Opening the "black box": Four common implementation strategies for expanding the use of medications for opioid use disorder in primary care.

Background: Despite the persistent increase in overdose deaths, access to medications for opioid use disorders remains limited. Recent federal funding aimed at increasing access prompts a need to understand if implementation strategies improve access. Methods: This is an analysis of data from 174 primary care clinics enrolled in a state-wide medications for opioid use disorders (MOUD) implementation effort in California. We examined clinic use of one of four implementation strategies: learning collaboratives, Project Extension for Community Health care Outcomes (ECHO), didactic webinars, and clinical skills trainings. The primary implementation outcome was categorical change in new patients prescribed buprenorphine. Univariate and multivariate logistic regressions were used to determine the impact of clinic attendance in all or individual implementation strategies, respectively, on patient growth. Results: Clinics attending learning collaboratives, Project ECHO, and clinical skills trainings had significantly higher odds of patient growth (odds ratio [OR] = 3.56; 95% confidence interval [CI] = 1.78, 7.10, p < .001), (OR = 3.39; 95% CI = 1.59, 7.24, p < .01), (OR = 3.90, 95% CI = 1.64, 9.23, p < .01) than non-attending clinics. The impact of attendance at learning collaboratives (OR = 5.81, 95% CI = 1.89, 17.85; p < .01), didactic webinars (OR = 3.59; 95% CI = 1.04, 12.35; p < .05), and clinical skills trainings (OR = 3.53, 95% CI = 1.06, 11.78, p < .05) on patient growth was greater for Federally Qualified Health Centers. When comparing strategies in multivariate models, only the relationship between learning collaborative attendance and new patients prescribed buprenorphine remained significant (OR = 2.57; 95% CI = 1.12, 5.88; p < .05). Conclusions: This study reported on a large, statewide, implementation-as-usual project offering four typical implementation strategies. Clinic attendance at learning collaboratives, a multi-component strategy, had the most consistent impact on new patients prescribed buprenorphine. These results suggest that while a broad array of strategies was initially reasonable, optimizing the selection of implementation strategies could be more effective. Plain Language Summary: Access to life-saving medications for opioid use disorder, such as buprenorphine, remains limited despite strong evidence of effectiveness. Systems and organizations often select from a variety of implementation strategies aimed at expanding access to these medications. However, scant research exists to enable these organizations to select the most effective and efficient strategies. Our study-within a large state-wide system of care-examined the impact of primary care clinic attendance in four common implementation strategies on new patients prescribed buprenorphine. Learning collaboratives were the strategy that most consistently improved outcomes. These results highlight the challenges to strategy selection inherent in implementation-as-usual systems-level approaches. The field needs evidence-based information on which implementation strategies are most likely to yield desired implementation outcomes.

Implementation of the hub and spoke model for opioid use disorders in California: Rationale, design and anticipated impact.

As part of the State Targeted Response to the opioid epidemic, California has adopted the Hub and Spoke model to expand access to medications for opioid use disorder, particularly buprenorphine, throughout the state. By aligning opioid treatment programs as hubs with primary care, office-based practitioners, and other health care settings as spokes, a broader treatment model can reach more people with opioid use disorder, improve access to medications for opioid use disorders, and decrease overdose deaths. Expanding access requires expanding knowledge and intensive implementation support of new practices. This paper describes the rationale, specific activities and anticipated impact of the implementation plan in California's Hub and Spoke system. Training and technical assistance are designed to: increase the number and capacity of waivered prescribers; enhance skills of prescribers and multidisciplinary teams; and create systems change. Activities include buprenorphine waiver trainings and provider support, a practice facilitator program, Project ECHO sessions, webinars, clinical skills trainings, and regional learning collaboratives. This overview highlights the steps California is taking to build treatment capacity to address the opioid epidemic.

Preliminary results of the evaluation of the California Hub and Spoke Program.

In August 2017, California launched the Hub and Spoke Program to address the growing number of opioid overdose deaths in the state. The program connects opioid treatment programs ("hubs") with office based opioid treatment settings, like primary care clinics ("spokes") to build a network of treatment expertise and referral resources. A key objective of this program is to expand access to medications for opioid use disorders (MOUD), with a particular focus on getting more buprenorphine into spokes. This article describes the preliminary results of the evaluation of the California Hub and Spoke program. Using a mixed methods approach, this portion of the evaluation measures changes in numbers of MOUD patients and providers, and barriers and facilitators to implementation. Findings reveal that, in the first 15 months of the program, 3480 new patients started buprenorphine in 118 spokes, increasing treatment initiations by 94.7% over baseline. The number of waivered spoke providers also increased 52.4% to 268. Although these data demonstrate promising growth in the network, challenges to expanding treatment access remain. Provider activity was among the most notable. Despite growth in the number of spoke providers with waivers to prescribe buprenorphine, only 68.7% (n = 184) were actively prescribing to patients. A survey of providers found that those who were not yet using their waivers lacked the confidence and mentorship they needed to prescribe. Provider knowledge and attitudes toward MOUD, fear of legal consequences, and limited patient outreach were also contributing factors. Recommendations for strengthening Hub and Spoke program implementation include facilitating mentor linkage for prescribers, expanding the support offered to spoke providers, and offering additional training and technical assistance aimed at provider stigma. Efforts to address these recommendations are described in a companion paper (Miele et al., under review).

Predictors of Continued Use of Extended-Released Naltrexone (XR-NTX) for Opioid-Dependence: An Analysis of Heroin and Non-Heroin Opioid Users in Los Angeles County.

Extended-release naltrexone (XR-NTX) is associated with an increased number of opioid-free days, improved adherence rates in substance use disorder treatment programs, and reduced cravings and drug-seeking behaviors. There is little evidence on the predictive associations between baseline characteristics of opioid-dependent patients and XR-NTX utilization. Some studies have demonstrated better pharmacotherapy adherence and/or retention rates among non-heroin opioid users compared to heroin users. This study examines predictive associations between characteristics of patients and XR-NTX utilization, as well as participants' urge to use opiates. Our findings suggest that XR-NTX may contribute to decreases in urges to use among both heroin and non-heroin opioid users. Non-heroin opioid users and heroin users were retained in XR-NTX treatment for comparable periods of time. However, those who identified as homeless, injected opioids (regardless of opioid-type), or were diagnosed with a mental illness were less likely to be retained in treatment with XR-NTX.