Expanding access to opioid use disorder treatment with buprenorphine in rural primary care settings

背景：阿片类药物使用障碍（OUD）影响大量VA患者， 后果，包括过量和死亡。虽然药物治疗被认为是最有效的治疗方法， 对于OUD，它在VA内仍然未得到充分利用。农村患者尤其如此， 比居住在城市地区的退伍军人更容易接受OUD药物治疗。解决农村地区的不平等问题 由于农村地区受到不成比例的影响， 类阿片危机的后果，包括与类阿片有关的死亡率。 意义/影响：提高所有退伍军人获得OUD药物的机会是VA的一个主要优先事项。 拟议的研究将解决农村退伍军人获得医疗保健的巨大差距， 潜在的积极影响成千上万的农村退伍军人与OUD谁目前缺乏获得证据- 基于OUD治疗。 创新：拟议的研究利用了农村设施的知识和经验， 成功地将丁丙诺啡纳入初级保健，为制定执行战略提供信息， 支持农村初级保健丁丙诺啡治疗。 具体目标： 目标1：表征a）VA机构随时间推移的初级保健丁丙诺啡处方率和B） 农村与城市退伍军人基于初级保健的丁丙诺啡处方的差异。 目的2）在农村设施中，以改善初级保健为基础的丁丙诺啡处方，定性探索 采用的实施战略、成功的促进因素以及克服实施障碍的方法。 目标3）制定和试行一项执行战略，以促进启动和扩大 在一个VA设施内的农村CBOC中开丁丙诺啡处方。 方法：本研究采用混合方法序贯解释性设计，其中每个方法的结果 目标为后续目标的设计和实施提供信息，而后续目标本身又将其置于背景之中并加以阐述 初步调查结果目的1是一项利用国家VA数据的回顾性队列研究。目标2利用定性 对农村医疗机构中的临床管理人员和直接护理提供者进行了访谈， 随着时间的推移，基于初级保健的丁丙诺啡处方率有所提高。目标3是一项试验计划， 将通过形成性评价方法对实施战略进行评价。 后续步骤/实施：目标3试点将在第5年向IIR #2通报CDA，这将是一个多阶段的 在VISN 20的农村社区银行内实施战略的中心试验，包括阿拉斯加，华盛顿， 俄勒冈州和莎士比亚-拥有相当数量的农村初级保健点的州。

Background: Opioid use disorder (OUD) affects a significant number of VA patients, and has serious consequences, including overdose and death. While medication is recognized as the most effective treatment for OUD, it remains under-utilized within VA. This is particularly true for rural patients, who are 37% less likely to receive a medication for OUD than Veterans residing in urban areas. Addressing the rural disparity in access to medication has become increasingly important as rural areas have been disproportionately impacted by the consequences of the opioid crisis, including opioid-related mortality. Significance/Impact: Enhancing access to medication for OUD for all Veterans is a major priority within VA. The research proposed will address a substantial disparity in health care access for rural Veterans, and has the potential to positively impact thousands of rural Veterans with OUD who currently lack access to evidence- based OUD treatment. Innovation: The proposed research leverages the knowledge and experience of rural facilities that have been successful in integrating buprenorphine into primary care to inform the design of an implementation strategy to support rural, primary care buprenorphine treatment. Specific Aims: Aim 1: Characterize a) VA facilities’ rates of primary care buprenorphine prescribing over time and b) differences in primary care-based buprenorphine prescribing for rural versus urban Veterans. Aim 2) Among rural facilities with improved primary care based buprenorphine prescribing, qualitatively explore implementation strategies utilized, facilitators to success, and methods to overcome implementation barriers. Aim 3) Develop and pilot test an implementation strategy to facilitate the initiation and scale-up of buprenorphine prescribing in rural CBOCs within one VA facility. Methodology: This study utilizes a mixed methods sequential explanatory design, in which findings from each Aim inform the design and conduct of subsequent Aims, which themselves contextualize and elaborate upon initial findings. Aim 1 is a retrospective cohort study utilizing national VA data. Aim 2 utilizes qualitative interviews with a sample of clinical administrators and direct care providers embedded within rural facilities that have improved their rate of primary care-based buprenorphine prescribing over time. Aim 3 is a pilot trial of the implementation strategy that will be evaluated via formative evaluation methods. Next Steps/Implementation: The Aim 3 pilot will inform IIR #2 in year 5 of the CDA, which will be a multi- center trial of the implementation strategy within rural CBOCs of VISN 20, comprising Alaska, Washington, Oregon, and Idaho—states with a considerable number of rural primary care locations.