Patient Initiation of Treatment for Opioid Use Disorder and Referral to a Randomized Study: Lessons from the Homer Study

Context: Using buprenorphine in primary care is a proven strategy to treat opioid dependence and use disorder (OUD). Buprenorphine treatment includes induction (beginning treatment), stabilization, and maintenance. Guidelines support induction at the clinic, telehealth, or at home. No randomized comparative effectiveness research (CER) study provides evidence to support decisions about which induction option best fits individual patients. Objective: To understand and address barriers to patients initiating buprenorphine treatment and practices referring patients to a randomized study. Study Design: This sub-study within a randomized CER trial comparing buprenorphine treatment induction methods used a sequential mixed-methods design analyzing 263 field notes and 50 practice member surveys. Setting: 63 primary care and mental health care practices associated with the State Networks of Colorado Ambulatory Practices and Partners and American Academy of Family Physicians National Research Network. Population: Providers and staff in study practices. Instrument: Structured field notes completed by research staff from June 2021 through January 2022. Surveys of providers and staff in February 2022. Results: Significant practice and system factors took attention away from identifying patients and providing treatment including: provider and staff turnover or leave, low patient volume, lack of patient interest in starting treatment, and disruptions and priorities related to COVID-19. Less common were uncertainty and unclear protocols for identifying and referring elibible patients. Practice members reported the volume of study-eligible patients was affected by: patients having already started treatment elsewhere, street use of buprenorphine, competing local treatment programs, and an emerging focus on micro-dosing for treating fentanyl use. Practices also reported patient factors influencing referral to the study including: lack of patient interest or trust in the study, patients not wanting or able to wait to be randomized, or patient preferences for a specific induction method. Conclusions: Effects of the COVID-19 pandemic affect patient initiation of OUD treatment and study enrollment. Patient preference for induction type emerged as a major factor in not participating in the study. Both practice- and patient-related factors affected identification of patients for OUD treatment and patient referral to a randomized study.