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

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.

Improving access to buprenorphine for rural veterans in a learning health care system.

OBJECTIVE: To describe a learning health care system research process designed to increase buprenorphine prescribing for the treatment of opioid use disorder (OUD) in rural primary care settings within U.S. Department of Veterans Affairs (VA) treatment facilities. DATA SOURCES AND STUDY SETTING: Using national administrative data from the VA Corporate Data Warehouse, we identified six rural VA health care systems that had improved their rate of buprenorphine prescribing within primary care from 2015 to 2020 (positive deviants). We conducted qualitative interviews with leaders, clinicians, and staff involved in buprenorphine prescribing within primary care from these sites to inform the design of an implementation strategy. STUDY DESIGN: Qualitative interviews to inform implementation strategy development. DATA COLLECTION/EXTRACTION METHODS: Interviews were audio-recorded, transcribed verbatim, and coded by a primary coder and secondary reviewer. Analysis utilized a mixed inductive/deductive approach. To develop an implementation strategy, we matched clinical needs identified within interviews with resources and strategies participants had utilized to address these needs in their own sites. PRINCIPAL FINDINGS: Interview participants (n = 30) identified key clinical needs and strategies for implementing buprenorphine in rural, primary care settings. Common suggestions included the need for clinical mentorship or a consult service, buprenorphine training, and educational resources. Building upon interview findings and in partnership with a clinical team, we developed an implementation strategy composed of an engaging case-based training, an audit and feedback process, and educational resources (e.g., Buprenorphine Frequently Asked Questions, Rural Care Model Infographic). CONCLUSIONS: We describe a learning health care system research process that leveraged national administrative data, health care provider interviews, and clinical partnership to develop an implementation strategy to encourage buprenorphine prescribing in rural primary care settings.

"They Ask Questions, But They Don't Want the Answers"-Perceptions of Clinical Communication Among Veterans Discontinuing Buprenorphine for the Treatment of Opioid Use Disorder.

BACKGROUND: Many patients with opioid use disorder (OUD) discontinue treatment prematurely, increasing their risk of opioid-related overdose and death. While patient-centered care is considered the gold standard in treating chronic illness, it may be practiced less frequently in the context of OUD care. Patient-provider communication can influence patients' care experiences, potentially having an impact on treatment retention and care decision-making. METHODS: This study was conducted at the VA Portland Health Care System from March 2021 to April 2022. We conducted qualitive interviews with patients who had discontinued buprenorphine for the treatment of OUD within the past year. Coding and analysis were guided by inductive qualitative content analysis. Retrospective medical record review identified clinical and demographic characteristics of participants. RESULTS: Twenty patients completed an interview. Participant age ranged from 28 to 74 years (median 63 years). Ninety percent of participants were white and 90% male. Many participants expressed frustration and feelings of disempowerment in OUD care processes. Patients with a history of long-term prescribed opioid use frequently expressed stigmatizing views of OUD, and perceptions of disagreement with providers over diagnosis and care choices. Elderly patients and those with multiple comorbidities expressed confusion over significant aspects of their care, as well as difficulty navigating treatment logistics like appointment requirements and medication dose changes. Some patients reported later restarting buprenorphine in new settings, and described feeling respected and involved in care decisions as a facilitator for continuing treatment. CONCLUSIONS: Prioritizing patient-centered communication in OUD treatment could improve the patient experience and potentially support treatment retention. Subgroups of OUD patients, such as those with a history of long-term prescribed opioid use, elderly patients with multiple comorbidities, or those who express stigmatizing medication views, could particularly benefit from tailored communication strategies that address their individual concerns.

Patients' Perspectives on Discontinuing Buprenorphine for the Treatment of Opioid Use Disorder.

OBJECTIVES: Buprenorphine and other medications for opioid use disorder (OUD) are recommended as standard of care in the treatment of OUD and are associated with positive health and addiction-related outcomes. Despite benefits, discontinuation is common, with half of patients discontinuing in the first year of treatment. Addressing OUD is a major clinical priority, yet little is known about the causes of medication discontinuation from the patient perspective. METHODS: From March 2021 to April 2022, we conducted qualitative interviews with patients who had discontinued buprenorphine for the treatment of OUD within the past 12 months. Eligible participants were selected from 2 Veterans Health Administration Health Care Systems in Oregon. Coding and analysis were guided by conventional qualitative content analysis. RESULTS: Twenty participants completed an interview; 90% were White and 90% were male, and the mean age was 54.2 years. Before discontinuation, participants had received buprenorphine for 8.3 months on average (range, 1-40 months); 80% had received buprenorphine for less than 12 months. Qualitative analysis identified the following themes relating to discontinuation: health system barriers (eg, logistical hurdles, rules and policy violations), medication effects (adverse effects; attributed adverse effects, lack of efficacy in treating chronic pain) and desire for opioid use. Patient description of decisions to discontinue buprenorphine could be multicausal, reflecting provider or system-level barriers in interaction with patient complexity or medication ambivalence. CONCLUSIONS: Study results identify several actionable ways OUD treatment could be modified to enhance patient retention.

Let's Talk About Firearms: Perspectives of Older Veterans and VA Clinicians on Universal and Dementia-Specific Firearm Safety Discussions.

OBJECTIVES: Veterans experience high rates of fatal and non-fatal firearm injuries. This risk may be compounded among Veterans who are rural-residing, aging, and/or experiencing cognitive decline or dementia. Firearm safety discussions are not broadly implemented across Department of Veterans Affairs (VA) healthcare settings due, in part, to concerns of causing Veterans to disengage from care. This study examines perceptions about firearm safety discussions to inform healthcare-based harm-reduction efforts. METHODS: We conducted interviews with 34 Veterans (median age 70) and 22 clinicians from four VA facilities that treat high rates of rural patients with firearm-related injuries. RESULTS: Most Veterans accepted the idea of universal firearm safety discussions at the VA. Some reported they might not be forthright in such discussions, but raising the topic would not stop them from engaging with VA care. Veterans and clinicians unanimously endorsed firearm safety discussions for older patients experiencing cognitive decline or dementia. CONCLUSIONS: VA patients and clinicians are amenable to firearm safety discussions during healthcare visits and especially endorse the need for such discussions among high-risk populations. CLINICAL IMPLICATIONS: Universal firearm safety discussions could be incorporated into standard VA practice, particularly for Veterans experiencing cognitive decline or dementia, without risking Veteran disengagement from care.

Buprenorphine use and courses of care for opioid use disorder treatment within the Veterans Health Administration.

BACKGROUND: Retention of patients in buprenorphine medication treatment for opioid use disorder (B-MOUD) reduces harms associated with opioid use disorder (OUD). We sought to characterize the patients receiving B-MOUD and courses of B-MOUD in a large healthcare system. METHODS: We conducted a retrospective, open cohort study of patients with OUD who either did or did not receive B-MOUD courses within the Veterans Health Administration (VHA) from January 2006 through July 2019, using VHA clinical data. We compared patients receiving or not receiving B-MOUD, characterized B-MOUD courses (e.g., length and doses), and examined persistence, across patient characteristics, over time. We used analyses for normally or non-normally distributed continuous variables, categorical data, and persistence over time (Kaplan-Meier persistence curves). RESULTS: We identified 255,726 Veterans with OUD; 40,431 (15.8%) had received 63,929 B-MOUD courses. Compared to patients with OUD without B-MOUD, patients with B-MOUD were younger, more often of white race, and had more co-morbidities. The frequency of new B-MOUD starts and prevalent B-MOUD patients ranged from 1550 and 1989 in 2007 to 8146 and 16,505 in 2018, respectively. The median duration of B-MOUD was 157 (IQR: 37-537) days for all courses and 33.8% patients had more than one course. The average proportion days covered was 90% (SD: 0.15), and the average prescribed daily dose was 13.44 (SD: 6.5). CONCLUSIONS: Within a VHA B-MOUD cohort, courses increased more than 10-fold from 2006 to 2016 with nearly half of patients experiencing multiple courses. Patient demographics seem to dictate the length of courses.

"I'm Clean and Sober, But Not Necessarily Free": Perceptions of Buprenorphine Among Patients in Long-Term Treatment.

BACKGROUND: Patients receiving buprenorphine for the treatment of opioid use disorder (OUD) experience a roughly 50% reduction in mortality risk relative to those not receiving medication. Longer periods of treatment are also associated with improved clinical outcomes. Despite this, patients often express desires to discontinue treatment and some view taper as treatment success. Little is known about the beliefs and medication perspectives of patients engaged in long-term buprenorphine treatment that may underlie motivations to discontinue. METHODS: This study was conducted at the VA Portland Health Care System (2019-2020). Qualitative interviews were conducted with participants prescribed buprenorphine for ≥2 years. Coding and analysis were guided by directed qualitative content analysis. RESULTS: Fourteen patients engaged in office-based buprenorphine treatment completed interviews. While patients expressed strong enthusiasm for buprenorphine as a medication, the majority expressed the desire to discontinue, including patients actively tapering. Motivations to discontinue fell into 4 categories. First, patients were troubled by perceived side effects of the medication, including effects on sleep, emotion, and memory. Second, patients expressed unhappiness with being "dependent" on buprenorphine, framed in opposition to personal strength/independence. Third, patients expressed stigmatized beliefs about buprenorphine, describing it as "illicit," and associated with past drug use. Finally, patients expressed fears about buprenorphine unknowns, including potential long-term health effects and interactions with medications required for surgery. CONCLUSIONS: Despite recognizing benefits, many patients engaged in long-term buprenorphine treatment express a desire to discontinue. Findings from this study may help clinicians anticipate patient concerns and can be used to inform shared decision-making conversations regarding buprenorphine treatment duration.

Access to Medications for Opioid Use Disorder in Rural Versus Urban Veterans Health Administration Facilities.

BACKGROUND: For patients with opioid use disorder (OUD), medications for OUD (MOUD) reduce morbidity, mortality, and return to use. Nevertheless, a minority of patients receive MOUD, and underutilization is pronounced among rural patients. OBJECTIVE: While Veterans Health Administration (VHA) initiatives have improved MOUD access overall, it is unknown whether access has improved in rural VA health systems specifically. How "Community Care," healthcare paid for by VHA but received from non-VA providers, has affected rural access is also unknown. DESIGN: Data for this observational study were drawn from the VHA Corporate Data Warehouse. Facility rurality was defined by rural-urban commuting area code of the primary medical center. International Classification of Diseases codes identified patients with OUD within each year, 2015-2020. We included MOUD (buprenorphine, methadone, extended-release naltrexone) received from VHA or paid for by VHA but received at non-VA facilities through Community Care. We calculated average yearly MOUD receipt; linear regression of outcomes on study years identified trends; an interaction between year and rural status evaluated trend differences over time. PARTICIPANTS: All 129 VHA Health Systems, a designation that encompasses one or more medical centers and their affiliated community-based outpatient clinics MAIN MEASURES: The average proportion of patients diagnosed with OUD that receive MOUD within rural versus urban VHA health care systems. KEY RESULTS: From 2015 to 2020, MOUD access increased substantially: the average proportion of patients receiving MOUD increased from 34.6 to 48.9%, with a similar proportion of patients treated with MOUD in rural and urban systems in all years. Overall, a small proportion (1.8%) of MOUD was provided via Community Care, and Community Care did not disproportionately benefit rural health systems. CONCLUSIONS: Strategies utilized by VHA could inform other health care systems seeking to ensure that, regardless of geographic location, all patients are able to access MOUD.

Expanding access to medications for opioid use disorder through locally-initiated implementation.

BACKGROUND: Despite demonstrated efficacy, medication treatment for opioid use disorder (MOUD) remain inaccessible to many patients, with barriers identified at the individual, clinic and system level. A wide array of implementation strategies have guided efforts to expand access to MOUD, with most centered around externally-facilitated approaches to practice change. While effective, such approaches may be inaccessible to those clinics and systems that lack the resources necessary to partner with an external team, suggesting a need to identify and describe change-processes that are internally developed and promoted. METHODS: Guided by the Consolidated Framework for Implementation Research (CFIR), we utilized qualitative interviews and ethnographic observation to investigate the planning, design and implementation of a locally-initiated process to expand access to MOUD within one health care system. All study documents were coded by a primary coder and secondary reviewer using a codebook designed for use with the CFIR. To analyze data, we reviewed text tagged by key codes, compared these textual excerpts both across and within documents, and organized findings into themes. Processes identified were mapped to established implementation science constructs and strategies. RESULTS: Interviews with clinicians and administrators (n = 9) and ethnographic observation of planning meetings (n = 3) revealed how a self-appointed local team developed, established broad support for, and successfully implemented a Primary Care-based Buprenorphine Clinic and E-Consult Service to expand access to MOUD to patients across the health care system. First, national and local policy changes-including altered clinical practice guidelines, performance pay incentives regarding opioid prescribing, and a directive from VA Central Office increased individual staff and administrators' perception of the need for change and willingness to invest time and resources. Then, a self-appointed interdisciplinary team utilized cross-clinic meetings and information gathering to identify appropriate, and widely supported, models of care delivery and care consultation. Finally, the team increased staff investment in these change efforts by bringing them into the planning process and encouraging collaborative problem solving. CONCLUSIONS: This study reveals how a local team developed and built widespread support for new processes of care that were tailored to local needs and well-positioned for sustainability over time.

Perioperative Management of Buprenorphine/Naloxone in a Large, National Health Care System: a Retrospective Cohort Study.

BACKGROUND: Medication for opioid use disorder, including buprenorphine and methadone, is considered the gold standard treatment for opioid use disorder (OUD). As the number of patients receiving buprenorphine has grown, clinicians increasingly care for patients prescribed buprenorphine who present for surgery and require management of perioperative pain. OBJECTIVE: To describe practice patterns of perioperative and post-surgical use of buprenorphine among patients prescribed buprenorphine for OUD who experience major surgery. DESIGN: Retrospective cohort study utilizing data from the VA Corporate Data Warehouse (CDW), a national repository of patient-level data. Data not accessible in CDW, including clinical instructions to patients to modify buprenorphine dose, were accessed via chart review. PARTICIPANTS: National sample of patients receiving care through the Veterans Health Administration. MAIN MEASURES: We report descriptive statistics on the incidence of buprenorphine dose hold prior to, during, and immediately following surgery, as well as post-surgical outcomes. Multivariable logistic regression identified socio-demographic and clinical characteristics associated with perioperative hold. KEY RESULTS: Our final sample comprised 183 patients, the majority of whom were white and male. Most patients (66%) experienced a perioperative buprenorphine dose hold: during the pre-operative, day of surgery, and post-operative periods, 40%, 62%, and 55% of patients had buprenorphine held. Buprenorphine dose hold was less likely for patients who had experienced homelessness/housing insecurity in the year prior to surgery (aOR = 0.25; 95% CI 0.10-0.61) as well as patients residing in rural areas (aOR=0.29; 0.12-0.68). Within the 12-month period following surgery, 122 patients (67%) were retained on buprenorphine, 10 patients (5.5%) had experienced an overdose, and 15 (8.2%) had died. CONCLUSIONS: We identified high rates of perioperative buprenorphine dose holds. As holding buprenorphine perioperatively does not align with emerging clinical recommendations and carries significant risks, educational campaigns or other provider-targeted interventions may be needed to ensure patients with OUD receive recommended care.

Twelve-Month Retention in Opioid Agonist Treatment for Opioid Use Disorder Among Patients With and Without HIV.

Although opioid agonist therapy (OAT) is associated with positive health outcomes, including improved HIV management, long-term retention in OAT remains low among patients with opioid use disorder (OUD). Using data from the Veterans Aging Cohort Study (VACS), we identify variables independently associated with OAT retention overall and by HIV status. Among 7,334 patients with OUD, 13.7% initiated OAT, and 27.8% were retained 12-months later. Likelihood of initiation and retention did not vary by HIV status. Variables associated with improved likelihood of retention included receiving buprenorphine (relative to methadone), receiving both buprenorphine and methadone at some point over the 12-month period, or diagnosis of HCV. History of homelessness was associated with a lower likelihood of retention. Predictors of retention were largely distinct between patients with HIV and patients without HIV. Findings highlight the need for clinical, systems, and research initiatives to better understand and improve OAT retention.

Adjunct interventions to standard medical management of buprenorphine in outpatient settings: A systematic review of the evidence.

BACKGROUND: A growing body of research has examined adjunctive interventions supportive of engagement and retention in treatment among patients receiving buprenorphine for opioid use disorder (OUD). We conducted a systematic review of the literature addressing the effect on key outcomes of adjunctive interventions provided alongside standard medical management of buprenorphine in outpatient settings. METHODS: We included prospective studies examining adults receiving buprenorphine paired with an adjunctive intervention for the treatment of OUD in an outpatient setting. Data sources included Medline, Cochrane Central Register of Controlled Trials, CINAHL and PsycINFO from inception through January 2020. Two raters independently reviewed full-text articles, abstracted data and appraised risk of bias. Outcomes examined included abstinence, retention in treatment and non-addiction-related health outcomes. RESULTS: The final review includes 20 manuscripts, 11 randomized control trials (RCTs), three secondary analyses of RCTs and six observational studies. Most studies examined psychosocial interventions (n = 14). Few examined complementary therapies (e.g., yoga; n = 2) or technological interventions (e.g., electronic pill dispensation; n = 3); one study examined an intervention addressing structural barriers to care (patient navigators; n = 1). Low risk of bias RCTs found no evidence that adding psychosocial interventions to buprenorphine treatment improves substance use outcomes. CONCLUSIONS: Research is needed to identify adjunctive interventions with potential to support medication adherence and addiction-related outcomes for patients engaged in buprenorphine treatment. Data from clinical trials suggest that lack of ready access to psychosocial treatments should not discourage clinicians from prescribing buprenorphine.

Patients' perceptions of the pathways linking chronic pain with problematic substance use.

ABSTRACT: Approximately one-half of patients with substance use disorders (SUDs) experience chronic pain. Yet, how patients perceive the relationship between their substance use and chronic pain remains poorly understood. We sought to identify how patients with comorbid SUD and chronic pain describe the relationship between, and mechanisms linking, these conditions. We conducted qualitative interviews with 34 patients engaged in SUD treatment who were also diagnosed with chronic pain. Interviews were transcribed verbatim and coded by both primary and secondary coders. Qualitative content analysis guided coding and analysis. Patient interviews revealed 3 primary pathways. One group of participants described SUD as developing independently from their experiences of chronic pain. A second group of participants described turning to substances to self-manage or cope with the physical and emotional aspects of chronic pain. A third group of participants described encounters with opioid medications as the causal agent initiating a SUD. Our findings build on research that has identified chronic pain and SUD as developmentally similar and mutually reinforcing, by revealing the ways in which patients themselves understand and experience the interconnections between their substance use and chronic pain.

Supporting family caregivers of Veterans: Participant perceptions of a federally-mandated caregiver support program.

OBJECTIVES: To understand patients' and caregivers' experiences with and perceptions of a federally-mandated program within the Department of Veterans Affairs (VA) that provides educational and monetary support to family caregivers of post-9/11 Veterans. METHODS: Twenty-six Veterans and their family caregivers were recruited to participate in individual and dyadic interviews. Interviews lasted between 60 and 90 min and took place between August 2016 and July 2018 in Oregon and Louisiana. Interviews were recorded, transcribed and coded by multiple team members. Recurrent themes and categories were identified through close examination of coded text and comparison within and across transcripts. RESULTS: Three main themes emerged in the data: 1) appreciation of the caregiver program for validating and compensating family caregiver work; 2) perception that some caregiving activities are less visible, and thus go unrecognized and uncompensated; 3) concern about loss of benefits. CONCLUSIONS: Implications and policy recommendations for programs to support family caregivers, both within the VA and in the context of the broader national movement to support family caregivers, are discussed.

Employment and vocational rehabilitation experiences among veterans with polytrauma/traumatic brain injury history.

Evidence suggests that Iraq and Afghanistan war veterans with polytrauma/traumatic brain injury (TBI) history and neurobehavioral symptoms may face difficulties returning to work, yet also encounter barriers to accessing, navigating, and engaging in Department of Veterans Affairs (VA) vocational rehabilitation programs. This study utilized qualitative interviews and focus groups with veterans with documented polytrauma/TBI history to explore veterans' perceived barriers to employment and vocational rehabilitation program participation, as well as to solicit thoughts regarding interest in an evidence-based vocational rehabilitation program, the Individual Placement and Support model of Supported Employment (IPS-SE). Veterans identified physical, emotional, cognitive, and interpersonal barriers to finding and maintaining work that they described as linked with their polytrauma/TBI symptoms and sequelae. Communication and logistical issues were described as the primary barriers to vocational rehabilitation program access, while barriers to program utilization included eligibility characteristics, fear of losing financial benefits, and a military-cultural belief of self-sufficiency that made help-seeking difficult. Finally, veterans endorsed key aspects of IPS-SE, such as staff serving as translators, advocates, and navigators of the job search and maintenance process. Policy recommendations are addressed. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Barriers to Utilization of Prescription Drug Monitoring Programs Among Prescribing Physicians and Advanced Practice Registered Nurses at Veterans Health Administration Facilities in Oregon.

OBJECTIVE: To identify barriers to using state prescription drug monitoring programs (PDMPs) among prescribing physicians and advanced practice registered nurses across a variety of Veterans Health Administration (VA) settings in Oregon. DESIGN: In-person and telephone-based qualitative interviews and user experience assessments conducted with 25 VA prescribers in 2018 probed barriers to use of state PDMPs. SETTING: VA health care facilities in Oregon. SUBJECTS: Physicians (N = 11) and advanced practice registered nurses (N = 14) who prescribed scheduled medications, provided care to patients receiving opioids, and used PDMPs in their clinical practice. Prescribers were stationed at VA medical centers (N = 10) and community-based outpatient clinics (N = 15); medical specialties included primary care (N = 10), mental health (N = 9), and emergency medicine (N = 6). METHODS: User experience was analyzed using descriptive statistics. Qualitative interviews were analyzed using conventional content analysis methodology. RESULTS: The majority of physicians (64%) and advanced practice registered nurses (79%) rated PDMPs as "useful." However, participants identified both organizational and software design issues as barriers to their efficient use of PDMPs. Organizational barriers included time constraints, clinical team members without access, and lack of clarity regarding the priority of querying PDMPs relative to other pressing clinical tasks. Design barriers included difficulties entering or remembering passwords, unreadable data formats, time-consuming program navigation, and inability to access patient information across state lines. CONCLUSIONS: Physicians and advanced practice registered nurses across diverse VA settings reported that PDMPs are an important tool and contribute to patient safety. However, issues regarding organizational processes and software design impede optimal use of these resources.

Setting Expectations, Following Orders, Safety, and Standardization: Clinicians' Strategies to Guide Difficult Conversations About Opioid Prescribing.

BACKGROUND: Evidence has continued to accumulate regarding the potential risks of treating chronic pain with long-term opioid therapy (LTOT). Clinical practice guidelines now encourage clinicians to implement practices designed to reduce opioid-related risks. Yet how clinicians implement these guidelines within the context of the patient encounter has received little attention. OBJECTIVE: This secondary analysis aimed to identify and describe clinicians' strategies for managing prescription opioid misuse and aberrant behaviors among patients prescribed LTOT for chronic pain. DESIGN: Individual interviews guided by a semi-structured interview protocol probed: (1) methods clinicians utilize to reduce prescription opioid misuse and address aberrant opioid-related behaviors; (2) how clinicians respond to misuse; and (3) resources and constraints faced in managing and treating misuse among their patients. PARTICIPANTS: Interviews were conducted with 24 physicians and nurse practitioners, representing 22 Veterans Health Administration (VA) facilities across the USA, who had one or more patients in their clinical panels who were prescribed LTOT for the treatment of chronic non-cancer pain. APPROACH: Qualitative content analysis was the analytic approach utilized. A codebook was developed iteratively following group coding and discussion. All transcripts were coded with the finalized codebook. Quotes pertaining to key themes were retrieved and, following careful review, sorted into themes, which were then further categorized into sub-themes. Quotes that exemplified key sub-themes were selected for inclusion. KEY RESULTS: We detail the challenges clinicians describe in navigating conversations with patients around prescription opioid misuse, which include patient objection as well as clinician ambivalence. We identify verbal heuristics as one strategy clinicians utilize to structure these difficult conversations, and describe four heuristics: setting expectations, following orders, safety, and standardization. CONCLUSION: Clinicians frequently use verbal heuristics to routinize and increase the efficiency of care management discussions related to opioid prescribing, redirect responsibility, and defuse the potential emotional charge of the encounter.

Predictors of timely opioid agonist treatment initiation among veterans with and without HIV.

BACKGROUND: Opioid use disorder (OUD) is prevalent among people with HIV (PWH). Opioid agonist therapy (OAT) is the most effective treatment for OUD and is associated with improved health outcomes, but is often not initiated. To inform clinical practice, we identified factors predictive of OAT initiation among patients with and without HIV. METHODS: We identified 19,698 new clinical encounters of OUD between 2000 and 2012 in the Veterans Aging Cohort Study (VACS), a national observational cohort of PWH and matched uninfected controls. Mixed effects models examined factors predictive of OAT initiation within 30-days of a new OUD clinical encounter. RESULTS: 4.9% of both PWH and uninfected patients initiated OAT within 30 days of a new OUD clinical encounter. In adjusted models, participants with a psychiatric diagnosis (aOR = 0.54, 95% CI 0.47 - 0.62), PWH (aOR = 0.79, 95% CI 0.68-0.92), and rural residence (aOR = 0.56, 95% CI 0.39-0.78) had a lower likelihood of any OAT initiation, while African-American patients (aOR = 1.60, 95% CI 1.34-1.92), those with an alcohol related diagnosis (aOR = 1.76, 95% CI 1.48-2.08), diagnosis year 2005-2008 relative to 2000-2004 (aOR = 1.24, 95% CI 1.05-1.45), and patients with HCV (aOR = 1.50, 95% CI 1.27-1.77) had a greater likelihood of initiating any OAT within 30 days. Predictive factors were similar in the total sample and PWH only models. CONCLUSIONS: PWH were less likely to receive timely OAT initiation than demographically similar uninfected patients. Given the health benefits of such treatment, the low rate of OAT initiation warrants focused efforts in both PWH and uninfected populations.

Clinical Strategies for the Treatment and Management of Patients Prescribed Long-term Opioid Therapy.

OBJECTIVES: Across diverse health care systems, growing recognition of the harms associated with long-term opioid therapy (LTOT) for chronic pain has catalyzed substantial changes to policy and practice designed to promote safer prescribing and patient care. Although clear goals have been defined, how clinics and providers should most effectively implement these changes has been less well defined, and facilities and providers have had substantial flexibility to innovate. METHODS: Qualitative interviews were conducted with 24 Department of Veterans Affairs (VA) clinicians across the United States who prescribe LTOT for chronic pain. Interviews probed the practices and initiatives providers utilized to meet opioid safety requirements and address common challenges in caring for patients prescribed LTOT. RESULTS: Innovative strategies in the design and organization of clinical practice (urine drug testing, informed consent, limiting transfer requests, specialty patient panel) and resources utilized (engaged pharmacists, non-opioid pain treatments, intra-organizational collaborations) are described. CONCLUSIONS: We conclude with recommendations designed to improve opioid prescribing practices, both within the VA and in other settings.

Provider reasons for discontinuing long-term opioid therapy following aberrant urine drug tests differ based on the type of substance identified.

OBJECTIVE: Urine drug testing (UDT) is increasingly performed as a means of identifying aberrant behavior that may be grounds for discontinuation of long-term opioid therapy (LTOT). Little is known, however, about the ways in which positive UDT results may differentially inform decisions to discontinue LTOT based on the type of substance for which the UDT screened positive. The aim of this study was to examine the likelihood of clinician-initiated discontinuation of LTOT attributed to positive UDT results across three discrete categories of substances: (1) cannabis, (2) alcohol or illicit substances (excluding cannabis), and (3) controlled prescription medications that were not prescribed. DESIGN: This retrospective study utilized the US Department of Veterans Affairs (VA) Health Care System. Corporate Data Warehouse to assemble a sample of 600 patients with substance use disorders and matched controls who were discontinued from LTOT in 2012. Comprehensive manual medical record review identified UDT results in the year prior to discontinuation and reason(s) for discontinuation. PATIENTS, PARTICIPANTS: Patients with one or more UDTs positive for a single substance (N = 185) comprised the study sample. MAIN OUTCOME MEASURE(S): Likelihood of clinician-initiated discontinuation attributed to a positive UDT across the three categories. RESULTS: Patients with one or more UDTs positive for cannabis were more likely to be discontinued from opioid therapy as a result of the positive UDT compared to those with one or more UDTs positive for nonprescribed prescription medication (adjusted odds ratio [OR] = 18.05, 95% CI = 7.29-44.66). Similarly, patients with UDTs positive for alcohol or illicit substances were more likely to be discontinued for the positive UDTs relative to patients who tested positive for nonprescribed prescription medications (adjusted OR = 13.10, 95% CI = 4.81-35.68). No difference in UDT-related discontinuation decisions was evident between patients with UDTs positive for alcohol/illicit substances versus cannabis (adjusted OR = 1.47, 95% CI = 0.57-3.77). CONCLUSIONS: High odds of UDT-related discontinuation were found in patients who tested positive for cannabis, alcohol, or illicit substances, relative to nonprescribed prescription medications.