Water into Sand: OUD Pharmacotherapy and Implementation science: Why Training on Evidence-Based Practices is Never Enough

Mat Roosa, LCSW-R
NIATx Coach and Consultant

Todd Molfenter, PhD
NIATx Director
Director, Great Lakes ATTC, MHTTC, and PTTC

It’s an all-too-common three-step story:

1. A health care provider organization is trained in an evidence-based practice (EBP).
2. The provider seeks to implement the EBP.
3. The EBP is never implemented or is not sustained following the initial implementation.

Most substance use disorder (SUD) treatment providers have insight into this problem. They know that they need to do more than learn an EBP to ensure its effective implementation. They also know that just training staff on the EBP can be like pouring water into sand: Without a vessel to hold and sustain it, the EBP vanishes.

Medications for opioid use disorder (MOUD), also known as medication-assisted treatment (MAT), offer a compelling example of this implementation and sustainment challenge. Expanding access to MAT is a top public health priority. The Food and Drug Administration (FDA) has approved three evidenced-based medications: a partial opioid agonist (buprenorphine), a full opioid agonist (methadone), and an opioid antagonist (extended-release naltrexone). Medication-assisted treatment for OUD is linked with better clinical comes (SAMHSA, 2018; Thomas et al., 2014) and lower overdose rates (LaRochelle et al., 2018; Schwartz et al., 2013 ).

Despite the significant public health need for this life-saving treatment, MAT remains underutilized (Jones, Campopiano, Baldwin, McCance-Katz, 2015). In 2016, only 41% of U.S. treatment facilities offered at least one of the medications (Jones A, Honermann B, Sharp A, Millett, G, 2018). People seeking treatment continue to face long waits for service, and many counties across the nation do not have a single opioid agonist prescriber (Stein et al., 2015).

Does a feasible strategy exist to implementation of MAT?  How can we build providers’ confidence that investing in training will improve treatment outcomes for patients with OUD?

What is the vessel to ensure that EBP implementation is sustained and results in quality care?

Lessons from Implementation Science

Implementation science seeks to promote the uptake of EBPs such as OUD MAT into routine practice. This new and rapidly evolving field offers helpful insights into effective strategies to support adoption and expansion of OUD MAT.

Implementation Science Finding 1: Training Alone is Ineffective

Organizations often turn to training to remedy the implementation gap. As William Miller discovered with Motivational Interviewing (MI), training alone did not develop practitioners’ MI proficiency over time (Miller et al. 2004).

Special training and certification are required for physicians, nurse practitioners, and physician assistants who seek to prescribe buprenorphine. Training is essential for an effective service, yet training and certification do not always lead to effective implementation. A significant number of  prescribers with buprenorphine waivers either do not prescribe at all or prescribe far below capacity after completing training (Thomas et al., 2017). Reasons cited for not prescribing or under prescribing include physician concerns about their own lack of understanding of SUDs, inadequate psychosocial support for patients, lack of institutional support (Hutchinson et al., 2014) and concerns about diversion of the medication (Huhn & Dunn, 2017). These study results suggest that while training helps develop core practice skills for prescribing buprenorphine, it does not change organizational or clinician behavior.

A barrier to wider use of methadone is that it can only be provided through highly regulated federally approved opioid treatment programs. One advantage of extended-release naltrexone, the third medication approved for threating OUD, is that it is not a controlled substance and any healthcare professional licensed to prescribe medication may prescribe extended-release naltrexone.

Implementation Science Finding 2: Coaching & Feedback is Effective

Miller and others found that coaching that includes feedback was important to sustaining the gains made during the initial MI training (Schwalbe, Oh, & Zweben, 2014). Other studies support the importance of coaching in implementing evidence-based practices (Gustafson et al., 2013).

As noted above, a common barrier to OUD MAT implementation is clinician discomfort with prescribing these medications. Physicians cite their lack of training in working with patients with substance use disorders, or with OUD (Lin, Lofwall, Walsh, & Knudsen, 2019). This is where coaching or mentoring could be helpful (Hutchinson, 2014). ECHO training has become a popular tool to train prescribers via case examples (Scallan et al., 2017). Organizations have also started to use learning collaboratives and other programs that offer sequential training and coaching to build  MAT capacity (Ford et al., 2017). Intensive technical assistance often includes coaching to support implementation and organizational sustainment. The Providers Clinical Support System (PCSS) provides training; the focus is on buprenorphine waiver training, but PCSS also supports use  of extended-release naltrexone.

Implementation Science Finding 3: Use a Standardized Improvement Model

Organizations that use a structured, systematic change model yield better organizational change results, including new practice implementation than those that do not. Three structured change models include FOCUS-PDCA (Saxena &. Shulman, 2004); the Meyers Framework (Meyers, Durlak, & Wandersman, 2012), and the PARIHS Framework (Rycroft-Malone, 2004.)

The Addiction Technology Transfer Center (ATTC) Network’s Technology Transfer Model offers the field a multi-phased conceptual model. In this model, a new practice evolves from an idea to full implementation, where the new practice is integrated into an organization’s standard operations. (ATTC, 2011). Coaching to support new practice implementation aligns well with the ATTC Network’s current emphasis on technical assistance that helps organizations adopt and sustain EBPs effectively.

The NIATx organizational change model has been used to implement medications for treatment of alcohol use disorder and OUD in more than 100 multi-site projects. The five guiding principles of the NIATx model, which emerged from an analysis of decades’ worth of research on why certain projects fail and others succeed, have a proven record of success with projects to increase patient access to and retention in treatment. These principles also apply in efforts to implement EBPs.

Using the NIATx Five Principles to increase MAT Use

1. Understand and Involve the Customer. Conduct a patient walkthrough (to understand the customer experience). Regularly conduct a patient simulation where someone completes the process  as a consumer who is eligible for and interested in OUD  MAT. This walk-through will help organizations understand how receptive their systems are to this clinical therapy.

2. Fix key problems that concern the executive director. Have an Executive Sponsor, or top senior leader, who advocates for OUD MAT use. Adoption requires the engagement of senior leaders who provide support and resources to ensure successful implementation The Executive Sponsor also remove barriers to the use of OUD MAT.

3. Pick a Powerful Change Leader to provide day-to-day leadership for the changes required to both clinical and administrative systems for implementation of OUD MAT.

4. Get ideas from outside the organization or field. OUD MAT has been implemented in diverse healthcare settings. Find them and learn from them! For example, Korthuis et al. provide descriptions of primary care models to support use of MOUD Your regional ATTC can assist with this

5. Use rapid-cycle testing to establish effective changes. Conduct pilot tests or improvement cycles. Treat MAT implementation as an organizational change project by developing a change team, tracking progress, and continually testing new approaches to increase MAT support use. Organizations that do this have much greater OUD MAT use rates than those that do not.

In addition to these five principles, a new principle has emerged based on the NIATx work with sites implementing OUD MAT: Engage a physician or clinical champion. This principle has benefitted MAT adoption projects, particularly in the beginning.

“If I had a dollar for every time a health care provider was trained and then did not implement an EBP…”    QI Coach

Too many of us have experienced the frustration and folly of training-only implementation efforts. We have primed the pump, turned the spigot, and then watched this precious resource drain away into the dry desert sand. Whenever a health care provider seeks training in an EBP, they need to ask themselves whether or not they are committed to implementation strategies to sustain the practice. If not, they might be better off canceling their EBP training plans. The only thing worse than being thirsty in the desert is watching your water sift away.

But rather than growing cynical about EBP implementation, we would do well to appreciate the  promise of these vessels that can hold and sustain an EBP. When providers access technical assistance and coaching, , they will be able to thrive in their EBP implementation and build continuous improvement into the future of their service delivery system.

The emerging strategies from implementation science provide us with a vessel to implement and sustain OUD MAT, to deliver quality care, and to save lives.

 

Resources

NIATx Buprenorphine Implementation Toolkit

ATTC Network: Taking Action to Address Opioid Misuse

SAMHSA TIP 63: Medications for Opioid Use Disorder

 

References

Addiction Technology Transfer Center (ATTC) Network Technology Transfer Workgroup. (2011). Research to practice in addiction treatment: key terms and a field-driven model of technology transfer. Journal of Substance Abuse Treatment, 41(2), 169-178.

Ford, J. H., Abraham, A. J., Lupulescu-Mann, N., Croff, R., Hoffman, K. A., Alanis-Hirsch, K., ... & McCarty, D. (2017). Promoting adoption of medication for opioid and alcohol use disorders through system change. Journal of Studies on Alcohol and Drugs, 78(5), 735-744.

Gustafson, D. H., Quanbeck, A. R., Robinson, J. M., Ford, J. H., Pulvermacher, A., French, M. T., ... & McCarty, D. (2013). Which elements of improvement collaboratives are most effective? A cluster-randomized trial. Addiction, 108(6), 1145-1157.

Huhn, A. S., & Dunn, K. E. (2017). Why aren't physicians prescribing more buprenorphine? Journal of substance abuse treatment, 78, 1-7.

Hutchinson, E., Catlin, M., Andrilla, C. H. A., Baldwin, L. M., & Rosenblatt, R. A. (2014). Barriers to primary care physicians prescribing buprenorphine. The Annals of Family Medicine, 12(2), 128-133.

Jones A, Honermann B, Sharp A, Millett, G. Where multiple modes of medication-assisted treatment are available. Health Affairs Blog January 8, 2018. https://www.healthaffairs.org/do/10.1377/hblog20180104.835958/full/?tr=y&auid=17509590&.

Jones, C. M., Campopiano, M., Baldwin, G., & McCance-Katz, E. (2015). National and state treatment need and capacity for opioid agonist medication-assisted treatment. American journal of public health, 105(8), e55-e63.

Korthuis, P. T., McCarty, D., Weimer, M., Bougatsos, C., Blazina, I., Zakher, B., ... & Chou, R. (2017). Primary care–based models for the treatment of opioid use disorder: a scoping review. Annals of internal medicine, 166(4), 268-278

Larochelle, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality. A cohort study. Annals of Internal Medicine. June 19, 2018.

Lin, L. A., Lofwall, M. R., Walsh, S. L., & Knudsen, H. K. (2019). Perceived need and availability of psychosocial interventions across buprenorphine prescriber specialties. Addictive Behaviors.

Meyers, D. C., Durlak, J. A., & Wandersman, A. (2012). The quality implementation framework: a synthesis of critical steps in the implementation process. American journal of community psychology, 50(3-4), 462-480.

Rycroft-Malone, J. (2004). The PARIHS framework—a framework for guiding the implementation of evidence-based practice. Journal of nursing care quality, 19(4), 297-304.

Saxena, S., Ramer, L., & Shulman, I. A. (2004). A comprehensive assessment program to improve blood-administering practices using the FOCUS–PDCA model. Transfusion, 44(9), 1350-1356.

Scallan, E., Davis, S., Thomas, F., Cook, C., Thomas, K., Valverde, P., ... & Byers, T. (2017). Supporting peer learning networks for case-based learning in public health: Experience of the Rocky Mountain Public Health Training Center with the ECHO training model. Pedagogy in Health Promotion, 3(1_suppl), 52S-58S.

Schwalbe, C. S., Oh, H. Y., & Zweben, A. (2014). Sustaining motivational interviewing: A meta-analysis of training studies. Addiction, 109(8), 1287-1294.

Schwartz, R. P., Gryczynski, J., O’Grady, K. E., Sharfstein, J. M., Warren, G., Olsen, Y., ... & Jaffe, J. H. (2013). Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995–2009. American journal of public health, 103(5), 917-922.

Stein, B. D., Gordon, A. J., Dick, A. W., Burns, R. M., Pacula, R. L., Farmer, C. M., ... & Sorbero, M. (2015). Supply of buprenorphine waivered physicians: the influence of state policies. Journal of substance abuse treatment, 48(1), 104-111.

Substance Abuse and Mental Health Services Administration. Medications for Opioid Use Disorder. Treatment Improvement Protocol (TIP) Series 63, Full Document. HHS Publication No. (SMA) 18- 5063FULLDOC. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018.

Thomas, C. P., Fullerton, C. A., Kim, M., Montejano, L., Lyman, D. R., Dougherty, R. H., ... & Delphin-Rittmon, M. E. (2014). Medication-assisted treatment with buprenorphine: assessing the evidence. Psychiatric Services, 65(2), 158-170.

P., Doyle, E., Kreiner, P. W., Jones, C. M., Dubenitz, J., Horan, A., & Stein, B. D. (2017). Prescribing patterns of buprenorphine waivered physicians. Drug and alcohol dependence, 181, 213-218.

U.S. Department of Health and Human Services. Strategy to Combat Opioid Abuse, Misuse, and Overdose: A Framework Based on the Five-Point Strategy. 2018.