Table 2.

Examples of barriers and facilitators described by facilities and classified by i-PARIHS constructs

	i-PARIHS construct	Barrier example	Facilitator example
Innovation (focus or content of innovation effort)	Degree of fit with existing practice and values	Approval for buprenorphine is difficult given current requirements for 4 positive consecutive urine drug screens for opiates and no other substances	An established pain clinic has a current role in identifying patients with OUD, initiating buprenorphine, and transferring care back to primary care
	Clarity	M-OUD treatment is referred to community clinics (non-VHA providers), so roles and responsibilities of VHA staff regarding M-OUD is not clear	Facility currently has clear criteria that patient misuse or diversion (selling) of buprenorphine results in loss of medication eligibility
	Relative advantage	No barriers reported	Non-VHA community clinics can have long wait lists and may not accept VHA insurance, which provides a relative advantage for VHA facilities to treat and manage patients on M-OUD
Context (multiple layers that can facilitate or constrain implementation)	Local level: Mechanisms for embedding change	Clinic staff attempted to remove restrictions on where buprenorphine initiations could occur (currently only in the emergency room in a separate building); however, they were met with resistance due to concerns for adverse events related to buprenorphine initiation	Facility previously identified team to clarify and implement buprenorphine initiation strategies to increase access
	Organizational level: Organizational priorities	VHA employs multiple initiatives to improve Veteran care, which often leads to competing priorities	Organizational leadership is aware SUD-16 metric is low and are requesting improvement
	External Heath System Level: Environmental stability	Rurality of facility brings the challenge of maintaining an adequate number of trained and waivered staff to provide adequate coverage	No facilitators reported
Recipients (people who enact and influence the implementation)	Motivation	Limited interest from non-SUD disciplines and clinics to manage patients on buprenorphine	Providers want to get the necessary training to prescribe buprenorphine
	Skills and knowledge	Facility does not have a provider who is waivered to prescribe	Facility has a new provider with experience in a buprenorphine clinic
	Time, resources, and support	Lack of adequate space and provider capacity to prescribe buprenorphine and manage an increase in patient caseload	Mental health residential programs have staff who can be re-allocated to provide buprenorphine and manage patients