Feasibility and acceptability of an online ECHO intervention to expand access to medications for treatment of opioid use disorder, psychosocial treatments and supports

Abstract

Background:

Buprenorphine combined with psychosocial support is the standard of care for treatment of opioid use disorder (OUD) in office-based primary care settings. However, uptake of this treatment has been slow due to a number of addressable barriers including providers’ lack of training, staffing concerns, stigma and the need for ongoing support and consultation. This study examined acceptability and feasibility of an online Extensions for Community Healthcare Outcomes (ECHO) model intervention developed to support rural primary care clinics to expand treatment and is part of a larger study tracking the impact of participation in this ECHO on expansion of MOUD in rural primary care.

Methods:

We developed a comprehensive, 12-week online education and mentorship intervention using ECHO aimed at supporting the entire primary care clinic to start or expand treatment using MOUD, psychosocial treatments and recovery supports. We tracked participation and collected feedback using qualitative interviews and post-session questionnaires.

Results:

Sixty-seven primary care staff across 27 rural clinics in New Mexico participated in the study including 32 prescribers and 35 clinic support staff. Average participation was 4/12 sessions. Post-session questionnaires showed positive feedback, including that 95% or more respondents agreed or strongly agreed that the sessions were relevant and improved their confidence. Qualitative interview themes included strong endorsement of the ECHO curriculum. Clinical duties were the most common barrier to attending sessions.

Conclusions:

Engagement of 27 clinics, the range of staff and providers who participated, and positive feedback gathered through survey and qualitative interviews provide evidence of feasibility and acceptability of MOUD ECHO to support expansion of this treatment. However, barriers to participation present an important threat to feasibility. Understanding feasibility and acceptability is an important component of research on the impact of ECHO to expand MOUD treatment.

Introduction

The opioid epidemic is a profound public health crisis.^1,2 Treatment for opioid use disorder (OUD) using FDA approved medications including methadone, buprenorphine or naltrexone, sometimes referred to as Medications for Opioid Use Disorder (MOUD), is the standard of care.³ Despite evidence supporting MOUDs, integration in primary care settings has been slow. One factor is that methadone cannot be prescribed in a primary care setting. Per federal regulations, patients must receive this treatment from an Opioid Treatment Program (OTP). Additionally, federal law mandates patients physically attend the OTP at least six days a week to receive the medication at treatment entry. Rosenblum et al. demonstrated that a number of states have few or no OTPs; moreover, the existing methadone clinics are primarily located in large urban centers, and residents of rural locations often have to travel great distances to access this medicine.⁴ Studies have shown that among individuals with substance use disorders, longer travel distances are associated with shorter length of stay and lower probability of completion and aftercare utilization.^5,6 In fact, any travel distance of over 10 miles has been associated with higher likelihood of missed doses of methadone.⁷ These factors present challenges to methadone treatment particularly for rural communities.

Alternatively, buprenorphine, can be prescribed in an office-based setting by any physician, nurse practitioner, or physician assistant following completion of training in its use. This creates an opportunity for expanding access to MOUDs and comprehensive care in these underserved rural settings. Unfortunately, it has been demonstrated that 20 million Americans live in counties with no buprenorphine waivered providers; in fact, 57% of rural counties, comprising about 30% of all individuals who live in rural locations, lack a buprenorphine waivered provider.^8,9 This highlights an unacceptable provider shortage. Documented barriers to uptake of treatment for OUD using MOUDs combined with psychosocial supports in primary care settings include lack of behavioral healthcare providers, stigmatizing views toward clients with OUD, diversion concerns, lack of staff to support clinic workflow, provider lack of confidence in their ability to provide the treatment; and time commitment to obtain the required DATA Waiver Eligibility Training (Waiver).^10–12 This time commitment is 8 hours for Medical Doctors (MDs) and Doctors of Osteopathic Medicine (DOs), and 24 hours for Nurse Practioners (NPs), Physician Assistants (PAs) and other qualified personnel. Once waivered, all qualified providers can treat up to 30 patients in the first year. Then, they can apply to treat up to 100 patients in year 2 and up to 275 patients in year 3 and beyond. The SUPPORT for Patients and Communities Act of 2018 provides additional details on waivered providers’ treatment capacity (PL 115–271). Additionally, some providers obtain the waiver but never start prescribing or stop soon after they begin.¹² Andrilla et al. reported that in rural United States, physicians with a 30 patient waiver were treating, on average, just 8.8 patients, and over half (53%) were not treating any patients at all.⁸

To address these barriers and support expansion of OUD treatment in rural primary care settings using MOUD, a team of MOUD experts and researchers developed an innovative telementoring Extensions for Community Healthcare Outcomes (ECHO^©) program focused on treatment of OUD using buprenorphine, psychosocial treatments and supports (referred to hereafter as MOUD ECHO). ECHO sessions are interactive and conducted in real time, providing didactics, consultation and case-based learning opportunities to support providers and staff to successfully implement new evidence-based approaches. The ECHO model was developed at the University of New Mexico, the seminal study detailing the positive impact on improved outcomes for patients with Hepatitis C.¹³ Since this time, the ECHO model has been applied to address a range of health conditions with promising results.¹⁴

The MOUD ECHO filled a gap by providing easily accessible online support for clinics to learn about, start, and expand this treatment. Although other ECHOs were being developed or implemented to support MOUD, these were not always publically accessible. For example in New Mexico, one was exclusively implemented within a large healthcare system and open only to its members (details of this ECHO content are not published); the other was open during the time of our MOUD ECHO only to clinics enrolled in a federally-funded study, and is currently no longer being implemented.¹⁵ Furthermore, neither were solely focused on buprenorphine expansion. The MOUD ECHO was developed and is being provided currently as part of a 5-year implementation study examining acceptability and feasibility of this ECHO intervention and the relationship between participation in the ECHO and the following outcomes: treatment expansion including obtaining the DATA waiver, prescribing buprenorphine, and expanding the number of patients receiving this treatment. The goals of the present manuscript are to describe the MOUD ECHO program, provide evidence of its acceptability and feasibility, and discuss how this ECHO and its associated research contributes to our limited knowledge of how the ECHO model impacts expansion of comprehensive treatment using MOUD in rural primary care.

Methods

MOUD ECHO was developed in 2017 with funding from the Agency for Healthcare Research and Quality with the goal of examining the impact of the ECHO model on expanding comprehensive treatment using MOUD in rural primary care. It was developed by the study Principal Investigator and co-investigators with expertise in providing MOUDs, psychosocial treatment and supports. This included a psychiatrist and a family medicine physician, both of whom are dual board certified in addictions, as well as a PhD level therapist. The target audience for the MOUD ECHO is the entire clinic, including potential buprenorphine prescribers (Physicians, Nurse Practitioners, and Physician Assistants) and other practice staff. For prescribers, the content is geared toward those who have never prescribed buprenorphine and those treating up to 30 patients. Advertising for the MOUD ECHO and study recruitment includes email, fax, and phone calls to clinics; in-person clinic recruitment, use of local practice-based research networks and associated listservs, word of mouth, and placement on the Project ECHO internet home page. MOUD ECHO sessions are held Tuesdays 12–1pm, and are split between 30 minutes of didactic and 30 minutes for case presentation and discussion. There is no fee for providers to participate. Continuing Medical Education (CME) and Continuing Education Units (CEU) credits are offered for all sessions and anyone requesting these completes a brief post session questionnaire assessing knowledge and usefulness of the session related to MOUD expansion.

The research components focus on rural primary care providers in New Mexico. These voluntary components include documentation of ECHO session participation and conducting qualitative interviews to understand barriers to attendance and usefulness of sessions for startup or expansion of buprenorphine treatment. Qualitative interviews were conducted via telephone and digitally recorded, professionally transcribed, and coded by an expert in qualitative research to identify major themes. Clinic staff and providers who are not eligible to participate in the study (e.g. urban settings, non-primary care, those with more than 30 patients on buprenorphine) are invited to join in the sessions but do not participate in research components. This study was approved by the Human Research Protections Office at the University of New Mexico.

Overview: MOUD ECHO

Table 1 provides an overview of MOUD ECHO curriculum content. This includes the eight core sessions (shaded in Table 1), and four rotating lectures to keep content fresh each cycle (shown in italics). All content is evidence-based and designed to address several known barriers to MOUD expansion (listed at top of Table 1). Every 12-session cycle is comprised of six prescribing sessions, three sessions focused on psychosocial treatment, and three that focus on clinic functioning. The six prescribing sessions include an overview of FDA approved medications (buprenorphine, methadone, naltrexone), four hours of the required Eligibility Waiver Training (DATA 2000), specifics of formulation and dosing, treatment of co-occurring psychiatric illnesses, best practices with special populations, and management of acute and chronic pain. Psychosocial support sessions introduce the stages of change model and overview of Motivational Interviewing, Cognitive Behavioral Therapy and relapse prevention, and principles of the Community Reinforcement Approach for adults and adolescents. Clinic functioning sessions cover screening, assessment and monitoring; brief intervention techniques; understanding and building a team-based approach to care, and harm reduction.

Table 1.

Twelve session ECHO curriculum & relationship to implementation barriers.

Known barriers to implementation: (1) negative attitudes of persons with substance use disorder and low motivation to treat; provider stigma; (2) lack of access to psychosocial supports; (3) lack of coordination w/ broader health care community; (4) limited resources for initiation; on-going financing; (5) limitations in knowledge, skills, experience; certification & on-going training/support
Session focus: P = prescribing, T = therapy, CF = clinic functioning
Topic	Description	Barriers
Overview of OUD and treatments (P)	Overview of opioid use disorder, history, epidemiology, treatment; approved medications; psychosocial components	1, 3, 5
Harm reduction (CF)	A key educational component is helping providers to understand harm reduction (e.g. less harmful opioid use rather than abstinence) and how to work with patients with this treatment goal.	1, 5
Waiver eligibility training (P)	4.5-Hour interactive waiver training component required by Drug Enforcement Agency to prescribe buprenorphine. Additional required modules must be completed online	1, 2, 3, 4, 5
Screening and assessments (CF)	Screening and assessment tools for substance use disorder and how to diagnose; difference between screening and confirmatory drug tests, as safety-monitoring (e.g. liver function); use of the prescription drug monitoring report; alternatives for stigmatizing language	1, 3, 4, 5
Stage of change; intro to motivational interviewing (T)	Understanding the stages of change model and how it applies to patient interactions; “101” motivational Interviewing training overview and its role in opioid treatment	1, 2, 5
Details of formulation and dosing of buprenorphine (P)	Efficacy of detoxification vs. maintenance treatment; steps involved in in-office and at-home inductions; managing precipitated withdrawals; choosing maintenance dose; optimal duration of treatment. The “nitty gritty” details.	1, 4, 5
Team based approach (CF)	How to utilize the team approach to leverage limited resources; members of the treatment team and their roles; role of the prescriber; putting the team based approach into practice; billing codes for buprenorphine/naloxone; naltrexone; behavioral therapies; activation of additional billing codes	1, 3, 4, 5
Treatment of co-occurring psychiatric illnesses (P)	Considerations and treatment of persons with co-occurring mental health disorders, e.g., anxiety, depression. attn. to benzodiazepines and possible dangerous combinations; alternative treatments for anxiety (pharmacological and nonpharmacological)	1, 2, 3, 4, 5
Cognitive behavioral therapy/Relapse prevention (T)	Relapse prevention strategies as outlined by Alan Marlatt, including refusal skills, avoiding high risk situations, tolerating cravings, apparently inconsequential decisions, abstinence violation effect, and outcome expectancies	1, 2, 4, 5
Management of acute and chronic pain (P)	Stigma and how it may impact pain management in patients with Opioid Use Disorder; basic principles of managing both acute and chronic pain in patients on methadone, buprenorphine, and naltrexone	1, 3, 5
Concerned significant others and family intervention (T)	Introducing the importance of including family and concerned significant others; concrete techniques for engaging and including concerned significant others in treatment	1, 2, 4, 5
Best practices for prescribing with special populations (P)	Best practices for treating adolescents, pregnant women, postpartum women, as well as individuals with co-occurring medical illnesses, including hepatitis C, HIV, liver/renal dysfunction	1, 2, 3, 4, 5

Sessions in italics can rotate, replacing these with sessions below in same category (P, T, or CF).

Primary care providers and staff can join the ECHO at any point in the cycle and can continue after the cycle is completed, allowing access to missed sessions and ongoing support. To ensure every 12-session cycle contains new topics for participants who join beyond the 12 weeks, the four italicized sessions in Table 1 can be replaced with new content each cycle. Table 2 provides a list of additional lectures that can be “rotated in” to any 12-session cycle to replace the non-core lectures (i.e. those in italics). In order to ensure the cycle always has six prescribing, three therapy, and three clinic functioning lectures, new lectures rotated in must be from the same category as the one being replaced. For example, “Harm Reduction” in Table 1 is a rotating topic in the Clinic Functioning category. Therefore, this lecture can only be replaced with one of the other Clinic Functioning lectures shown in Table 2. In the current MOUD ECHO, all four of the italicized lectures are replaced with new lectures each cycle. The choice of exactly which additional lecture to rotate in can simply follow in the order in which they are listed in Table 2. However, it is acceptable for choices to be made by the clinical team based on ECHO discussion and questions. For example, if participants are asking questions about how to work with pregnant women, the clinical team may choose to rotate in the lecture that focuses on this topic in the next cycle.

Table 2.

Rotating didactic lectures.

Prescribing
Benzodiazepines in a primary care setting	Distinguishing between therapeutic and non-therapeutic benzodiazepines; understand different approaches to tapering benzodiazepines among patients; adjunctive methods to help with benzodiazepines detoxifications.
Diversion management plan in office-based setting	Reasons for use of diverted buprenorphine. Understand components of preventing diversion. Creating practical plan for monitoring and responding to possible diversion
Managing co-occurring stimulant disorder	Prevalence of stimulant use disorder in patients in treatment for Opioid Use Disorder. Use of stimulants not absolute contra-indication for Medications for Opioid Use Disorder. Evidence-based interventions for stimulant use disorders
Managing co-occurring alcohol use disorder	Signs and symptoms of alcohol withdrawal syndrome. Practice protocols to properly manage alcohol withdrawals. Approved medications and evidence-based psychosocial interventions for treatment of alcohol use disorder
Co-occurring medical diagnoses	Medical screening tests and vaccinations recommended for persons with Substance Use Disorder; physical problems that may arise due to alcohol, tobacco and other substance use; potential effects of substances on pregnancy and fetal development; treatment options.
Pregnancy and postpartum care of women with opioid use disorder	Prevalence of Opioid Use Disorder in pregnancy; screening recommendations; risks of Opioid Use Disorder in pregnancy; treatment with buprenorphine; prenatal care; labor and management; Neonatal Opioid Withdrawal Symptoms
Therapy
Trauma disorders and trauma informed care	Introduction to trauma exposure and associated disorders; recommended treatments for trauma exposed individuals with co-occurring substance abuse.
Role of group in effective treatment of OUD	Review of best practice therapeutic approaches for developing and implementing group therapy with the OUD population.
Treatment planning and ASAM criteria	Review of the gold standard placement criteria from American Society of Addiction Medicine and how to apply this tool for determining level of care; review of best practice approaches to treatment planning and how to use treatment planning to move patients up and down in levels of care and move toward recovery goals.
Harm reduction	Introduction to the harm reduction model and where medication for opioid use disorder treatment fits within that model; review of specific interventions to be used within a harm reduction model.
Risk assessment and crisis planning:	Introduction to best practice risk assessment processes for suicidal and homicidal risk, warning signs and protective factors; introduction to the 5 factor, 5 step model of risk assessment and review of the purpose and process of crisis planning for increase safety.
Community reinforcement approach for adults and for adolescents.	Introduction to community reinforcement approach for adults and adolescents. Functional analysis of substance use and of prosocial behavior, happiness scales; functional goal setting and tracking, goal formation, leisure questionnaire, relationship happiness scale, communication skills.
Clinic functioning
Confidentiality and office-based opioid treatment	Spirit behind confidentiality regulations pertaining to buprenorphine treatment. Pros and cons of heightened confidentiality requirements; basics of 42 Code of Federal Regulations Part 2.
Concerns and questions: Drug Enforcement Agency and billing	Overview of common billing mistakes and how to bill for all aspects of medication assisted treatment. Concerns with Drug Enforcement Agency involvement and review of their role guest presenters: Drug Enforcement Agents & State Medicaid staff.

Results

Participation

Sixty-seven primary care providers and staff across 27 rural clinics in New Mexico consented into the study between December 2017 and August 2019 (see Table 3; study enrollment ongoing). Thirty-two were early prescribers or potential prescribers of buprenorphine (Physicians, Nurse Practitioners, and Physician Assistants). Most prescribers who joined did not have their DATA waiver (n = 17), while seven had the waiver but were not prescribing, and eight had started prescribing. Thirty-five non-prescribers also participated. This included any other clinic staff who were not in the “prescriber” category such as therapists, counselors, case managers, medical assistants, administrators (leadership as well as clinic support staff), community support workers, and front desk staff. Attendance was tracked for all participants during their first 12-week cycle (one full ECHO cycle) and average attendance overall was 4.1 sessions. For prescribers only (excluding other clinic staff) attendance was slightly higher at 5.0 sessions.

Table 3.

Participant demographics in MOUD ECHO December 2017 through August 2019.

	All N (%)	Prescribers N (%)	Non-prescribers N (%)
Totals	67	32 (47.76)	35 (52.24)
Gender
Male	21 (31.34)	16 (50.00)	5 (14.29)
Female	46 (68.66)	16 (50.00)	30 (85.71)
Race
AI/AN	1 (1.49)	1 (3.13)	0 (0.00)
Asian	2 (2.99)	2 (6.25)	0 (0.00)
Black, African American	3 (4.48)	3 (9.38)	0 (0.00)
Native Hawaiian, Pacific Islander	1 (1.49)	0 (0.00)	1 (2.86)
White Hispanic	21 (31.34)	4 (12.50)	17 (48.57)
White Non-Hispanic	35 (52.24)	21 (65.63)	14 (40.00)
Other	4 (5.97)	1 (3.13)	3 (8.57)
Ethnicity
Latino, Hispanic	23 (34.33)	6 (18.75)	17 (48.57)
Rural	67 (100)	32 (47.76)	35 (52.24)
Prescriber degree Medical doctor		12 (37.50)
Physician’s assistant		5 (15.63)
Nurse practitioner		14 (43.75)
Doctor of osteopathic medicine		1 (3.13)
Non-presciber role
Medical assistant			6 (17.14)
Nurse			5 (14.29)
Administrator			8 (22.86)
Community health worker			1 (2.86)
Therapist/Social worker			7 (20.00)
Front office			2 (5.71)
Peer support worker			1 (2.86)
Other			5 (14.29)
MOUD experience (at baseline)
No data waiver		17 (53.13)
Had waiver, but not prescribing		7 (21.88)
Prescribing to 1 or more patients		8 (25.00)

Qualitative interviews

The research team attempted to contact all 67 study participants after their first 12-week cycle to complete the post ECHO cycle interview (Table 4). Fifty-three providers completed the interview (79%). Interview feedback was highly positive. Major themes identified included strong endorsement of the ECHO session topics/content. One prescriber said that the sessions helped to address previous concerns with prescribing, “They’ve been great sessions and really opened my eyes to prescribing medications and how to treat the patient, so really changed my mind on preexisting fears I had on Suboxone.” Participants also appreciated accompanying session materials and hearing from peers, as per the ECHO model, “I find them [sessions] to be very helpful. I think what I appreciate the most is the articles that support the presentations or even the power points … also, just hearing my peers (Prescriber).” Participants also emphasized the importance of the case-based patient presentations and discussion, noting that having multiple prescribers and staff from diverse primary care settings in the sessions helped translate the session content through the discussion, “Someone asks the questions, and that leads into a discussion on how to treat this patient, and I liked when everyone kind of gets involved with it (Prescriber).” Further, participants noted that the ease of access to the online sessions was essential for rural practices, “I would say it was helpful because it gave me access. I might not have been able to participate if I had to drive to do it (Non-prescriber).” The vast majority participants said that the 1-hour ECHO was an appropriate timeframe. Feedback that was less positive did not pertain to the content of the session but rather to barriers to attending. Participants struggled with weekly attendance given patient care challenges, other competing demands in their practice settings, and lack of support to attend from clinical leadership/medical directors. For example, one prescriber commented, “If we are … still in with a patient, were going to be paying attention to that first. This [ECHO] will obviously take second.” Work conflicts were common across prescribers and other clinic staff. There were no negative comments about the ECHO, but a few minor suggestions to improve it, such as shorter time frame (45 min) and preferring to hear from the experts rather than other providers and clinic staff during the case presentation and discussion period.

Table 4.

Qualitative interview questions^*.

Please tell me about your experience attending the ECHO sessions. What ECHO sessions did you find useful for supporting your implementation of MAT and how was that session helpful to you/your clinic? ECHO sessions last about 1 hour. Is that about the right amount of time for the sessions? Please explain why or why not. ECHO sessions have time for learning (didactic), as well as time to learn from real cases and to get consultation. Which aspect did you like the best? What was most useful for you? Please tell me what you think about the sessions being available online – in what ways is the online format helpful? In what ways was it not helpful? In order to help other providers participate in ECHO MAT sessions successfully, can you tell us in a bit more detail about some of the barriers you faced in attending?

^*At time of interviews, the term MAT was the preferred term by the research funder to describe medications for opioid use disorder, combined with psychosocial treatment and community recovery support.

CME and CEU post session questionnaires

Continuing Medical Education (CME) and Continuing Education Units (CEUs) post-session questionnaire results were also highly positive (Table 5). These were collected after each session from any person who requested CMEs or CEUs and includes both prescribers (CME responses, n = 120) and other clinic staff (CEU responses, n = 166). We gathered a total of 286 CME and CEU post session questionnaires. Responses were anonymous. The vast majority of providers requesting CMEs agreed or strongly agreed that the concepts and materials presented were “relevant to my work” (99%), the sessions “prepared me to apply the concepts to my work” (99%), and that they “planned to implement one new idea/intervention from what I learned within the next three months” (97%). Those requesting CEUs had similar positive responses, agreeing or strongly agreeing that “confidence in my abilities related to the discussion improved” (96%), “I learned a lot about the topic that I can use next time I see an individual with a similar problem” (95%) and “information from this activity will be incorporated into my practice within the next month” (89%).

Table 5.

Continuing education evaluation feedback December 2017–August 2019.

CME	The concepts and materials presented are relevant to my work.		These sessions have prepared me to apply the concepts to my work		I plan to implement one new idea/intervention from what I learned within the next three months
	N	%	N	%	N	%
No response, NA	0	0	0	0	0	0
Disagree, strongly disagree	1	1	1	1	4	3
Neither agree nor disagree	0	0	0	0	0	0
Agree, strongly agree	119	99	119	99	116	97
Total	120	100	120	100	120	100
CEU	My confidence in my abilities related to the discussion topic improved.		I learned a lot about the discussion topic that I can use next time I see an individual with a similar problem.		Information from this activity will be incorporated into my practice within the next month
	N	%	N	%	N	%
No response, NA	4	2	5	3	16	10
Disagree, strongly disagree	3	2	3	2	3	2
Neither agree nor disagree	0	0	0	0	0	0
Agree, strongly agree	159	96	158	95	147	89
Total	166	100	166	100	166	100

Discussion

This report describes the MOUD ECHO curriculum and presents evidence of the acceptability and feasibility of this approach to expand OUD treatment using buprenorphine, psychosocial treatments and supports in rural primary care. The comprehensive nature of the curriculum highlights that expansion of this treatment includes prescribing, therapy, and clinic functioning with competence developed over time with ongoing support. Given the complex nature of this treatment, participating in education and support venues to expand MOUD may help to increase access to this treatment, help reduce associated morbidity and mortality and address the growing opioid public health crises. Such associated morbidity and mortality includes rising transmission of infectious disease through needle use, increasing numbers of children needing foster care after caregiver overdose death, and the growing need for opioid treatment in underserved rural areas with workforce shortages.¹⁶ There are recently completed studies that examine the impact of educational and support interventions on expansion of use of MOUD, and associated psychosocial treatments and supports, on increased access to treatment. For example, one study is examining Medicaid claims data to show increased treatment access and other health outcome measures such as rates of OUD¹⁷ (Cochran et al., 2019). Forthcoming publications from these studies will help further assess the impact of these types of interventions on access to care.

Provider feedback and engagement in the MOUD ECHO are positive indications of acceptability and feasibility, two important implementation outcome measures.¹⁸ Regarding acceptability, or the perception among implementation stakeholders that a given practice is agreeable/palatable, feedback was overwhelmingly positive, from both prescribers and non-prescribers. Regarding feasibility, or the extent to which a new treatment or innovation can be successfully integrated into practice (in this case, the ECHO model), the participation of 67 providers across 27 clinics provides evidence of the feasibility to engage rural primary care providers. However, results also showed that participants overall attended a third of the full cycle’s 12 sessions (4/12), with attendance among prescribers being slightly higher (5/12). Given the barriers to attendance obtained from the qualitative interviews, particularly clinical duties and patient care, these data present important threats to the feasibility of this model to expand treatment using MOUD, and associated psychosocial treatments and recovery supports. In considering this, it is important to understand that the ECHO model is not designed to require or even expect attendance at every session. Rather, sessions are an opportunity for providers to build their capacity through learning new information, obtaining specialized consultation, and participating in facilitated clinical reasoning. Variation in attendance is common in ECHO clinics.^19,20 For example, in the Integrated Addictions and Psychiatry ECHO (IAP) implemented in New Mexico starting in 2005, less than half of all participants attended more than one session¹⁵. Similarly, Tofighi et al, report the average participation in their OUD ECHO at just over half of the sessions.²¹ Attendance is impacted by factors such as previous training, experience, and interest in the session topic, work conflicts and patient care. Therefore, understanding the relationship between participation and actual implementation of MOUD —including buprenorphine prescribing and adding new patients—is of critical importance. This is the primary implementation outcome of the larger 5-year study for which the MOUD ECHO was developed. This component of the research collects data on accomplishment of five key implementation benchmarks associated with expanding MOUD including obtaining the waiver, obtaining the license, starting to prescribe, and adding additional patients onto the provider’s MOUD panel. Understanding the impact of participation levels (number of sessions attended) on buprenorphine prescribing in a dose-response analysis will fill an important gap in the literature on the impact of the ECHO model on expansion of buprenorphine treatment in rural primary care. Indeed, the Tofighi study is the only published study evaluating the effects of an ECHO model specifically designed to provide primary care providers with support and training in the treatment of OUD and found minimal improvements buprenorphine prescribing.²¹

The present study’s qualitative analyses revealed that the main reason for missing sessions was conflict with clinical/work duties/lack of time, which is consistent with barriers reported in prior studies.¹⁴ Therefore, holding sessions during the lunch hour and providing CMEs and CEUs were important steps to encourage participation given clinical demands. However, structural barriers such as provider lack of time is not easily addressed by the MOUD ECHO, nor in fact any training and support intervention, whether in-person or online. Structural barriers to attendance in ECHO sessions may be better addressed through policy changes such as allowing providers to bill for time spent in training and consultation and linking incentives to patient outcomes and care quality, rather than fee for service models. A more detailed description of participation in this MOUD ECHO, challenges and recommendations to enhance engagement has been previously published.²²

The results of this study should be considered in the context of limitations. First, qualitative feedback only represents 80% of study participants. Therefore, it is possible that participants who did not complete the interview maintain different perspectives than results reported for interviewees. Furthermore, highly positive CME and CEU responses reflect only persons who requested these credits and therefore do not represent feedback from everyone who attended the ECHO session and did not request these credits. The study also has notable strengths. It contributes to limited research literature concerning feasibility and acceptability of the ECHO model to expand treatment for MOUD supported by evidence from qualitative interviews, surveys and participation data. Further, it provides the context for the ongoing study examining the impact of this ECHO on MOUD implementation. Finally, it presents the MOUD ECHO curriculum in detail to help support other providers and health systems to develop and implement similar ECHOs to support ongoing MOUD expansion. PowerPoints and didactic recordings for the main 12 sessions, and many of the rotating lectures, are available upon request to help other clinics develop similar ECHO supports to help expand this treatment in local settings.

While other ECHOs have been developed to address substance use disorders and MOUD specifically, many of these are developed to serve particular healthcare systems or research studies and are not publically accessible or published which makes it challenging to compare these with the MOUD ECHO. Many publications of similar ECHOs report on short term outcomes like knowledge gained or self-efficacy, but not on implementation outcomes such as acceptability, feasibility, and tracking specific changes in prescribing. For example, Sockalingam et al. describe using the ECHO model to significantly improve knowledge of treating mental illnesses and substance use disorders among primary care providers.²³ Exceptions include the IAP ECHO that reported similar variation in participation, a measure of feasibility.¹⁵ However, key differences in the IAP study were that participation in IAP was limited to Federally Qualified Health Centers involved in the study, was longer in duration (2 hours) and more broadly focused on behavioral health disorders. Also, the OUD ECHO study by Tofighi et al. was implemented with urban, publically funded primary care provider sites rather than in rural settings. Although the Tofighi study found that ECHO was feasible to implement and reported similar attendance to our study, differences include participation mainly from physicians (there were no non-prescribers) and finding only minimal improvements in buprenorphine prescribing.²¹ Findings from our larger MOUD ECHO study will contribute to this limited literature through its tracking buprenorphine prescribing over a two year period, providing important implementation data to inform our understanding of the role of the ECHO model in expansion of MOUD treatment in rural primary care.

Data availability statement

Data for this manuscript can be made available upon reasonable request to the corresponding author.