Project Description Narrative:
Wisconsin has experienced a significant increase in opioid-related overdoses and overdose deaths each year. According to the Wisconsin Department of Health Services, the rate of opioid-related emergency department visits in Wisconsin increased 24.2% between 2018 and 2020, and the rate of deaths increased 45.6% in the same time frame. Milwaukee County experiences over three times the national average for opioid deaths, with a 75% increase in nonfatal overdose incidents since 2019. While rural areas in Wisconsin have fewer overdose deaths than urban areas, overdose rates are over the national average for rural areas in the U.S.
The vast majority of individuals with opioid use disorder (OUD) in the United States do not receive treatment. Expanding access to primary care-based treatment for OUD addresses significant gaps and reduces opioid-related morbidity, although efforts to expand the providers to meet the need for treatment has remained frustratingly modest.
Previously, primary care physicians (PCP) were required to apply for a waiver (the X-waiver) to prescribe BUP in the ambulatory setting. Although efforts to increase the number of PCPs with X-waivers was somewhat successful, many who received the waiver never prescribed buprenorphine or prescribed to a number of patients that was well below the number allowed. Recently, this requirement was lifted, allowing all providers with a Drug Enforcement Administration (DEA) license to provide induction and maintenance prescriptions to the patients as part of their comprehensive treatment plan regardless of training.
Although removal of the waiver training is a positive step, barriers remain in place that prevent a PCP from prescribing BUP to their patients instead of referring to psychiatry or addiction medicine. Barriers include stigma or bias against treating people with opioid use disorder, lack of confidence or training in buprenorphine treatment, lack of psychosocial support services, and difficulties billing insurance. A recent study showed that primary care providers who received X-waiver training were more likely to understand and have confidence in the mechanism of buprenorphine and consider their training on treating OUD to be adequate than those who had not received it, suggesting that additional training and support may be needed to meaningfully increase the number of PCPs prescribing buprenorphine. Another recent study showed that few PCPs in the Mayo health system saw removal of the X-waiver favorably. Those who did were more likely to prescribe buprenorphine. Office-based buprenorphine treatment is a particularly feasible option in rural settings, yet prior to the elimination of the X-waiver only 60% of rural counties in the U.S. had a provider with an X-waiver to prescribe buprenorphine.
This project will assess attitudes toward medication for OUD and people with OUD and barriers to buprenorphine prescribing. The researchers' training will address these in an ECHO (Extension for Community Healthcare Outcomes) to increase primary care providers' willingness and capacity to treat opioid use disorder with buprenorphine.
To address opioid overdose, it is necessary to also address retention in buprenorphine treatment. Retention in MOUD is generally low, although highly variable, from 19%-94% at three-month, 46-92% at four-month, 3-88% in six-month, and 37%-91% at 12-month follow-up in randomized controlled trials. While there are currently no recommended treatment durations for MOUD, longer duration of treatment is associated with better treatment outcomes and lower risk of opioid overdose. Research suggests many program-related policies that may lead to discontinuation of MOUD, including discharge from clinics for missing an appointment or using other substances. Some MOUD clinics require abstinence from all substances and patients who fail to achieve this are discharged from care. Receiving higher doses of MOUD was also associated with better treatment retention, suggesting that some patients may not receive an adequate dose to control cravings.
In response to these poor rates of retention, some studies have implemented low-barrier MOUD treatment with softened rules focusing more on retention than abstinence; these have shown similar rates of retention than conventional MOUD treatment while engaging a higher risk population. In this project, researchers will recommend a low-barrier harm reduction approach to retain people with OUD in treatment. The researchers will use ECHO to address these challenges and increase screening and treatment of buprenorphine in primary care settings. ECHO has been used in primary care settings to improve treatment of many different conditions including hepatitis, dementia, complex medical conditions, diabetes, hospital discharge of older adults and multiple sclerosis. A recent study successfully used an ECHO program to increase buprenorphine prescription into rural primary care settings. The project team aims to first assess primary care PCPs' knowledge, attitudes, and barriers toward treating OUD with buprenorphine in primary care settings. They will use these results to inform their ECHO project, which they will pilot in four primary care settings.