Increasing buprenorphine access for veterans with opioid use disorder in rural clinics using telemedicine

Abstract

Background:Having prescribers use clinical video teleconferencing (telemedicine) to prescribe buprenorphine to people with opioid use disorder (OUD) has shown promise but its implementation is challenging. We describe barriers, facilitators and lessons learned while implementing a system to remotely prescribe buprenorphine to Veterans in rural settings. Methods: We conducted a quality improvement project aimed at increasing the availability of medications for OUD (MOUD) to Veterans. This project focused on tele-prescribing buprenorphine to rural sites via a hub (centralized prescribers) and spoke (rural clinics) model. After soliciting a wide-range of inputs from site visits, qualitative interviews of key stakeholders at rural sites, and review of preliminary cases, a “how-to” toolkit was developed and iteratively refined to guide tele-prescribing of buprenorphine. After internal and external facilitation strategies were employed, Veterans with OUD at three clinics were transitioned to buprenorphine treatment via telemedicine. Results: Factors impacting adoption of the tele-prescribing intervention were mapped to the Consolidated Framework for Implementation Research (CFIR) constructs. Barriers to adoption included concerns about legality of tele-prescribing a controlled substance, conflicting interests between different stakeholders, and coordination with an existing buprenorphine program requiring more attendance and abstinence from Veterans than the tele-prescribing program required. Factors facilitating adoption included a sense of mission around combating the opioid epidemic, preexisting use of and comfort with tele-prescribing, and rural sites’ control over Veterans referred to tele-prescribers. A total of 12 patients from rural areas were successfully transitioned onto buprenorphine, of whom 9 remained on buprenorphine 6 months after initiation of treatment. Conclusions: Implementing tele-prescribing was negotiated with stakeholders at the target clinics and operationalized in a toolkit to guide future efforts. Implementation issues can be addressed by activities that foster collaboration between hubs (centralized prescribers) and spokes (rural clinics) and by a toolkit that operationalizes tele-prescribing procedures.

Keywords:

• Medication treatment for OUD (MOUD)
• opioid use disorder
• telemedicine
• buprenorphine

Acknowledgments

The authors acknowledge Jonathan T. Walker, MD, Kevin K. Kruse, MD, Timothy McIntire, MD, Louis Trevisan, MD, Gabriela Garcia Vassallo, MD, Jennifer Bergmann, Psy.D., Staff at the participating CBOCs. The funding organization had no role in the design and conduct of the study; collection; management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The views expressed in this article are those of the authors and do not necessarily represent the view of the Department of Veterans Affairs.

Author contributions

Nicole Brunet, PharmD, BCPP. internal facilitator, collection of data, interpretation of results, writing and revisions.

David T. Moore, MD, PhD. external facilitator, provided telemedicine services/buprenorphine to Veterans at spoke sites, project conception and design, interpretation of results, writing, revisions.

Dora Lendvai Wischik, RN, MSN. external facilitator, literature search, writing and revisions.

Kristin M. Mattocks, PhD, MPH. collection, interpretation and analysis of interview data; writing of interview portion of manuscript.

Marc I. Rosen, MD. external facilitator, project coordinator, project conception and design, interpretation of results, analysis, writing, revision.

Additional information

Funding

The project described was supported by QUERI PII 18-178 (Rosen P.I.) “Making Medication Assisted Treatment Available to Veterans with Opioid Use Disorders at CBOCs using Telemedicine” from the United States (U.S.) Department of Veterans Affairs Health Services Research & Development Service of the VA Office of Research and Development. 4/1/2018-3/31/2019.