Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle.
Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle.
JAMA Netw Open. 2023 Aug 1;6(8):e2328627. doi: 10.1001/jamanetworkopen.2023.28627.
Medication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist.
To evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD.
DESIGN, SETTING, AND PARTICIPANTS: This survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022.
Implementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services.
Data included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods.
Sixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care.
The results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.
阿片类药物使用障碍（MOUD）的药物治疗（例如丁丙诺啡和纳曲酮）可在初级保健中提供，但实施存在障碍。
评估一项实施干预措施超过 2 年，以探索多学科初级保健（PC）团队启动或扩大 MOUD 的经验和观点。
设计、地点和参与者：这项基于调查和人种学的定性研究在 12 个地理位置和结构上各不相同的初级保健诊所进行，这些诊所于 2020 年 7 月至 2022 年 7 月参加了一项混合有效性实施研究，包括 PC 团队（处方临床医生、非处方行为健康护理经理和咨询精神科医生）。调查数据分析于 2022 年 2 月至 4 月进行。
实施干预措施（外部实践促进），将 OUD 治疗与现有的心理健康服务合作护理相结合。
数据包括（1）对初级保健团队的定量调查，这些调查进行了描述性分析，并与定性结果进行了三角剖分，以及（2）对诊所实施会议的人种学观察的定性现场记录，使用快速评估方法进行了分析。
62 名初级保健团队成员完成了调查（41 名女性[66%]；1[2%]美国印第安人或阿拉斯加原住民，4[7%]亚洲人，5[8%]黑人或非裔美国人，5[8%]西班牙裔或拉丁裔，1[2%]夏威夷原住民或其他太平洋岛民，和 46[4%]白人），其中 37（60%）年龄在 25 至 44 岁之间。对实施会议（n=362）和调查数据的分析确定了 4 个主题，描述了与 PC 团队在实施过程中提供 MOUD 相关的多层次因素，这些主题在不同诊所之间存在经验差异。主题包括与临床行政后勤相关的挑战，这些挑战限制了快速获得护理和患者参与的能力，以及临床医生与患者讨论 MOUD 护理方面的信心。这些挑战与 PC 团队对扩大 MOUD 护理的态度相矛盾。
这项对 PC 团队观点的调查和定性研究的结果表明，PC 团队需要在预约安排方面具有灵活性，并能够有效地与 OUD 患者接触，同时需要持续培训，以保持临床医生在面对不断发展的阿片类药物相关临床问题时的信心。未来的工作应解决与工作量负担和时间表灵活性有限相关的结构性挑战，这些挑战阻碍了 PC 环境中 MOUD 的扩大。
