CLAUDIA R. AMURA, PhD, MPH
University of Colorado Anschutz Medical Campus

Opioid use disorders (OUD) have become a national crisis and a huge burden for people with problematic opioid use, their families, and their communities. Colorado rural counties show the highest rates of opioid overdose deaths, and present unique risks such as isolation, low access to treatment or opportunities for overdose reversal. In July 2019, the Colorado Senate approved expansion of the Medication for (MOUD) pilot program to increase access to care in rural areas. Here we focus on lessons learned and plans for sustainability.

Under SB19-001, 8 clinical service organizations received funding to bring MOUD into 20 rural Colorado counties in a Hub and Spoke system that expanded to 47 sites in 20 rural counties. In collaboration with the Center for Prescription Drug Abuse Prevention, the CU College of Nursing provided clinical expertise, oversight, and evaluation of the program.

Informed by the Reach, Effectiveness, Adoption, Implementation, Maintenance and Practical Robust Implementation and Sustainability Model (RE-AIM/PRISM) frameworks, and using a stakeholder-involved approach, we conducted team-based Strengths, Weaknesses, Opportunities and Threats (SWOT) analyses with each “Hub” to understand needs and plan for MOUD clinical service sustainability.

Since January 2020, the Hub and Spoke system doubled the health provider capacity to serve 979 new MOUD patients across the rural areas covered. The COVID-19 pandemic deeply impacted patient retention, requiring sharp adaptations to service provision and outreach activities in order to adhere to social distancing requirements. Despite these challenges, sites developed a network of treatment expertise and referral for patients in under-served, geographically isolated rural areas. Adaptive capabilities included the development of case management and care coordination systems, new partnerships between clinical sites, judicial systems, and community organizations, and utilization of peer-support specialists for patient tracking and connection to resources. Analyses of barriers and successes also helped academic and community partners define opportunities and plans for sustainability. These include leveraging existing community and local relationships, solidifying care coordination systems built during this time, and seeking additional funding for ongoing clinical services, case management and peer support specialists.

Working in multidisciplinary teams and focusing on local needs helped overcame numerous barriers encountered while implementing OUD treatment and behavioral health interventions in primary care rural settings. Lessons learned from this effort should result in program implementation improvement and stronger care coordination systems. This state-sponsored MOUD program has the potential to enhance outcomes and generate sustainable solutions for addressing the opioid crisis in Colorado.

JESSE M. HINDE
RTI International

Given that substance use and substance use disorders among people with HIV are both prevalent and problematic, improving the integration of substance use treatment within HIV service settings is urgently needed. As part of the Substance Abuse Treatment to HIV Care Project, the Implementation & Sustainment Facilitation (ISF) strategy was found to be an effective adjunct to the Addiction Technology Transfer Center (ATTC) strategy for helping integrate a motivational interviewing-based brief intervention (MIBI) for substance use disorders. This presentation will discuss the results from the cost and cost-effectiveness study and highlight methodological considerations and lessons learned.

Thirty-nine HIV service organizations recruited in the central United States (n=14), western United States (n=11), and eastern United States (n=14). Two staff from each of the 39 HIV service organizations (N=78) were randomized to receive either the ATTC-only condition or the ATTC+ISF condition.

We estimated costs using primary data on the time spent by staff in each strategy and delivering MIBIs. We conducted staff-level cost-effectiveness analyses on the number of MIBIs implemented, average MIBI quality scores, and total client days abstinent per staff.

Per-staff costs were $3,256 for the ATTC strategy and $5,940 for ATTC+ISF, resulting in an incremental cost of $2,684. ATTC+ISF significantly increased the number of MIBIs delivered (3.73) and the average MIBI quality score (61.45), yielding incremental cost effectiveness ratios (ICERs) of $719 and $44. Client days abstinent increased between 19 and 60 days per staff, depending on the model, with ICERs ranging across models from $45 to $144. We estimated an ICER for quality-adjusted life-years, which ranged from $48,084 to $153,929.

Based on ICERs falling below the approximately $50 average reimbursement of a MIBI, the ISF strategy as an adjunct to the ATTC strategy was found to improve quality and is potentially cost-effective for days abstinent. ISF as an adjunct to the ATTC strategy may be cost-effective for improving the integration of MIBIs for substance use disorders within HIV service organizations if scaled up to reach more clients. Further, our results highlight two critical challenges in conducting cost-effectiveness analyses as part of a hybrid trial: MIBI delivery targets kept recruitment below cost-effective levels, and the definition of an aggregated days abstinent measure strongly influences interpretation. Future hybrid trials should consider these design issues to ensure robust economic conclusions can be drawn.

KELLI SCOTT
Brown University

The opioid overdose epidemic is a public health emergency in the United States. The majority of drug overdose deaths involve opioids and overdose is a leading cause of death among persons under age 55. Medication for opioid use disorder (MOUD) is the gold standard evidence-based treatment for OUD, however treatment engagement and maintenance in long term recovery are suboptimal. There is a critical need to supplement MOUD with psychosocial interventions, however high patient volume and the need for flexible treatment limits psychosocial treatment use in opioid treatment programs (OTPs). Measurement-based care (MBC), which involves administration, review, and discussion of client self-report data in counseling, is one evidence-based intervention that may enhance OTP engagement and outcomes. This two-phase hybrid implementation-effectiveness pilot trial seeks to evaluate MBC’s potential in OTPs through: 1) mixed method development of an MBC protocol; and 2) pilot implementation of MBC in community OTPs.

Treatment providers, leadership, and patient stakeholders will be recruited from eight OTPs that offer MOUD throughout the New England region in Phase 1 of the study. Four OTPs that participated in Phase 1 will be selected to participate in Phase 2 MBC implementation.

Phase 1 will employ Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) to build community partnerships with OTPs and evaluate factors impacting MBC implementation. RAPICE methodology will include clinical ethnography, cognitive interviews (n = 48), and quantitative surveys (n = 80). The quantitative surveys will evaluate Consolidated Framework for Implementation Research domains including MBC attitudes, MBC characteristics, implementation climate, organizational functioning, and organizational workflow and documentation practices. RAPICE data will be analyzed by a multidisciplinary team to: a) adapt an MBC protocol for use in OTPs; and b) select four OTPs with high implementation potential for Phase 2 participation. Phase 2 OTPs will engage in a collaborative MBC electronic health record (EHR) integration process followed by a one-day MBC training and ongoing monthly consultation for six months. All Phase 2 study outcomes will be drawn from the OTP EHRs. Effectiveness outcome measures will include treatment attendance and opioid abstinence pre- and post-MBC implementation. Implementation outcome measures will include provider MBC exposure (percent of total counseling sessions where MBC administered) and MBC fidelity (MBC administration, review, and discussion).

This pragmatic pilot trial aims to advance a significant public health issue by enhancing the quality of OUD care through the development and evaluation of a stakeholder-driven MBC protocol. Results from this trial will inform larger scale MBC implementation to enhance OTP treatment provision.