Champions Among Us: Leading Primary Care to the Forefront of Opioid Use Disorder Treatment

Internal Medicine Resident Addiction Training at the Veteran's Health Administration: A Qualitative Evaluation of Site Directors' Response to the 2022 ACGME Requirements

BACKGROUND

Substance use disorders (SUDs) are prevalent in the USA yet remain dramatically undertreated. To address this care gap, the Accreditation Council for Graduate Medical Education (ACGME) approved revisions to the Program Requirements for Graduate Medical Education (GME) in Internal Medicine, effective July 1, 2022, requiring addiction medicine training for all internal medicine (IM) residents. The Veterans Health Administration (VHA) is a clinical training site for many academic institutions that sponsor IM residencies. This focus group project evaluated VHA IM residency site directors' perspectives about providing addiction medical education within VHA IM training sites.

OBJECTIVE

To better understand the current state, barriers to, and facilitators of IM resident addiction medicine training at VHA sites.

DESIGN

This was a qualitative evaluation based on semi-structured video-based focus groups.

PARTICIPANTS

Participants were VHA IM site directors based at a VHA hospital or clinic throughout the USA.

APPROACH

Focus groups were conducted using a semi-structured group interview guide. Two investigators coded each focus group independently, then met to create a final adjudicated coding scheme. Thematic analysis was used to identify key themes.

KEY RESULTS

Forty-three participants from 38 VHA sites participated in four focus groups (average size: 11 participants). Six themes were identified within four pre-defined categories. Current state of training: most VHA sites offered no formal training in addiction medicine for IM residents. Barriers: addiction experts are often located outside of IM settings, and ACGME requirements were non-specific. Facilitators: clinical champions help support addiction training. Desired next steps: participants desired incentives to train or hire local champions and a pre-packaged didactic curriculum.

CONCLUSIONS

Developing competent clinical champions and leveraging VHA addiction specialists from non-IM settings would create more addiction training opportunities for IM trainees at VHA sites. These insights can likely be applied to IM training at non-VHA sites.

Care Practices of Mental Health Clinical Pharmacist Practitioners Within an Interdisciplinary Primary Care Model for Patients With Substance Use Disorders

BACKGROUND

Clinical pharmacist practitioners (CPPs) play an increasingly important role in interdisciplinary care for patients with substance use disorders (SUDs). However, CPPs' scope of practice varies substantially across clinics and settings.

OBJECTIVES

We sought to describe CPP practices and activities within an interdisciplinary, team-based primary care clinic dedicated to treat Veterans with histories of substance use disorders, experience of homelessness, high medical complexity, and other vulnerabilities.

METHODS

We conducted a retrospective cohort study of CPP activities using Department of Veterans Affairs (VA) administrative data in 2019.

RESULTS

CPPs provided care for 228 patients, including 766 in-clinic visits, 341 telephone visits, and 626 chart reviews, with an average of 2.5 hours spent per patient per year. Patients seen by CPPs frequently experience mental health conditions and SUDs, including depression (66%), post-traumatic stress disorder (52%), opioid use disorder (OUD) (45%), and alcohol use disorder (44%). CPPs managed buprenorphine medications for OUD or chronic pain in 76 patients (33%). Most CPP interventions (3330 total) were for SUDs (33%), mental health conditions (24%), and pain management (24%), with SUD interventions including medication initiation, dose changes, discontinuations and monitoring. As part of opioid risk mitigation efforts, CPPs queried the state's prescription drug monitoring program 769 times and ordered 59 naloxone kits and 661 lab panels for empaneled patients.

CONCLUSION

CPPs managed a high volume of vulnerable patients and provided complex care within an interdisciplinary primary care team. Similar CPP roles could be implemented in other primary care settings to increase access to SUD treatment.