Variations in evidence-based clinical practices in nine United States Veterans Administration opioid agonist therapy clinics

https://doi.org/10.1016/j.drugalcdep.2004.01.009Get rights and content

Abstract

Background: Opioid agonist therapy (OAT) for opioid dependence has a strong evidence base, but clinical practice often does not conform to evidence-based practices. The goal of the OpiATE Initiative is to improve patient outcomes by implementing four evidence-based practices in United States Veterans Administration OAT clinics: (1) long-term maintenance orientation, (2) adequate dosing, (3) adequate counseling, and (4) use of contingency management.

Methods: The OpiATE monitoring system (OMS) was developed to help clinics assess concordance with evidence-based practices. For each patient, counselors record current agonist dose, recent counseling frequency, length of treatment, and urine toxicology results. For patients with sub-standard agonist doses, an algorithm was used to determine if the current dose was clinically appropriate. Maintenance orientation was assessed using the abstinence orientation scale.

Results: Concordance with counseling recommendations was uniformly high, concordance with maintenance orientation and dosing recommendations varied widely across clinics, and concordance with contingency management principles was low. Abstinence orientation scores were negatively correlated with dose and patient retention. Dose was negatively correlated with percent of urine screens positive for non-medical opioids and other illicit substances.

Conclusions: The OMS was well accepted by clinic staff. Wide variability in clinical practices and outcomes across clinics supports the importance of individualizing quality improvement strategies to address specific performance gaps.

Introduction

In 1998, the Health Services Research and Development Service of the United States Veterans Health Administration (USVA) launched a national initiative, the Quality Enhancement Research Initiative (QUERI), to improve patient outcomes and quality of life through implementation of evidence-based clinical practice guidelines. Eight disease groups, one of which was substance use disorders, were chosen based on their frequency, and the severity and cost of the disability they caused (Demakis et al., 2000). The QUERI Substance Use Disorder Module (QSUD) chose opioid agonist therapy (OAT) as the first focus of efforts to translate research into practice. Opioid agonist therapy (OAT) has considerable evidence supporting its effectiveness and its cost effectiveness (Ball and Ross, 1991, Barnett, 1999, Ling et al., 1998, Marsch, 1998, Newman and Whitehill, 1979, Zaric et al., 2000). Evidence has also accumulated concerning the contribution to patient outcomes of specific practices within OAT programs (Caplehorn, 1994, Hartel et al., 1995, McGlothlin and Anglin, 1981, McLellan et al., 1993, Sees et al., 2000, Stitzer et al., 1992). Available evidence suggests that implementation of these practices varies across OAT programs (D’Aunno and Vaughn, 1992, D’Aunno and Pollack, 2002, Hamilton and Humphreys, 1996). This discrepancy between the evidence base and clinical practice along with the relatively small number and contained nature of OAT programs within the USVA made OAT an ideal candidate for QSUD to begin its quality improvement process. The opioid agonist therapy effectiveness (OpiATE) Initiative was launched in the spring of 2001 as a research demonstration project to develop and evaluate methods for translating evidence-based OAT practices.

One key goal of the OpiATE Initiative is to improve outcomes for patients enrolled in USVA OAT programs through implementation of evidence-based OAT practices. Patient retention and percentage of urine screens positive for illicit opioids were selected as outcome measures because they are easy for programs to measure, changes in program practices should directly produce change in these outcome measures, and they are predictive of longer-term outcomes such as increased psychosocial and physical well-being and decreased mortality (Cacciola et al., 1998, del Rio et al., 1997, Morral et al., 1997, Morral et al., 1999). Four specific practices within OAT have a solid evidence base and have been demonstrated to affect these patient outcomes. These four practices are: (1) maintenance orientation, where patients are encouraged to continue receiving OAT as long as it is beneficial rather than being encouraged to discontinue it (Caplehorn et al., 1998, Gossop et al., 2001, Magura and Rosenblum, 2001, Sees et al., 2000), (2) use of adequate opioid agonist doses (Caplehorn et al., 1993a, McGlothlin and Anglin, 1981, Strain et al., 1993, Strain et al., 1999, (3) adequate counseling support (Broome et al., 1999, Hser, 1995, Joe et al., 1999, Magura et al., 1998), and (4) systematic application of contingency management principles (Rowan-Szal et al., 1994, Silverman et al., 1996, Stitzer et al., 1980, Stitzer et al., 1992). In this paper, we describe the baseline profiles of nine USVA OAT clinics with respect to these four practices.

Section snippets

Recruitment of clinics

Out of a total of 34 USVA OAT clinics existing at that time, eight sites were eliminated because they were participating in another study and one site was eliminated because it was at the principal investigator’s institution. Among the remaining 25 sites, 11 were chosen based on existing data from a periodic survey of USVA OAT clinics regarding clinic size, geographic location, and average opioid agonist dose (Hamilton and Humphreys, 1996). An attempt was made to achieve a sample that

Clinic demographics

Nine USVA OAT clinics participated in the OpiATE Initiative. The clinics represent various geographic locations including east coast, mid-west, and west coast. As with the majority of OAT clinics, all are located in metropolitan areas. The clinics serve from 44 to 211 patients, with a mean patient population of 131 (S.D.=65). USVA OAT clinics in general have a mean patient population of 140 (S.D.=103,min=8,max=405), indicating that our sample includes clinics with a restricted size range

Discussion

Wide variability in policies and practices exists within nine USVA opioid agonist therapy clinics. These results indicate that the surveyed clinics generally met or exceeded recommendations for counseling frequency. Most clinics had a mix of staff that supported a maintenance orientation and staff that supported an abstinence orientation indicating room for improvement within USVA OAT clinics which could perhaps best be addressed by increased education and training on the benefits of methadone

Acknowledgments

This work was supported by grant number SUT01-035-1 from the Health Services Research Division of the US Veterans Administration. The opinions expressed here are those of the authors, and do not represent those of the Veterans Administration. The authors would like to extend their thanks to the following OAT clinic staff members for the time and effort that they contributed to participation in the OpiATE Initiative: Fatmatta Alhusain, Frank Aviles, Elizabeth Caliboso, Donald Calsyn, Paul

References (45)

  • M.L Willenbring et al.

    Evidence-based clinical practice guidelines in substance use disorders: a survey of VA substance abuse treatment program leaders

    J. Subst. Abuse Treat.

    (2004)
  • Ball, J.C., Ross, A., 1991. The Effectiveness of Methadone Maintenance Treatment. Springer Verlag, New...
  • P Barnett

    The cost-effectiveness of methadone maintenance as a health care intervention

    Addiction

    (1999)
  • J.S.A Cacciola et al.

    The early course of change in methadone maintenance

    Addiction

    (1998)
  • J.R Caplehorn

    A comparison of abstinence-oriented and indefinite methadone maintenance treatment

    Int. J. Addict.

    (1994)
  • J.R Caplehorn et al.

    Methadone dose and heroin use during maintenance treatment

    Addiction

    (1993)
  • J.R Caplehorn et al.

    Measuring and comparing the attitudes and beliefs of staff working in New York methadone maintenance clinics

    Subst. Use Misuse

    (1997)
  • J.R Caplehorn et al.

    Attitudes and beliefs of staff working in methadone maintenance clinics

    Subst. Use Misuse

    (1996)
  • J.R Caplehorn et al.

    Physicians’ attitudes and retention of patients in their methadone maintenance programs

    Subst. Use Misuse

    (1996)
  • J.R Caplehorn et al.

    Clinic policy and retention in methadone maintenance

    Int. J. Addict.

    (1993)
  • T D’Aunno et al.

    Changes in methadone treatment practices: results from a panel study, 1988–1995

    Am. J. Drug Alcohol Abuse

    (1999)
  • T D’Aunno et al.

    Changes in methadone treatment practices: results from a national panel study, 1988–2000

    J. Am. Med. Assoc.

    (2002)
  • Cited by (33)

    • Evidence of validity and reliability of the Opiate Dosage Adequacy Scale (ODAS) in a sample of heroin addicted patients in buprenorphine/naloxone maintenance treatment

      2018, Drug and Alcohol Dependence
      Citation Excerpt :

      Therefore, the clinician’s aim should not be to give all patients the highest possible dose of buprenorphine, but rather to provide each individual with a dose that 1) allows the patient to stop the continued use of heroin, 2) provides opioid blockade according to the patient’s individual tolerance level, and 3) suppresses both objective and subjective opiate withdrawal symptoms (OWS) and significantly reduces craving (as measured by ODAS). In many patients, all these effects can be achieved at doses lower than those recommended in these meta-analyses, especially in patients whose clinical condition has stabilized after a period of time in the maintenance program (Willenbring et al., 2004). The second clinical application of ODAS would be as an adjunct in routine clinical practice to guide the B/N dose adjustment on an individual basis.

    • Contingency Management Abstinence Incentives: Cost and Implications for Treatment Tailoring

      2017, Journal of Substance Abuse Treatment
      Citation Excerpt :

      The current results show that two-thirds of the expenditures for an abstinence incentive program were paid to individuals entering the study with a negative urine toxicology or breath alcohol test, a group whose outcomes were not significantly improved compared to standard treatment controls by exposure to an abstinence incentive intervention delivered as part of the computer-assisted therapeutic education system. These results are important because CM implementation is limited by perceived costs (Benishek et al., 2010; McGovern et al., 2004; Willenbring et al., 2004). These data suggest that the overall effectiveness of CM interventions may be improved by tailoring treatments based on early treatment drug use status.

    • A Pressing Need for Pharmacotherapy Development to Treat Drug Addiction. An Editorial from a Legal Perspective

      2016, International Review of Neurobiology
      Citation Excerpt :

      Importantly, experimental studies have found that the combination of medication and counseling is more effective than counseling alone at preventing relapse (Hesse & Pederson, 2008; USDHHS, 2015c). Also, the retention rate for MAT is greater than the retention rate for either counseling or 12-step groups (Caplehorn, 1994; Caplehorn, MacNeil, & Kleinbaum, 1993; Trautmann & Wittchen, 2012; Willenbring, Hagedorn, & Postier, 2004). Unfortunately, all medications for treating opiate dependence are underutilized by opiate-dependent individuals in the United States, underprescribed by physicians, rarely available within in-patient rehabilitation centers, rarely used within prisons (Nunn et al., 2009), and underused within drug courts (Matusow et al., 2013; NADCP, 2011; SAMHSA, 2014).

    • The cost of concordance with opiate substitution treatment guidelines

      2010, Journal of Substance Abuse Treatment
      Citation Excerpt :

      Despite these limitations, the MOST study identified the potential impact of interventions to improve the guideline concordance of opioid substitution treatment programs, such as the successful effort of the VA Quality Enhancement Research Initiative (Willenbring, Hagedorn, Postier, & Kenny, 2004).

    View all citing articles on Scopus
    View full text