Nearly 70% of drug overdose deaths involve an opioid, and rural communities are disproportionately affected.1,2 The following tips can help family physicians manage medications for opioid use disorder (MOUD) when practice resources are limited.
1. Obtain a waiver for MOUD, but don't go it alone. Recruit another clinician in your practice to do the same so that you can provide backup and informal consults to one another. Federal guidelines no longer require waiver training for MOUD treatment of up to 30 patients at a time, but you do need to submit a "Notice of Intent" to obtain a waiver to prescribe buprenorphine for the treatment of OUD. Those who complete an approved waiver training may treat up to 100 MOUD patients at one time, or 275 patients at one time after one year. Under a new program from HRSA, facilities may even be able to receive $3,000 for each eligible waivered clinician.
Also, identify a registered nurse (RN) or medical assistant who can support MOUD treatment by managing intake calls and scheduling, training other staff to room these patients, facilitating clinic-based inductions, helping manage home-based inductions by phone, and coordinating care between the clinic and off-site services and facilities.
2. Take steps to reduce the potential stigma of addiction. For example, teach staff to use non-stigmatizing language when discussing addiction and its treatment, and “mainstream” addiction care as a part of routine primary care so that staff members develop a non-judgmental attitude and patients and their families become more open to these discussions.
3. Offer home-based inductions of buprenorphine when appropriate. Home-based inductions have been shown to be feasible and safe, have equivalent rates of adverse events and retention compared with clinic-based inductions, and are often preferable for patients.3,4 Home-based inductions can be self-led using detailed instructions or supported virtually by a trained RN using phone or video telemedicine. See the FPM article by Landeck and Zgierska for an outline of one model for RN-supported home-based inductions.
4. Use group visits. If specialized mental health or addiction medicine services or organized peer support services are not available in your area, group visits can provide both MOUD support and peer support. The visits can involve a waivered clinician and a group of patients, or may include recovery coaches, addiction or mental health professionals, RN care coordinators, or social workers.
5. Partner with local services. Take some time to familiarize yourself with the existing resources in your community, county, or state — including addiction counseling, recovery coaches, peer support services, and various treatment services.
6. Use telehealth to partner with specialists to manage complex or high-risk patients. Many states and health care systems have developed telehealth resources to support rural primary care clinicians in caring for patients with substance use disorders. Telehealth can also be used to provide addiction medicine consultation. Establishing communication, consultation, and referral pathways between primary care and specialty care offers support for primary care clinicians and facilitates efficient and timely handoffs — from primary to specialty care for patients who need a higher level of care, and from specialty to primary care for stable patients who require stepped-down care.
See the full FPM article: "Six Tips to Effectively Treat Opioid Use Disorder in Rural Areas."
1. Wilson N, Kariisa M, Seth P, Smith H, Davis NL. Drug and opioid-involved overdose deaths — United States, 2017–2018. MMWR Morb Mortal Wkly Rep. 2020;69(11): 290–297.
2. Grimm CA. Geographic disparities affect access to buprenorphine services for opioid use disorder. U.S. Department of Health and Human Services Office of Inspector General. Jan. 29, 2020. Accessed April 16, 2021. https://oig.hhs.gov/oei/reports/oei-12-17-00240.asp
3. Cunningham CO, Giovanniello A, Li X, Kunins HV, Roose RJ, Sohler NL. A comparison of buprenorphine induction strategies: patient-centered home-based inductions versus standard-of-care office-based inductions. J Subst Abuse Treat. 2011;40(4):349–356.
4. Lee JD, Grossman E, DiRocco D, Gourevitch MN. Home buprenorphine/naloxone induction in primary care. J Gen Intern Med. 2009;24(2):226–232.
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