December 2021

In This Issue: HSR&D Advances Research in Providing Healthcare for Veterans in Rural Settings
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Expanding Access to Opioid Use Disorder Treatment in Rural Primary Care Settings

Feature Article

Takeaway: This study will address a substantial disparity in healthcare access for Veterans living in rural areas and has the potential to positively impact thousands of Veterans with opioid use disorder (OUD) who currently lack access to evidence-based treatment.

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, and deaths among Veterans due to OUD and overdose continue to rise. This is particularly true for VA patients living in rural settings, 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. The use of efficacious and cost-effective medications for the treatment of opioid use disorder (MOUD), including buprenorphine, is associated with reduced opioid use and mortality (FORUM, Spring 2020).

The objectives of this Career Development Award – are to leverage 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 primary care buprenorphine treatment in rural settings. Specific study aims include: 

• Characterize VA facilities’ rates of primary care buprenorphine prescribing over time, as well as differences in primary care-based buprenorphine prescribing for Veterans living in rural settings compared to Veterans living in urban settings;
• Explore implementation strategies, facilitators to success, and methods to overcome implementation barriers among rural facilities with improved primary care-based buprenorphine prescribing; and
• Develop and pilot test an implementation strategy to facilitate the initiation and scale-up of buprenorphine prescribing in rural VA community-based outpatient clinics (CBOCs).

Methodology

Aim 1 is a retrospective cohort study utilizing national VA data. Aim 2 will utilize qualitative interviews with a sample of clinical administrators and direct care providers embedded within rural VA 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. This pilot study will inform the design of a multi- center trial of the implementation strategy among rural CBOCs within VISN 20, comprising Alaska, Washington, Oregon, and Idaho—states with a considerable number of rural primary care locations.

Findings

In preliminary unpublished research, the study team mapped changes in the share of patients diagnosed with opioid use disorder who received buprenorphine from 2015-2020 and identified substantial improvements across all parent facilities as well as rural parent facilities specifically (See Figure). 

The x-axis indicates the percent of patients within each VA parent facility who received buprenorphine to treat OUD within calendar year 2015; the y-axis indicates the percent of patients within each VA parent facility who received buprenorphine to treat OUD in calendar year 2020. Parent facilities on the diagonal line evidence no change. Urban parent facilities are indicated by blue circles, rural parent facilities are indicated by red triangles.

Anticipated Impact

This study will address a substantial disparity in healthcare access for Veterans living in rural areas and has the potential to positively impact thousands of Veterans with opioid use disorder (OUD) who currently lack access to evidence-based treatment. 

Principal Investigator

Jessica Wyse, PhD, MA, MPP, is a core investigator with HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC) in Portland, OR.

Publications:

Wyse J, Herreid-O’Neill A, Dougherty J, et al. Perioperative management of buprenorphine/naloxone in a large, national health care system: a retrospective cohort study. Journal of General Internal Medicine. September 2021;20:1-7. Online ahead of print.

Wyse J, McGinnis K, Edelman E, et al. Twelve-month retention in opioid agonist treatment for opioid use disorder among patients with and without HIV. AIDS and Behavior. September 8, 2021;1-1. Online ahead of print.

Wyse J, Morasco B, Dougherty J, et al. Adjunct interventions to standard medical management of buprenorphine in outpatient settings: A systematic review of the evidence. Drug and Alcohol Dependence. July 29, 2021;228:108923.

View study abstract