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

Abstract

Background The Veterans Health Administration (VHA) is invested in expanding access to medication treatment for opioid use disorder (MOUD) to save lives. Access varies across VHA facilities and, thus, requires implementation strategies to promote system-wide adoption of MOUD. We conducted a 12-month study employing external facilitation that targeted MOUD treatment among low-adopting VHA facilities. In this study, we sought to evaluate the patterns of perceived barriers over 1 year of external implementation facilitation using the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Methods We randomly selected eight VHA facilities from the bottom quartile of the proportion of Veterans with an OUD diagnosis receiving MOUD (< 21%). The 1-year external implementation intervention included developmental evaluation to tailor the facilitation, an on-site visit, and monthly facilitation calls. Facilitators recorded detailed notes for each call on a structured template. Qualitative data was analyzed by coding and mapping barriers to the constructs in the i-PARIHS framework (Innovation, Recipients, Context). We identified emerging themes within each construct by month. Results Barriers related to the Innovation, such as provider perception of the need for MOUD in their setting, were minimal throughout the 12-month study. Barriers related to Recipients were predominant and fluctuated over time. Recipient barriers were common during the initial months when providers did not have the training and waivers necessary to prescribe MOUD. Once additional providers (Recipients) were trained and waivered to prescribe MOUD, Recipient barriers dropped and then resurfaced as the facilities worked to expand MOUD prescribing to other clinics. Context barriers, such as restrictions on which clinics could prescribe MOUD and fragmented communication across clinics regarding the management of patients receiving MOUD, emerged more prominently in the middle of the study. Conclusions VHA facilities participating in 12-month external facilitation interventions experienced fluctuations in barriers to MOUD prescribing with contextual barriers emerging after a facilitated reduction in recipient- level barriers. Adoption of MOUD prescribing in low-adopting VHA facilities requires continual reassessment, monitoring, and readjustment of implementation strategies over time to meet challenges. Although i-PARIHS was useful in categorizing most barriers, the lack of conceptual clarity was a concern for some constructs.

Conceptual and relational advances of the PARIHS and i-PARIHS frameworks over the last decade: a critical interpretive synthesis

“…Three of those articles discussed the dyadic relationship of facilitation with evidence [ 38 ], with context [ 38 – 40 ], or with recipients [ 40 ]. One article discussed temporal changes in other elements in response to facilitation [ 41 ].…”

“…Innovation, recipients, and c ontext respond to facilitation at different time points and to different degrees. Gustavson et al (2021) [ 41 ] Relationships between (i-)PARIHS elements (evidence, context, facilitation) and implementation outcomes Relative importance of (i-)PARIHS elements/sub-elements regarding necessity and sufficiency in impacting implementation outcomes Evidence is necessary but not sufficient to influence evidence-based practice uptake When there is a strong belief in evidence, strength in at least one contextual element (leadership, culture, or evaluation) is needed for uptake to occur; when there is limited belief in the evidence, strengths in the contextual elements unexpectedly reinforced the resistance to change. McCullough et al (2015) [ 42 ] When the evidence is robust, uptake of the evidence is mainly determined by individual factors (practitioners’ and patients’ behaviors, attitudes, emotional responses), inter-professional functioning, and the organization’s existing systems and processes.…”

Alcohol use Disorder Pharmacotherapy and Treatment in Primary Care (ADaPT-PC) Trial: Impact on Identified Barriers to Implementation

“…ADAPT-OUD successfully expanded access to medication treatments for opioid use disorder, which is likely at least in part due to these implementation enhancements. Analysis of ADAPT-OUD barriers across the timespan of the project supported the notion that implementation barriers fluctuate over time with knowledge and attitudes shifting early and more complex organizational issues requiring more time to address 29 …”

“…Analysis of ADAPT-OUD barriers across the timespan of the project supported the notion that implementation barriers fluctuate over time with knowledge and attitudes shifting early and more complex organizational issues requiring more time to address. 29 It must also be acknowledged that the national focus on addressing the opioid overdose epidemic impacted the success of ADAPT-OUD. Despite the fact that alcohol misuse and AUD affect a much larger number of individuals 1 and contribute to a larger number of deaths than opioid overdose, 30 addressing expansion of access to evidence-based pharmacotherapy for AUD has never received the same focused attention as expanding access to medication treatments for OUD.…”

Analysis of an Antibiotic Stewardship Program for Asymptomatic Bacteriuria in the Veterans Affairs Health Care System

“…A novel aspect of the Less is More for ASB project was the exploration of external and internal facilitation as an implementation strategy for antibiotic stewardship in both acute and long-term care. 13 , 14 , 15 Our centralized coordinating center served as the external facilitator, or the agency responsible for promoting and supporting positive change. 16 The external facilitators (L.G., J.N.V., L.M.D., and B.W.T.)…”