Medication treatment for opioid use disorders in primary care increases patient access
Clinicians at Boston Medical Center (BMC) showed that expanding the number of sites offering office-based opioid treatment with buprenorphine (OBOT B) utilizing addiction nurse care managers, trainings and technical support resulted in more physicians becoming waivered to prescribe buprenorphine and more patients accessing treatment at sites across Massachusetts. This model, highlighted online in the Journal of Substance Abuse Treatment, demonstrates the efficacy of this medication-assisted treatment modality as a sustainable way to treat greater numbers of patients with opioid use disorders in a primary care setting at community health centers (CHC).
In the United State, the number of people using prescription opioids increased from 1.4 million in 2004 to 1.9 million in 2013, according to the Substance Abuse and Mental Health Services Administration. A recent report issued by the Centers for Disease Control and Prevention and the Food and Drug Administration showed the rate of heroin overdose deaths skyrocketed 286 percent between 2002 and 2013. While pharmacological treatment exists for opioid use disorders, there are numerous barriers to access treatment, including the lack of physicians waivered to prescribe, providers who don't take insurance, waiting lists, and proximity to sites offering treatment.
To address barriers and improve patient access, providers at BMC, in collaboration with the Massachusetts Department of Public Health, developed the Collaborative Care Model of OBOT B in 2003, which brought treatment into primary care. While other opioid use disorder treatments typically take place outside of a doctor's office, OBOT B has patients receive their treatment under the direction of their primary care team, similar to other complex chronic diseases.
The nurse care manager (NCM) in this model serves as the point of contact for patients determining, in collaboration with waivered physicians, the most appropriate treatment plan. In particular, NCMs provide the day-to-day complex care management of patients, making it possible for physicians to manage the complexities of substance use disorders in their busy primary care practices.
Using this model, the data showed that within three years of the program's implementation, the number of waivered physicians in community health centers increased from 24 to 114, an increase of 375 percent. Two thirds of patients in OBOT B remained in care for more than 12 months, with steady increases over time, demonstrating the efficacy and maturation of treatment.
The percentage of African-American and Hispanic patients engaged in community based OBOT B programs were greater than rates for methadone maintenance treatment (MMT), which is another medication to treat opioid dependence. The rates for MMT were 3.5 percent for African-American patients and 11.8 percent for Hispanic patients, and for OBOT B, 5 and 23 percent, respectively.
"Integration of the nurse care manager model into primary care facilitates expanded access to treatment while also allowing patients to receive treatment for opioid dependence, a chronic disease, like they would for any other chronic condition," said Colleen LaBelle, RN, director of BMC's OBOT B program.
This program was piloted successfully at BMC and was then implemented at Massachusetts CHCs to further expand access. More than 8,000 patients have received treatment through OBOT B in Massachusetts, and BMC's program is the largest primary care practice in the state, currently serving approximately 500 patients with opioid dependence at any given time.
"This sustainable model has decreased the stigma that surrounds addiction by bringing treatment to patients where they access medical care and could serve as a model for other parts of the country," said LaBelle, who also leads training and technical support for the 17 OBOT B sites at CHCs in Massachusetts, all of which are modeled after BMC's program.