specialized, outpatient, office-based settings, including VA environments (Faluda et al., 2003; IOM Report, 2005; Stein et al., 2005). This change for the treatment of opioid dependence represents a radical shift from treatment within traditional specialty care settings to treatment within generalist settings, an approach advocated for by the Institutes of Medicine (Trafton et al., 2007; Vastag, 2003).

Current Practice

We have recently shown that buprenorphine treatment has been slow to be adopted in the VA (Fiellin & O'Connor, 2002). In FY2005, only 739 veterans were prescribed buprenorphine in office based practices.  Therefore, In September 2005, the SUD QUERI established a Buprenorphine Task Group (BTG) of interdisciplinary addiction experts to help improve the implementation of buprenorphine OAT within VA.

Methadone

Background

Established guidelines for methadone therapy (e.g., the VA/DoD Guideline for the Management of Substance Use Disorders) are supported by findings from a number of randomized trials (see a meta-analysis by March, 1998), and afford specific guidance on effective practices for retaining patients in methadone outpatient treatment.  They include providing 1) adequate methadone doses and 2) psychosocial services, 3) having a maintenance, rather than a detoxification goal, and 4) using rigorous contingency management techniques (e.g., allowing take-home doses of methadone after a patient provides a series of drug-free urine samples).

Promoting Evidence-Based Specialty Care for Patients with SUD

The SUD QUERI continues its efforts to promote engagement and retention in specialty care as a final common pathway to promote evidence-based practices for treatment of SUD. To do so, the SUD QUERI facilitates access to and appropriate use of opioid agonist therapies for treatment of opioid-dependence across outpatient settings.

Implementing Opioid Agonist Therapy (OAT)

Medication-assisted recovery for opioid dependence has a well-established evidence base as a cost-effective approach to improving treatment retention and clinical outcome. It is an identified priority in the MH Strategic Plan. In FY07, VHA served over 27,000 patients diagnosed with opioid dependence, but fewer than 1 in 5 received ongoing methadone or buprenorphine. Buprenorphine is the only medication approved for office-based OAT. PBM data show that 1,609 veterans received prescriptions from Q3FY06 to Q2FY07. Despite the substantial increase from 719 in FY05, this needs to improve.

Methadone Quality Improvement Project. The Methadone Work Group hosted a VHA teleconference on effective practices in November 2006 with 47 lines in use. A follow-up survey was sent out to clinic directors in May, 2007, with planned analysis in FY08 to assess practice change since the FY06 survey and also to determine practice areas to target for further improvement.

Implementing Buprenorphine. Buprenorphine Task Group (BTG) efforts to facilitate buprenorphine treatment of opioid dependence within VA include:

• Enhancing VHA organizational readiness to provide buprenorphine in specialty and nonspecialty settings. The BTG is providing external facilitation to 14 VA facilities funded by CO to establish buprenorphine treatment capacity. This includes a consult service consisting of VA "clinical experts", a resource guide and a monthly listserve-newsletter. Since March 2007, there have been 722 site contacts, including 246 from non-funded sites.
• Formulary availability. The BTG worked with Pharmacy and Therapeutics Committees at several sites to place buprenorphine on the formulary.
• Enhancing provider readiness to prescribe buprenorphine. The BTG evaluated course ratings and subsequent prescribing practices of 18 attendees at EES trainings during FY07. Because few physicians attended the trainings, despite free travel, in October 2007 the BTG planned and broadcasted a EES cyber seminar on buprenorphine treatment initially attended by 40 clinicians. The BTG also worked with SAMHSA/CSAT's Physician Clinical Support System (PCSS), to link providers with experienced mentors and successfully facilitated site visits with experienced "host" facilities.
• Identifying barriers and facilitators to buprenorphine implementation. The BTG completed two Rapid Response Projects. A survey of 62 key informants at 17 facilities identified barriers to implementation, including a lack of perceived patient need or staff-level interest, stigma about the diagnosis of opioid dependence, and concerns of diversion and "abstinence-based" philosophies. Common practice-level barriers included lack of administrative support, provider time, back-up coverage and continuity of care/integration. Buprenorphine implementation facilitators included provider interest and having a "champion" who promoted use. Our economic RRP showed that despite the higher cost of medication, buprenorphine treatment was less expensive overall than methadone treatment. Reports are in preparation for dissemination to VHA and at national meetings.
• Decision Support Tool for Opioid Medication Use. An ongoing SDP (Dr. Trafton, PI) is developing and evaluating an automated clinical decision support system (DSS) to implement the VA/DoD Guideline for the Management of Opioid Therapy for Chronic Pain. A major goal is to prevent the development of opioid use disorders related to pain medications. As referrals for buprenorphine treatment include patients with co-morbid pain and addiction, the BTG has explored with pain specialists inclusion of buprenorphine treatment advisories as part of the DSS.

Progress and Accomplishments

• Impacts, Contributions and Products
• Publications and Presentations
• Active and Completed Projects
• Planned Projects
• Implementation Pipeline (PDF)

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