Article Commentary: Stepped Care for Opioid use Disorder Train the Trainer (SCOUTT) Initiative: Expanding Access to Medication Treatment for Opioid use Disorder within Veterans Health Administration Facilities

Abstract

The US is confronted with a rise in opioid use disorder (OUD), opioid misuse, and opioid-associated harms. Medication treatment for opioid use disorder (MOUD)—including methadone, buprenorphine and naltrexone—is the gold standard treatment for OUD. MOUD reduces illicit opioid use, mortality, criminal activity, healthcare costs, and high-risk behaviors. The Veterans Health Administration (VHA) has invested in several national initiatives to encourage access to MOUD treatment. Despite these efforts, by 2017, just over a third of all Veterans diagnosed with OUD received MOUD. VHA OUD specialty care is often concentrated in major hospitals throughout the nation and access to this care can be difficult due to geography or patient choice. Recognizing the urgent need to improve access to MOUD care, in the Spring of 2018, the VHA initiated the Stepped Care for Opioid Use Disorder, Train the Trainer (SCOUTT) Initiative to facilitate access to MOUD in VHA non-SUD care settings. The SCOUTT Initiative's primary goal is to increase MOUD prescribing in VHA primary care, mental health, and pain clinics by training providers working in those settings on how to provide MOUD and to facilitate implementation by providing an ongoing learning collaborative. Thirteen healthcare providers from each of the 18 VHA regional networks across the VHA were invited to implement the SCOUTT Initiative within one facility in each network. We describe the goals and initial activities of the SCOUTT Initiative leading up to a two-day national SCOUTT Initiative conference attended by 246 participants from all 18 regional networks in the VHA. We also discuss subsequent implementation facilitation and evaluation plans for the SCOUTT Initiative. The VHA SCOUTT Initiative could be a model strategy to implement MOUD within large, diverse health care systems.

Early impacts of a multi-faceted implementation strategy to increase use of medication treatments for opioid use disorder in the Veterans Health Administration

“…Additionally, integration of buprenorphine within other clinics that have not traditionally prescribed it (e.g., primary care, mental health, pain specialty clinic) may not be achieved early in implementation; however, the external facilitation likely lays the groundwork and subsequent momentum to expand buprenorphine prescribing to other clinics outside of substance use disorder specialty clinics. The removal of “silos” through multi-level integration of care is important for implementation of buprenorphine since patients can potentially be identified for appropriate treatment and managed across multiple disciplines (e.g., mental health, primary care, pain specialty clinics, community-based services) [ 21 ]. Future efforts are needed to address broader issues such as insufficient workforce capacity, variation in state policies regarding M-OUD, and paucity of clinical guidelines for transferring patient care across disciplines and clinics.…”

“…Academic detailing is an effective educational outreach strategy commonly used to impact care in this patient population by targeting uptake of evidence-based practice at the provider level [ 30 , 36 ]. Academic detailing [ 30 , 36 ] and other approaches [ 21 , 37 ] designed to promote uptake of evidence-based practice could benefit from this rapid, developmental approach to tailoring implementation strategies to fit the complex and dynamic interaction between the clinical innovation (M-OUD), recipients, and context. Our mixed methods analysis of 6-month outcomes helps us to understand whether implementation interventions and strategies can make meaningful change in facility metrics quickly to, ultimately, impact patient outcomes.…”

“…The full effect of the intensive external facilitation on change in M-OUD prescribing at low-adopting VHA facilities will be observed at the completion of the parent ADaPT-OUD study (12 months following facility visits) [ 28 ]. Early results from our study can assist other implementation efforts to increase adoption of M-OUD in the VHA by identifying patterns of barriers and facilitators more or less conducive to change in uptake of M-OUD [ 21 ]. Future research will explore patterns of barriers or facilitators and the facilitation response over the course of the 12-month external facilitation intervention to determine how the types, sequence, and timing of implementation strategies impacted M-OUD adoption a the various facilities.…”

“…The VHA is invested in improving and increasing access to M-OUD, [12,13] yet rates of M-OUD prescribing for the population with OUD across VHA facilities range widely from 1 to 68% [3,[21][22][23][24][25]. VHA's efforts with respect to M-OUD adoption have included organization-level solutions, which tend to consist of passive diffusion (e.g., through guideline development) [11].…”

Fluctuations in barriers to medication treatment for opioid use disorder prescribing over the course of a one-year external facilitation intervention

“…Although the initial target was to increase MOUD use in the substance use disorder specialty clinics, the external implementation facilitation intervention expanded to promote prescribing of MOUD in other clinics-- including primary care, mental health, and pain specialty clinics-- depending on local facility needs and interests. The addition of these clinics into the implementation intervention offered an opportunity for greater impact on MOUD prescribing rates as issues with opioid use are frequently first identified in these settings and many Veterans are reluctant to follow through with a referral to substance use disorder specialty care due to stigma related to substance use disorders [ 12 ]. When a Veteran is seen and managed at a single clinic with a single provider or team, the potential for fragmented care and the associated negative outcomes is substantially reduced [ 13 ].…”