| Alford et al (2008) |
|
|
|
PCP: general internists NCM: Nurse Care Manager
|
PCP: overviewed prescribing and confirmed results of physical and oversaw NCM NCM: conducted home phone calls, initial assessment, tracked patients, on-call 24/7
|
Staff:
NCM completed initial assessment with PC confirming physical assessment NCM available 24 hours a day via cellphone for patients Scheduled induction Patients went through 4 step process: 1) eligibility verification 2) medication induction 3) medication stabilization 4) treatment maintenance
Patient:
Encouraged to engage in self-help groups/therapy (recommended and tracked), but no individual counseling explicitly given; "Intensified treatment" (substance abuse counseling) was provided to patients with ongoing opioid, other drugs, or alcohol use
|
Cell phone with NCM 24/7 Patient contract
|
Retention: 55% in Homeless vs. 61% in Housed at 12 mo. Treatment failure, drug use, and utilization of substance abuse treatment services were examined
|
|
18 Fair |
| Alford et al (2011) |
QE No comparison group -
Total
N = 408
|
|
-
Multi-disciplinary Care Model with PCP, Nurse Director, and NCM with 1 program coordinator (medical assistant)
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 2 mo Medication: Buprenorphine
|
PCP: general internist NCM: Nurse care manager with 1-day training in BP RN: Nurse program director Program Coordinator: Medical assistant
|
PCP: generalists with part-time clinical practices, reviewed and supplemented the NCM assessments (including laboratory results), performed physical examinations, prescribed buprenorphine, and followed patients at least every 6 months (more if needed) NCM: assessed qualification for OBOT assessment, education, obtained informed consent, developed treatment plans, oversaw medication management (direct supervision of BP), referrals, monitored for treatment adherence, and communicated with PCP, addiction counselors, and pharmacists Nurse Program Director: oversaw the NCM Program Coordinator: medical assistant trained to collect standardized intake information for individuals requesting OBOT
|
Staff:
-
The treatment model included 3 stages:
(1) NCM and physician assessment (appropriateness for OBOT and intake evaluations),
(2) NCM-supervised induction and stabilization (buprenorphine dose adjustments on days 1–7)
(3) maintenance (buprenorphine treatment with monitoring for illicit drug use and weekly counseling) or discharge (voluntary or involuntary)
Patient:
Encouraged patients to seek outside individual or group counseling, but NCM provided education and support; Required to follow prescribing guidelines, attend follow-up, and provide urine samples
|
|
Retention: 51.3% at 12 mo. At 12 mo, 91.1% of patients remaining in treatment had negative urine drug tests
|
|
18 Fair |
| Carrieri et al (2014) |
|
BP is accessible in PC as of 2014 in France; only SC provides methadone SC can transfer patients to PC after methadone stabilization takes place (~14 days, randomized in study) North, North-Eastern, South-Western and South-Eastern France Urban PCC & SCC
|
-
Multi-disciplinary Model between specialty care and primary care with a multidisciplinary team including pharmacists
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 12 mo, 3 and 6 mo follow up Medication: Methadone
|
|
PCPs and SCP: supervised methadone induction for 2+ wks Pharmacists: supervised methadone induction for 2+ wks Pharmacists and physicians involved in the trial had to report overdoses, signs of intoxication and lost-to-follow-up patients to the center of methodology and management
|
Staff:
All PCP and SCP had 1-day training for standardized methadone induction trial guidelines and procedures The PCP was responsible for dosing and supervision of induction after randomization occurred Starting dose: 30-40mg, with 10mg increases every 2–4 days until patient is stabilized The "intervention" included PCP or SCP doing supervised induction for at least 14 days for patient, then thereafter supervision only required in patients with overdose risk
-
Followed up with medical visits and phone interviews
Patient:
pre-enrollment medical questionnaire questionnaire at each scheduled visit (enrollment, 3, 6 and 12 mo) short self-administered questionnaire at all scheduled visits
urine rapid tests when available
|
|
Retention: Total sample: 73% at 12 mo.; 73% in PC and 50% in SC Self reported abstinence from street opioids 55% abstinent in PC, 33% in SC at 12 mo Higher satisfaction rates reported in PC-induced patients vs. SC (higher satisfaction with the explanations provided by PCP)* Engagement in treatment significantly lower in SC than in PC Early discontinuation rates significantly higher in the PC
|
|
23 Good |
| Colameco et al (2005) |
QE No comparison group -
Total
n = 35
|
|
-
Multi-disciplinary Model in which addiction counselor referred patients to PCP who then communicated with other treatment providers, family members, and patient pharmacies
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 12 mo Medication: Buprenorphine
|
|
PCP: interviewed the patient over the phone prior to study enrollment, oversaw prescriptions and monitoring Trained addiction counselors: referred patients to PCP
|
Staff:
PCP interviewed potential patients for 1 hour, discussed BP induction, and provided information packet Initial visit included: potential risks and benefits of treatment when compared to alternatives, admission criteria, and program requirements for ongoing treatment
Patient:
All patients required to participate in "group” counseling of choice (Narcotics Anonymous, faith-based programs, or group therapy at addiction treatment center) and individual MD counseling at center Patients had to return for monitoring 1x per month minimum: 30-minute assessments of treatment progress, and included clinical evaluation, drug testing, and communication with treatment providers, pharmacist, and family members
|
Phone calls to patients Patient contract
|
|
|
17 Fair |
| Cunningham et al (2008) |
Observational Cohort No comparison group -
Total
n = 41
|
|
-
Team—based care between pharmacist and physician to jointly induce and monitor patients treated with BP
Model(s):
Coordinated Care, Multi-disciplinary Care, Shared Care
Duration: 26 mo Medication: Buprenorphine
|
PCP: General Internist Pharmacist -
Patient
Social Worker
|
PCP: collaborated with the pharmacist to induce patient on BP as well as prescribe and monitor patient progress Pharmacist: monitored and observed patient induction on BP; held joint phone/appointment visits with patient as needed Social worker: provided routine care as needed, though not required with program
|
Staff:
PCP worked with pharmacist to induce patients onto BP Provided psychosocial, routine counseling as needed (i.e. motivational interviewing) BP dispensed on-site by the pharmacist
Patient:
|
|
Retention: 70.7% at 90 days 90-day retention in treatment as confirmed by medical records Results: 29 (70.7%) were retained in treatment at 90 days
|
|
17 Fair |
| Cunningham et al (2011) |
QE No comparison group Total n = 79
|
|
-
Multi-disciplinary Care Model with patient-centered home-based induction of BP vs. standard of care office-based induction
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 6 mo Medication: Buprenorphine
|
|
PCP: prescribed and monitored patient in either home induction or office-based induction; PCP also available to answer questions/concerns throughout induction and maintenance for patients Pharmacist: dispensed BP to patients from on-site pharmacy
|
Staff:
PCP either induced patients in office-based setting or provided patients for patient-induced take home induction with kits and BP education prior to induction All prescriptions and dispensing provided by pharmacist at on-site pharmacy
Patient:
|
Home based induction kit: instruction sheet & BP Six sections explaining contents of the kit, when to start taking BP/NX, things not to do, how to take BP/NX, plans to guide treatment and facilitate follow-up, and a log to track medications taken
|
Retention: N/A Self-report of opioid use in previous 6 months Results: Among all participants, opioid use declined from 88.6% at baseline to 42.0% at 1 month, 33.3% at 3 months, and 27.3% at 6 months Opioid use and any drug use consistently declined at each period in patient-centered home-based inductions, not in standard-of-care office- based inductions
|
|
20 Good |
| DiPaula& Menachery (2014) |
Observational Cohort No comparison group Total n = 12
|
|
-
Coordinated care with collaboration between physician and psychiatric pharmacist
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 12 mo Medication: Buprenorphine
|
|
PCP: induced patients on BP, followed-up with pharmacist and patient to confirm and document treatment Pharmacist: Met with patient initially, followed-up weekly/monthly Medical Assistant: collected urine tox, took vitals
|
Staff:
In initial visit, pharmacist met with patient to discuss: substance use, mental, and physical history as well as review clinical procedures and complete treatment contract with patient Physicians spent ~30 minutes after confirming treatment plan and discussed program with patient
Patient:
|
|
|
|
18 Fair |
| Doolittle & Becker (2011) |
Observational Cohort No comparison group Total n = 228
|
|
-
Physician-centric model where patients were self-referred, OUD care was provided within the practice with BP in conjunction with other comorbidities
Model(s):
Physician-Centric
Duration: tailored to patient, 4 year study Medication: Buprenorphine
|
|
|
Staff:
"Buprenorphine contract": patient agreed to attend all appointments, submit regular urine drug tests, and not receive early refills of BP until next appointment 16 mg dosing with home induction and shared decision-making on length of treatment
Patient:
Self-referred to clinic, met with 1–2 PCP for complete history/physical Patient has 1 week follow-up monthly appointments, and PCP on call via phone if "dope sick” or for questions and concerns
|
|
Retention: N/A Withdrawal, urine test, cocaine test, and treatment of comorbidities 82% negative urine drug screen 92% negative for cocaine, 88% positive for BP
|
|
15 Fair |
| Drainoni et al (2014) |
|
Boston, MA Urban, primary care setting 2 clinics (1 infectious disease and 1 general internal medicine) were utilized in the FAST PATH program
|
-
FAST PATH team-based model of integrated care developed by a physician, nurse, and addiction counselor case manager team that used BP in PC with addiction treatment
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: N/A Medication: Buprenorphine
|
|
|
Staff:
Provided ongoing primary care, medication assisted treatment when indicated (i.e. BP/NLX), HIV risk reduction counseling, individual and group counseling, referral to additional SUD treatment Aim was to expand/enhance treatment of alcohol and drug dependence among HIV infected and at-risk patients within PC settings 1 hour focus groups conducted by program manager and evaluator, semi-structured interview guide
Patient:
|
|
Retention: N/A Patients felt most strongly about their interactions with program staff Nonjudgmental, caring attitudes were highly valued Positively identified feature was group counseling format, but patients had mixed feedback on optimal content of counseling sessions Group care management to address holistic individual and individual needs
|
|
15 Fair |
| Drucker et al (2007) |
Observational Cohort No comparison group Total n = 14
|
Lancaster, PA, USA Rural PCC
|
-
“Lancaster Model”: PCP and community pharmacist worked collaboratively in sharing patient care
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 24 mo, 12 mo follow up Medication: Methadone
|
|
PCP: provided initial rx and act as case manager for patients; responsible for meeting with patient at least once a month Pharmacist: observed patient taking methadone at clinic, provided them with take-home rx, and communicated patient status and updates with PCP |
Staff:
PCP was responsible for meeting with patient and providing counseling as needed as patient’s case manager Pharmacist observed methadone induction and provided take-home doses and communicated with PCP after each observed dosage Pharmacist tracked rx’s and logged patients’ rx bottles
Patient:
|
|
Retention: 86% at 12 mo. Retention in treatment, concurrent drug use, and patient and provider satisfaction Results: 10 patients remained at end of study period, illicit drug use was not a significant issue for population given urine tox results, overall patient satisfaction was good (complaints of distance from PCP, hours since most all patients worked, and other patients trying to sell them drugs in waiting room)
|
|
17
Fair |
| Ezard et al (1999) |
Observational Cohort No comparison group Total n = 195
|
|
-
Community based service delivery in which patients were prescribed methadone via PCP then received daily dose from pharmacist at a separate site
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: N/A Medication: Methadone
|
|
|
Staff:
Patient:
|
|
|
|
16 Fair |
| Fiellin et al (2002) |
|
New Haven, CT, USA Urban Academic PCC
|
|
|
PCP: met with patients to assess progress once a month and supervised nursing staff Nurses: conducted the weekly counseling, met with patients 3x weekly for brief counseling, met with PCP and psychologist to review
|
Staff:
Nurses recruited from center's staff had no prior experience in substance abuse treatment Training in MM via designed manual and 3x 1 hour sessions on heroin dependence, BP, and counseling Weekly review of counseling issues with supervising PCP and doctorate level psychologist
Patient:
|
|
Retention: 79% at 13 wks. Illicit opioid use assessed by urine toxicology and treatment retention Positive urine toxicology results reduced significantly from 95% to 25% over 13 wks*
|
|
23 Good |
Fiellin et al (2004)
Assessed from Fiellin et al (2001)
|
|
|
Evaluated efficacy of OBOT- M vs. continuing treatment over 6 month follow-up largely coordinated by nurses -
Evaluated the OBOT-M efficacy via Randomized Control Trial from Fiellin (2001)
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 6 mo Medication: Methadone
|
PCP: all general internists, 4/6 certified in addictions medicine RN: nursing staff, and other office personnel |
PCP: during initial visit: reviewed the patient’s medical and substance abuse history and treatment records from the OTP, performed a physical exam, and discussed components of OBOT-M with patient Mandatory 2x 4 hr training sessions Nurses: main responsibility was coordination of care in terms of scheduling physician visits with patients and collecting urine specimens for drug screens |
Staff:
Physician training of opioids, methadone maintenance, role of psychosocial treatment -
Patients were given oral dispense of methadone once weekly then given 6 day supply of liquid methadone, coordinated by RN
Additional in-service training was provided at the office for nursing staff and other office personnel
Patient:
Patients scheduled to have 1x mo 30 min visits designed as counseling sessions to look for relapse, medication issues, health promotion, and participation in self-help or relapse prevention activities Patients were given oral dispense of methadone once weekly then given 6 day supply of liquid methadone Each patient had 1 medication dispensing visit per month at which they were asked to provide a urine for toxicology analysis (random urine screen all other visits)
|
Training & Resource Guide (developed specifically for program) Monthly on-site chart audits to assess MD adoption Med transfer logs to track receipt/ return of bottles
|
Retention: N/A -
Logistics of dispensing, the receipt of urine toxicology results, difficulties arranging psychiatric services, communications with the opioid treatment program, and non-adherence to medication as problematic
From Fiellin et al (2001):
No statistically significant differences between primary care versus narcotic treatment program for illicit opiate use. PCP patients did think the quality of care was excellent compared to narcotic treatment programs.* 50% of OBOT-M patients vs. 38% of control had self-report or urine tox for positive illicit drug use Ongoing illicit substance use (defined as clinical instability) found in 18% of OBOT-M patients vs. 21% in control 73% of OBOT-M patients thought quality of care was “excellent” vs. 13% of control
|
Clinical management issues: charting certain findings (i.e. positive urine drug screens), incorrect methadone bottle logs, reformatting logs, difficulty referring patients to psychiatric services, problems with patient's medication adherence, and unnecessary required counseling for patients with prolonged abstinence Training adequately prepared MDs
|
19 Fair |
| Fiellin et al (2006) |
|
New Haven, CT, USA Urban Academic PCC
|
Patient centered model with standard or enhanced medical management given to individual patients. 3 treatment arms:
standard MM + 1x wk medication dispensing standard MM + 3x wk medication dispensing, enhanced MM + 3x wk medication dispensing
-
Overall goal to assess differences in counseling and medication dispensing for BP patients
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 24 weeks Medication: Buprenorphine
|
|
PCP: met with patients monthly for 20 minutes Nurses: dispensed the BP & facilitated weekly manually guided standard or enhanced MM to individual patients Psychologists: met weekly with physician and nurse to review counseling
|
Staff:
Standard MM: brief, manually guided, medically focused counseling, ~20 min long Enhanced MM: similar to standard but longer session, 45 min long MM topics included: recent drug use and efforts to achieve or maintain abstinence, urine analysis results, advice for abstinence achievement/ maintenance Nurses dispensed the BP, and were the facilitators for the counseling sessions The nurses, physician, and psychologist met monthly to discuss the counseling sessions
Patient:
Patients met 3x week for 2-week induction/stabilization period and progressed to 16 mg (max 20–24 mg) BP daily for 24 weeks Take-home medication provided to patients for days on which they did not receive BP from office Adhere to treatment assignment, provide urine samples, and attendance to all follow-up
|
Recorded audio for counseling Electronic caps of medication bottles (Medication Event Monitoring System) Caps contain micro-processors that record, but don’t display date and time each bottle is opened
|
Retention: N/A No statistical significance in negative urine screens, maximum consecutive weeks of abstinence, reduction in frequency in illicit drug use or proportion of patients remaining in study between groups Overall significant reduction in illicit opioid and cocaine use Treatment satisfaction was significant with treatment group: higher satisfaction with standard MM and 1x wk medication dispensing*
|
|
21 Good |
| Fiellin et al (2013) |
|
New Haven, CT, USA Urban PCC
|
Patient centered model with randomization to 2 groups and followed over 12 weeks -
2 treatment arms:
1) Physician Management
2) CBT
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 24 weeks Medication: Buprenorphine
|
|
|
Staff:
Physician Management (PM): manual guided, medically focused, 15–20 minute weekly counseling session for first 2 wks, every other week for 4 wks, and then monthly Topics discussed: recent drug use and efforts to achieve or maintain abstinence, urine analysis results, abstinence advice on achievement /maintenance advice, review of medical/psychiatric symptoms, assess social, work, and legal function, group attendance, and urine screen results CBT: manual guided, weekly 50 min sessions provided for first 12 wks of treatment by trained masters and PhD clinicians Main components: performing functional behavior analysis, promoting behavioral activation, identifying/ coping with drug cravings, enhancing drug-refusal skills, enhancing decision-making about high-risk situation, and improving problem-solving skill
Patient:
|
|
Retention: 45% in PM; 39% in CBT at 6 mo. Self-reported frequency of illicit opioid use, maximum number of weeks abstinent from illicit opioids evidenced by urine tox and self-report Significant reductions from baseline in both treatments from 5.3 average days of opioid use to 0.4* No significant differences between groups Time had significant impact on retention rates*
|
However, PCPs cite lack of available ancillary psychosocial services a barrier For some patients psych may not be necessary
|
22 Good |
| Gossop et al (1998) |
|
|
-
GPs or Specialists provided methadone maintenance to patients
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 6 mo Medication: Methadone
|
|
PCP: responsible for prescribing medications Pharmacists: Responsible for supervision of medication in some clinic settings No discussion of who was performing the interviews
|
Staff:
Processes differed between groups At the program level, differences were found in the manner in which methadone was dispensed Fewer GP agencies (57%) than clinics (75%) prescribed daily dispensing of methadone 6 of the 8 clinics used supervised dispensing procedures (on site or supervised by a retail pharmacist) Supervision (to be provided at retail pharmacies) was used less often by GP agencies (14%)
Patient:
|
|
Retention: 66% of GP patients; 60% of SC at 6 mo. Over 50% reduction in heroin use for both groups No statistical difference between groups
|
|
19 Fair |
| Gossop et al (2003) |
|
|
-
OBOT-M with 5 of the 7 PC sites using coordinated care models (physician prescribing and clinic providing counseling services)
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 12 mo, follow up 24 mo Medication: Methadone
|
|
PCP: responsible for prescribing medication and provided medical care as required SCP: provided counseling services Pharmacists: direct supervision within retail pharmacy Data on patient outcomes was collected using interviews, but not discussed who collected them
|
Staff:
Patient:
|
|
Retention: 61% of PC; 53% of SC at 12 mo. Illicit drug use, drug injecting behaviors, alcohol use, crime, physician and mental health problems Significant reductions heroin use, non-prescribed methadone and benzodiazepine uses and stimulants Significant differences between PC and SC for: non-prescribed benzodiazepines and stimulants usage, frequency of alcohol use and psychological health Significant differences in psychological health, stimulant use, and non-prescribed benzodiazepine use between groups
|
|
17 Fair |
| Gruer et al (1997) |
Observational Cohort No comparison group Total n = 1971
|
Galsgow, Scotland, U.K. Urban PCC
|
Glasgow Scheme is a service led by former PCP with experience in OUD patient population -
Staffed by 4 teams of 2–3 specialist RNs working with MDs that each cover 25% of area covered by health board
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 12 mo Medication: Methadone
|
|
PCP: provided prescription and attended drug misuse training at least twice a year, completed the opiate treatment index for each patient, routine care as needed Nurses: trained in counseling and provide services as necessary Pharmacists: supervised dosage Drug counselors: provided patient counseling
|
Staff:
Trained team of PCP, Pharmacist, Drug counselor and RN in methadone and drug use, misuse, and abuse PCP given 5–20 patients Specific scheme guidelines for assessing and treating patients Only allowed to prescribe oral methadone 1 mg/ml Daily methadone self-administration with supervision under community pharmacist Patients with coexisting benzodiazepine dependence prescribed reducing doses of diazepam or nitrazepam Temazepam forbidden Brief details of each patient's attendance noted and health and social circumstances recorded initially and every 6 mo2
Patient:
All patients received regular additional counseling from a drug counselor or trained RN After assessment of the patient the service will usually initiate treatment only if the general practitioner agreed to participate in ongoing care thereafter A written contract is created with the patient Stabilized patient ongoing care returned to PCP with service still available for advice
|
|
|
Beneficial in establishing the Glasgow Drug Problem Service Scheme provides detailed guidance on methadone maintenance therapy Improves managing patients Positive continuing education for PCPs
|
13 Poor |
| Gunderson et al (2010) |
|
NYC, NY, USA Urban PC clinic
|
-
Patient centered model with unobserved vs. observed induction of BP
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 12 week follow up Medication: Buprenorphine
|
|
PCP: BP induction, provided routine care, and provided phone support to induced patients Pharmacists: dispensed BP Study personnel: picked up BP from pharmacy and stored in locked medicine cabinet and phone calls to patients
|
Staff:
Target daily maintenance dose is 12–16 mg with max of 32 mg Weekly clinical visits during 4-week induction and stabilization phase then decreased to monthly visits Urine toxicology with BP-specific immunoassay performed at all clinical visits as well as Research visits occurred every 4 wks (urine screen, self-reported substance use assessed, research scale administered)
Patient:
|
|
Retention: 45% at 3 mo. Successful induction one week after initial clinic visit Similar induction rates between groups 60% successfully inducted in both groups 30% experienced prolonged withdrawal 40% stabilized by week 4 No statistical significance in phone calls for home-induced patients in office vs. unobserved induction
|
|
21 Good |
| Haddad et al (2014) |
|
|
Comprehensive, coordinated care between NP, PCP, and Psych to deliver PC opioid maintenance therapy through BP while treating comorbidities -
Shared care between NP, PCP, and Psych to oversee day-to-day clinical work
Model(s):
Coordinated Care, Multi-disciplinary Care, Shared Care
Duration: N/A Medication: Buprenorphine
|
PCP RN: NP and nursing staff Pharmacist Psych: psychiatrist Behavioral counselor medical assistant
|
Physicians and psychiatrists: prescribed BP PCP could use the Electronic Health Record's pop up feature NP and nursing medical assistants: routine clinical care within their scopes of practice Behavioral health workers (psychiatrist and behavioral health counselors): used a health template during encounters
|
Staff:
PCP and Psych can prescribe BP, but NPs cannot PCPs have a NP, an assigned nurse, and a medical assistant Psych has the behavioral counselors for assistance
Patient:
|
|
Retention: 71.8% at 3 mo. Examined 9 QHI (HIV, HBV, HCV, Syphilis, hypertension, hyperlipidemia, cervical, breast, and colorectal cancers) Achieving at least an 80% QHI score was positively and independently associated with at least 3-month BMT retention & BMT prescription by PCP rather than addiction psychiatric specialists
|
|
18 Fair |
| Hersh et al (2011) |
|
|
Patient care delivered in 3 model sites OBOT Buprenorphine Induction Clinic (OBIC) initiated all BP treatment via part-time PCP and NP. Phone screening before scheduled evaluation/induction visit (Monday or Tuesday AM) Community Behavioral Health Service (CBHS) provided ongoing dosing with optional observed dosing -
Community Treatment sites: 2 PC clinics and 1 outpatient private dual-diagnosis group practice (provides outpatient mental health and addiction counseling services)
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 12 mo, follow up 1 mo, 3 mo, 6 mo Medication: Buprenorphine & Methadone
|
|
|
Staff:
Centralized induction clinic for BP staffed by PC and NP Patients initially given full physical/mental health assessment, BP and pilot program education, informed consent, and release of information Induction dose of 2-4mg on first day with option 2-4mg additional to reduce withdrawal and titrated to 12-16mg/daily of BP Visits 4–5 days first week with reduction to weekly visits
Patient:
Observed dosing for take-homes (day 3 of treatment) Informal methadone maintenance program helped refer patients to BP pilot Minimum requirements included: monthly counseling, quarterly urine toxicology screening, and quarterly visits with the treating PCP
|
|
Retention: 61% at 12 mo. Over 50% reduction in positive urine screens for methadone and morphine in first 30 days of treatment* Significant increase in paid-working days and decrease in reported drug problems No significant changes in medical or mental health problems Positive patient perceptions of the program (75% felt comfortable with PCP, 15% thought OBIC was very difficult, majority felt PCP knowledgeable and highly valued monthly counseling
|
Over time community PCPs grew increasingly comfortable leading to fewer pharmacy visits average of 2–3 visits per week to weekly, every other week, or monthly visits) OBOT database helped to facilitate communication between the PCPs, pharmacists, and counselors
|
20 Good |
| Kahan et al (2009) |
|
|
-
Multi-disciplinary Care program with nurse clinician, family therapist, 6 PCPs, clinical fellow in which patients receive brief counseling intervention, outpatient medical detox, pharmaco-therapy & follow-up
Model(s):
Coordinated Care, Multi-disciplinary Care, Shared Care
Duration: 4 mo Medication: Methadone
|
|
PCP: initial physical assessment, pharmacotherapy selection and induction NP: not stated Addiction therapist: initial assessment of patient including demographic, drug/alcohol use
|
Staff:
Patient first assessed by addiction therapist and then by PCP Consultation note faxed to PCP with brief history, diagnosis, and treatment recommendations Pharmacotherapy determined by PCP and consultation note
Patient:
Patients received brief counseling session and outpatient medical detoxification program After completion, patient reassessed
|
|
Retention: N/A Changes in self-reported substance use from interviews at intake and 3–4 months after initial office visit 13/29 OUD patients had statistically significant decreased MME and decline in mean number of drinks* 31% of participants participated in Alcoholics Anonymous or formal addictions treatment
|
|
20 Good |
| Lintzeris et al (2004) |
|
|
-
Compared delivery methods by specialist vs. community-based service providers via BP or Methadone
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 12 mo, follow up 3, 6 mo Medication: Buprenorphine & Methadone
|
|
|
Staff:
Patient:
Patients assigned to either control group (conventional methadone maintenance treatment program) or experimental group (BP treatment with option for methadone transfer) Subjects followed over 12 mo period with treatment coordinated by prescribing PCP Required monthly meetings and optional counseling services available Daily supervised induction of sublingual BP tablets (2 and 8 mg) with flexible doses Once stabilized, transition to alternate-day or 3-day dosing
|
|
|
Create readily available set of BP guidelines suited for community settings Medium-dose transfers from methadone to BP were difficult to conduct in community settings Pharmacies addressed problems of diversion and delays in dosing by crushing BP tablets and administering sublingual BP powder
|
20 Good |
| Lucas et al (2010) |
|
|
-
Multi-disciplinary care between 2–5 BP PCPs, social worker, substance abuse counselor, and nursing staff
Model(s):
Chronic Care, Coordinated Care, Multi-disciplinary Care
Duration: 12 mo Medication: Buprenorphine
|
|
PCP: collaborated with LPN and substance abuse counselor, oversaw prescribing, and met with patients for follow-up LPN: managed the patients Substance abuse counselor: met with patients to schedule follow-up and induction education
|
Staff:
Social worker and registered nurse ran the case management program, coordinated appointments, and assisted with overcoming barriers to adherence PCP met with patient after 4 wks
Patient:
Patient initial 2-day BP induction (3x BP daily dose) & progressed to clinic treatment until stabilized Unstructured counseling provided, urine drug tests, and take-home supplies of BP provided each visit
|
|
Retention: N/A Initiation and long-term receipt of opioid agonist therapy, PCP visit attendance, RNA CD4 cell count changes, and use of antiretroviral therapy Patient satisfaction higher in OBOT setting Clinic-based patients lower levels of reported injection use and Hep. C co-infection 78% of referred patients met with case manager (average 3 meetings) 64% started methadone or BP
|
|
23 Good |
| Michelazzi et al (2008) |
Observational Cohort No comparison group Total n = 33
|
Trieste, Italy Urban GP’s outpatient office
|
|
|
|
Staff:
Patient:
Patient was responsible for completing each of the evaluations which included: substance abuse, psychosocial health, personal data, urine analysis, and other pertinent medical histories
|
|
|
|
17 Fair |
| Moore et al (2012) |
|
|
-
Office based BP treatment with added CBT
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 14 weeks Medication: Buprenorphine
|
|
PCP: BP treatment, reviewed weekly therapists taped session to ensure competence and adherence to proper quality of care, meet with patients Therapists: led the CBT sessions
|
Staff:
Patient:
Final 2 wks PCP and patient established agreement for final tapered dosing Patients attended scheduled visits before induction, after induction, and at the end of month (total 5 visits)
|
|
Retention: PM+CBT: 19%; PM: 26% at 14 wks. Increase in negative urine screens* Decrease in opioid use* Physician management only had highest %negative urine screens & lowest % opiod use* CBT attendance associated with increased negative urine screens & abstinence length * Overall patient satisfaction was high
|
Difficulties arose with CBT Difficult finding office space, transportation and parking Problems coordinating care team and increased treatment costs Adaptive/ stepped-care model of treatment hypothesized to help high risk patients
|
21 Good |
| Mullen et al (2012) |
Observational Cohort No comparison group Total n = 1269
|
Ireland Urban PC &. SC centers
|
-
Coordinated care between multidisciplinary team in SC and community centers with SC
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 12 mo Medication: Methadone
|
PCP RN: Registered Nurse Psych: Psychiatrists Counselors
|
|
Staff:
PCPs trained by the Irish College of General Practitioners PCP can choose to prescribe and deliver methadone -
PCPs are part of care team for addiction treatment in Ireland
Methadone maintenance by PCP is central to drug treatment system
No standard clinical practice guidelines in Ireland so UK guidelines followed
Patient:
Attend all scheduled follow-up visits, adhere to methadone dosage Drug users transferred from community drug treatment centers to PC once stabilized
|
|
In SC and PC combined, retention: 61% at 12 mo. In SC and PC combined, treatment retention at 12 mo associated with age, gender, facility type, and dose Age and gender no longer significant when adjusted for other variables Patients attending SC site were 2x likely to leave program with 12 mo vs PCP site Biggest predictor of treatment retention was methadone dose regardless of type of treatment facility Patients receiving <60 mg of methadone were 3x more likely to leave treatment
|
|
22 Good |
| O'Connor et al (1998) |
|
|
-
Manual-guided clinical management with team-based approach in SC clinic with PCP
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 3 mo optional 10 week extension Medication: Buprenorphine
|
PCP: General Internists RN: NPs Physician Associates Counselors
|
PCP: prescribed treatment, performed initial assessment, followed patient throughout study (if PCP vs. SC) NP: ran semi-structured weekly group therapy Counselors: in SC provided substance abuse counseling and services
|
Staff:
Patient:
Patient required to attend initial referral and full clinical assessment, shared decision-making when establishing goals, medical and substance abuse history reviewed, PCP educated about risks/benefits of treatment, and mandatory weekly group therapy Followed-up weekly for 20 min (urine screen, treatment review, adapt goals to current status)
Staff:
Patient:
Patient attended clinic 3x week for prescription, urine screens, and self-reported follow up reports Patient attended mandatory weekly group therapy and optional 1x mo individual counseling session
|
|
Retention in treatment and urine toxicology Retention: 78% in PC; 52% in SC at 3 mo. PC patients (63%) had lower rates of opioid use than SC (85%)* PC higher 3+ week abstinence (43%) vs. SC (13%)* Higher patient satisfaction in PC
|
Properly trained General internists can provide OUD treatment Number of visits impractical for a PC workload Decreased prescription frequency can diminish long-run retention in treatment PCP remained willingly kept OUD patients in PC setting Reimbursement method for these services in PC is lacking (capitated Full-risk managed care plan possible solution)
|
21 Good |
| Ortner et al (2004) |
Observational Cohort No comparison group Total n = 60
|
|
-
Coordinated Care between SC and PC with long term PC care
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 3 mo Medication: Buprenorphine
|
|
|
Staff:
Patient:
|
|
Retention: 57% at 15 wks. (after completion of SC and PC segments) Urine samples for opioids, cocaine, and benzodiazepines, were positive in 28.9%, 19.6%, and 13.1%, respectively Self-report for depression and withdrawal symptoms: depressive symptoms never reached clinical relevance Withdrawal symptoms decreased within first week (patient in SC)* No significant differences between SC and PC retention rates between 3 week SC period and 12 week PC period or mean bupenorphine dose Across both SC and transition to PC, significant reduction in opioid use and cravings for heroin and cocaine*
|
|
19 Fair |
| Roll et al (2015) |
|
|
-
Shared medical appointments model run by PCP and certified addictions nurse with patients treated with OBOT-BP
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 1 mo Medication: Buprenorphine
|
|
|
Staff:
Patient:
Patient attended 75 min sessions about 1-4x a month Patients self-reported life circumstances, current health status, and mental health status during each visit
|
|
Retention: N/A Patient satisfaction, management of other comorbidities, vaccination, housing improvement, time spent working, and resolution of legal cases Patients reported liking group visit format Patients in program gained increased coping skills, had more stable housing and less legal difficulties Shared medical appointments for OUD was highly acceptable
|
|
13 Poor |
| Ross et al (2009) |
Observational Cohort No comparison group Total n = 190
|
|
-
A patient centered approach used to facilitate treatment through MM
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 1.5 mo Medication: Methadone
|
|
PCP: BP prescription as well as scope of care beyond NP and bridging patient NP: enrollment of physicals and routine care Social Workers and Mental health workers: mental health assessments, provided counseling, and linked to outside services
|
Staff:
PCP had primary role in prescribing medication and coordinating follow-up care Staff provided additional services to patient throughout process PCP oversaw medical issues and prescribing BP beyond NP scope NP provided limited prescribing and enrollment physicals Social workers and mental health workers provided mental health assessment, individual patient counseling, and financial aid, housing, and social assistance
Patient:
|
|
Retention: N/A Types of medication used for bridging in patients waiting for methadone treatment 79% patients undergoing bridging used long-acting formulation 70% used MS Contin or Codiene Contin Bridging is good option for individuals forced to wait for treatment Meetings with PCP increased change of enhanced long-term care continuity of treatment
|
Barriers to care: cost of the clinic, prescription challenges Staffing expenses high Significant effort required to reduce misuse of prescribed medications
|
16 Fair |
| Sohler et al (2009) |
|
|
Chronic Care Model: focus on patients and relationship with physician -
The model was modified to address home induction
Model(s):
Chronic Care, Physician-Centric
Duration: 30 days, follow-up 2 years post study initiation Medication: Buprenorphine
|
|
PCP: oversaw care for patients including BP prescribing, induction dosage, and patient follow ups RN: provided assistance as needed
|
Staff:
PCPs helped determine patient eligibility for office-based versus home-based induction PCP available for contact outside of clinic hours via phone, but patients called infrequently
Patient:
Patients attended initial visit to determine BP treatment process (office-based vs. home-based induction) Patients with home-based induction had initial PC center visit and required follow up within 1 wk Shared decision making in long term maintenance plan Patient self-management highly encouraged
|
PCP available via phone For home-based inductions, patients given home-induction kit with instructions (explained contents, what to do, when to start taking BP, things not to do, how to take it, plans to guide treatment and facilitate follow-up, and a log to track meds taken),
|
|
|
21 Good |
| Tuchman et al (2006) |
|
Albuquerque & Santa Fe, New Mexico, USA Primary care settings (including women’s specialty health clinic) as well as community pharmacy
|
-
Office-based prescribing with community pharmacy integration for methadone maintenance patients with support from social workers
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 12 mo Medication: Methadone
|
PCP: 8 hours of didactic methadone maintenance training NP: 8 hours of didactic methadone maintenance training Community Pharmacist: 8 hours of didactic methadone maintenance training Social Workers: Masters level clinician
|
Providers (4 PCP and 1 NP): provided continuous care for assigned methadone maintenance patients Responsible for faxing prescription to patient’s most convenient pharmacy Pharmacist: dispensed the methadone and oversaw the day’s methadone dosage Social worker: coordinated care and provided all psychosocial treatment
|
Staff:
The provider team provided all clinical care and prescribed methadone and were responsible for ensuring patient’s prescription was faxed to most convenient pharmacy Pharmacist was responsible for dispensing methadone as well as observation of daily dose and dispensing of take-home dose according to PCP’s orders Social worker met with each patient for psychosocial treatment once a month
Patient:
|
|
Retention: 100% in office based experimental group; 89% in MMT at 12 mo. Results: patients in the experimental group did as well or better than the control (routine methadone maintenance treatment program) Proportion of women continuing opioid use during study for experimental group was "significantly lower" in experiment group than control Pharmacy dispensing seen as positive given commentary, no statistics reported
|
|
20 Good |
| Walley et al (2015) |
|
|
-
Team of PCPs, NCM and licensed addiction counselor that collaborated to provide addiction care and patients had established treatment agreements with care teams
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 6 mo Medication: Buprenorphine
|
|
PCP: provided addiction treatment and primary care as needed NCM: initiated face-to-face BP inductions and RN pill counts Counselors: provided motivational interviews via a 12-step program
|
Staff: The team provided an initial multidisciplinary addiction assessment by PCP, NCM, Counselor Addiction pharmacotherapy included BP/NX, acamprosate, disulfram with established treatment agreements Case management referred patients to methadone maintenance treatment and detoxification programs Weekly team meetings held before PCP clinical session to discuss patient coordination of care and treatment plan
Patient:
|
|
Retention: N/A 60% had BP treatment 64% engagement by 6 mo, 49% had substance dependence BP treatment associated with engagement Self-reported depression baseline associated with substance dependence at 6 mo Housing status and polysubstance use not associated with engagement or substance dependence
|
Important for PCP to understand which patients more likely to engage Identify patients likely to have persistent substance use disorders Such knowledge helps target, tailor, and improve integration of addiction treatment and medical care
|
20 Good |
Weiss et al (2011)
[22]
Fiellin et al (2011)[23]
Korthuis et al (2011)
Korthuis, Tozzi, et al (2011)
Egan et al (2011)
Altice et al (2011) [23–26] |
Observational cohort study
No Comparison Group
Total n = 427
Included in analyses n = 303
Funded program n = 10 |
|
Multi-disciplinary care model with comprehensive medical and social services available to all participants within the BHIVES program in which a "specialist" model of BP/NX treatment (limited number of PCPs oversaw entire pharmacotherapy process) was employed -
Evaluated the implementation of BHIVES model from Fiellin et al (2011): analyzed patient outcomes (retention in treatment, treatment process in terms of BP dosing, and illicit substance use, across the 9 sites
Model(s):
Coordinated Care, Multi-disciplinary Care
Duration: 5 years (variable) Medication: Buprenorphine
|
|
|
Staff:
Patient:
|
|
Weiss et al (2011):
Evaluation and Support of programs to improve better understanding of BP/NX integration practices, services offered, staffing needs, PCP experiences/perceptions of BP/NX, perceived barriers and facilitators, sustainability measures, and recommendations for replication of integrated care program components Successful introduction of BMT program Many patients presented with multi-substance abuse and complex mental health comorbidities -
PCPs not in grant-funded programs adopted BP/NX tx more slowly
BHIVES outcomes from Fiellin et al (2011):
Retention: 74% at 3 mo. BP patients 33% less likely to use illicit substances -
Treatment retention associated with female gender, black race, and greater number of years since HIV diagnosis
Korthuis et al (2011):
78.4% of patients receiving bup/nx remained on treatment at 3 mo, 72.7% at 6 mo, 62.9% at 9 mo, & 53.1% at 12 mo -
Mean summary quality score increased over 12 mo from 45.6% to 51.6% for bup/nx patients*
Korthuis, Tozzi, et al (2011):
At 12 mo, average composite mental health-related quality of life (HRQOL) improved (38.3 to 43.4) and composite physical HRQOL did not change -
Bup/nx associated with improvements in HRQOL
Egan et al (2011):
Patients satisfied with Buprenorphine/Naloxone and reported overall increased quality of life Counseling seen as an important component -
All patients strongly positive about integrated care model
Altice et al (2011):
Retention on BUP/NX for 3+ quarters, significantly associated with increased ART initiating* Prescription of BUP/NX for 3+ quarters for patients on ART (at baseline) was not associated with statistically significant improvements in viral suppression and CD4 counts
|
Satisfaction with HIV & BP/NX integrated tx Challenges: Multi-OUD, mental health issues, poorly incorporating new procedures into practice, low psychiatric involvement Addiction med & OUD knowledge beneficial Complicated patients need outreach staff, case mgmt, & counseling Communication skills a positive
|
17 Fair |
