Collaborative care model involving physicians, pharmacists improves OUD outcomes
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A collaborative care model that utilizes buprenorphine-waivered physicians and community pharmacists was associated with high rates of opioid use disorder treatment retention and adherence, results of a pilot study showed.
The model was also well-received from participating pharmacists, physicians and patients, according to the study authors.
Less than 10% of primary care physicians in the United States have a waiver to prescribe buprenorphine, Li-Tzy Wu, DSc, MA, behavioral sciences director of the Duke Community Based Substance Use Disorder Research Program, and colleagues reported. A previous study showed that, among rural physicians, fewer than one in three with a waiver actually prescribe the medication.
“Provider capacity and treatment access barriers could be addressed by pharmacists,” Wu and colleagues wrote in Addiction.
During the pilot study, the researchers investigated the feasibility of transferring patients’ monthly buprenorphine treatment and maintenance care from their physician’s office to a community pharmacist for 6 months. Before doing so, they developed an operational care agreement to specify the specific roles of physicians and pharmacists. This document indicated that buprenorphine-waivered physicians were responsible for reviewing patient assessments, prescribing buprenorphine, keeping records for DEA inspections and offering clinical guidance and supervision to the pharmacist — as needed — for managing buprenorphine treatment and follow-up.
“Therefore, physicians no longer spent time in personal interaction with patients monthly, unless needed,” Wu and colleagues wrote.
Physicians also checked prescription drug monitoring programs (PDMP) for indications of opioid use diversion.
The pharmacists completed six 1-hour training modules and eight 1-hour face-to-face coaching meetings with physicians to review and discuss OUD care, processes and protocol-specific training. After patients provided consent, their prescription and maintenance care were transferred to pharmacists.
Six physicians from three clinics, six pharmacists from three community pharmacies and 71 adults who met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for OUD participated in the study, according to the researchers.
Wu and colleagues reported that after 6 months, 88.7% of patients were still enrolled in the study and 93.5% adhered to their buprenorphine regimen. No opioid-related ED visits, retention issues or safety events were reported. Pharmacists used the PDMP at 96.8% of visits. Only 4.9% of 61 urine drug screens collected during the study came back positive.
In addition, 93.7% of patients said they were very satisfied with the overall study experience, 90.5% were very satisfied with the quality of treatment offered, 96.8% felt treatment transfer from physician’s office to the pharmacy was not difficult and 95.2% said holding buprenorphine visits at the same place the medication is dispensed was very or extremely useful/convenient. These percentages were 100%, 100%, 83.3% and 100%, respectively, among the pharmacists and physicians.
“Overall success of this pilot trial offers strong support for a physician–pharmacist collaborative care model to help improve buprenorphine treatment access for OUD,” Wu and colleagues wrote. “Future randomized trials are needed to test the efficacy, effectiveness and implementation of physician–pharmacist collaborative care models for management and treatment of patients with OUD as part of real-world practice.”
Perspective
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Patients with untreated OUD remain a considerable health care concern and, undoubtedly, treatment access is a significant underlying reason. Buprenorphine, introduced about 20 years ago, fostered the ability to move addiction treatment from methadone clinics to physicians’ offices.
In order to prescribe buprenorphine from one’s office, a physician has to complete a training course and waiver examination, limiting acceptance of this practice. The vast majority of prescribing capacity (eg, waivered providers) is underutilized, though it is not clear if this is due to disinterest among potential patients or among potential prescribers. Trump’s administration had announced plans to remove the waiver requirement. However, mainstream media reports indicate Biden’s administration will not move forward with those plans.
In the recent pilot feasibility study by Wu and colleagues, the authors looked to expand the availability of buprenorphine treatment by enlisting the collaboration of community pharmacists. In this role, after evaluation by a credentialed and waivered physician, the pharmacist would take on the administrative responsibilities normally expected of the provider. These include assessing medication adherence and diversion, screening for ongoing substance use, and evaluating therapeutic effectiveness. They found, in their highly selected population of enrolled patients, that over a 6-month period, pharmacists were able to provide this care and that patients were highly satisfied. The study has several significant limitations, however, such as the lack of a control group, a low-risk patient population, and no true assessment of medication compliance other than patient declaration through “pill counts.”
Even if accurate, many questions remain about the study findings and the ability to take their successful outcome to the next level. Will community pharmacies be eager to participate in such a program? Do they have the time, skills and interest? Pharmacies have taken on the task of vaccine administration, but this is a well-compensated activity in a non-stigmatized population. Given the relatively poor health care coverage of patients with OUD, and the bias often expressed towards this population, gaining acceptance may not be as easy.
Are pharmacists truly prepared to interpret urine drug screen results and clinically assess patients’ ongoing mental health, substance use and treatment effectiveness? Would it be more cost effective to expand primary care office visits for patients with OUD? With the recent change in the buprenorphine waiver regulations, will this last option be increasingly accepted? Does medication treatment, without the wraparound of counseling and support provided by treatment programs, provide sufficient improvement in outcome, which in this case is remaining free from opioid use?
This study suggests that physician-pharmacist collaboration may be applicable, though likely in very select situations.
Professor and chair, department of emergency medicine and director, division of medical toxicology, Rutgers New Jersey Medical School
Chief of service in the ED at the University Hospital of Newark
Senior consultant, New Jersey Poison Information and Education System
Perspective
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There are a finite number of physicians who are qualified to provide buprenorphine treatment. This study, by utilizing pharmacists with their specific training and added expertise, describes a novel and interesting way to way to address the ongoing opioid epidemic.
Therefore, Wu and colleagues’ intervention is likely to be successful in settings outside of the ones studied in this particular paper.
Medical director, Rowan Family Medicine, N.J.
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