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

Despite more than a decade of investment in opioid use disorder (OUD) treatment infrastructure, the year 2020 saw the highest mortality related to opioid overdose in American history. Treatment access remains critically limited, with less than half of people living with OUD receiving any treatment. Primary care has been referred to as the "sleeping giant" of addiction care, as few primary care doctors currently prescribe medications to treat OUD. The "clinical champions" framework is a tool that has shown promise in creating the type of mentorship and culture change necessary to expand uptake of medication-based OUD treatment among primary care providers. The early success of this model and the increased availability of tools for broad implementation warrant further investment as a means of leading primary care into a larger role in combatting the opioid addiction epidemic.

On a recent morning, one of our resident physicians interested in addiction medicine came in before clinic began to ask advice about a challenging clinical case. The patient was under the care of one of his co-residents at a community hospital for cellulitis related to the intradermal injection of heroin. The infection had improved, and the patient was about to be discharged with nothing more than a paper list of local methadone clinics for her opioid use disorder (OUD). Unable to find needed expertise in addiction medicine at the hospital, the resident’s colleague had reached out to him for advice. The young doctor’s enthusiasm for addiction medicine had obviously rippled throughout his training program, and now he was poised to both mentor a colleague and to make a potentially life-saving difference in a patient’s care.

The resident was acting as a clinical champion: a clinician who acquires expertise to improve a specific aspect of medical care responsive to community need, then leverages that knowledge to facilitate learning and uptake of new practice patterns in local environments. Clinical champions help their peers expand scope of practice and improve care by disseminating evidence-based knowledge through training and longitudinal mentorship as trusted colleagues. Thus, the clinical champion for OUD serves as a facilitator and peer mentor to catalyze treatment adoption, especially through increasing medication-based treatment with buprenorphine and extended-release naltrexone in primary care. A 2020 systematic review of 14 studies evaluating the impact of clinical champions for OUD and other substance use disorders showed that they can inspire local culture change and increase high-value care across several different health care arenas.[1] In particular, clinical champions have demonstrated promise in expanding access to medication-based treatment for OUD in the primary care setting.[2,3]

Clinical champions could be of critical importance as we reckon with resurgent opioid-related deaths amid the COVID-19 pandemic. Despite substantial investment in developing OUD treatment infrastructure over the past decade, 2020 proved to be the deadliest year on record in an opioid addiction epidemic that has claimed hundreds of thousands of lives.[4] While the reasons for this are multifactorial, a persistent deficit in treatment access remains a crucial factor. Even with the increasing availability of medications such as buprenorphine and methadone, which reduce OUD-related mortality by more than 50%,[5] less than half of people with OUD currently receive any treatment.[6] In huge swaths of rural America, where 60% of counties lack a single provider licensed to prescribe buprenorphine, the scarcity of treatment options for people with OUD is particularly dire.[7]

Primary care holds great promise to expand OUD treatment access due to its geographic reach, care models adapted to chronic disease management, and focus on whole-person health. Receiving medications for OUD in primary care also removes the stigma of going to an addiction treatment program, which may prevent some individuals from seeking treatment. Yet, few primary care clinicians prescribe medications for opioid use disorder, citing barriers such as lack of confidence, insufficient local expertise, and inadequate institutional support.[8] Surmounting these barriers may best be accomplished by leveraging the influence of local champions, as clinicians often rely more on the experiences and advice of their colleagues than on expert recommendations when making decisions about adopting new practice patterns. The presence of even a single clinician acting as a local OUD treatment champion has been shown to increase uptake of buprenorphine prescribing among primary care providers.[2,3] Expanding this model may play a key role in increasing OUD treatment access within primary care.

The “Training of Trainers” model provides a readymade template for accomplishing this goal.[9] Initially developed in the non-profit sector, the model enlists a “master trainer” to teach a group of learners not only how to develop a particular skill but also how to teach that skill to others in their local environment. This approach can rapidly increase specialized expertise for clinicians in community settings, expanding access to mentored support much more effectively than relying on a small group of regional or national authorities.[10]

This concept is particularly well-suited to primary care-based OUD treatment. Over 60% of high-volume buprenorphine prescribers nationally are in primary care, compared to just 4.4% in specialty addiction practice.[11] Thus, the largest pool of potential OUD treatment experts is already embedded in primary care. Given an appropriate framework for mentoring, these clinicians could serve as the vanguard for a large-scale Train the Trainer initiative.

Effectively implementing the Training of Trainers model will require incentivizing both individuals and health systems to participate. Prospective clinical champions may require additional monetary compensation, paid non-clinical time to develop local trainings and mentoring activities, job title recognition, or institutional support to grow their own primary care-based addiction practices. Continuing education and longitudinal support are also key. Local champions may convene regular meetings to seek advice about challenging clinical cases and share mentoring strategies with one another. These meetings also provide opportunities for champions to reconnect with addiction experts to reinforce principles of high value, evidence-based care that can be disseminated within their respective clinics across the region.

To incentivize uptake among health systems, allocation of federal funds could reward recruitment and support training of OUD clinical champions. While monetary investment is necessary upfront to develop local training infrastructure, the cost savings of providing medication-based treatment for OUD, which has been estimated at up to $105,000 per person treated,[12] will almost certainly lead to substantial net savings through expanded access to treatment. For example, recruiting a single additional provider to prescribe buprenorphine to 30 patients that would not otherwise have access to treatment could lead to lifetime savings of over $3 million in healthcare costs.

Additionally, health systems must have ready access to high-quality training resources and implementation support. Fortunately, a strong training infrastructure is already in development. The Centers for Disease Control and Prevention has created a framework adapting the Training of Trainers model to healthcare settings,[9] and the Veterans Health Administration is currently implementing a model tailored to medication-based OUD treatment in primary care.[13] In rural areas, leveraging newly-expanded telehealth infrastructure may be an effective way to implement the Training of Trainers model when the pool of prospective local champions is limited. Programs such as Project ECHO already provide important virtual training resources and education to clinicians practicing in rural areas but generally are not structured to provide ongoing personal support.[14,15] Adding individualized mentorship by connecting “virtual” champions with rural clinicians for longitudinal support can enhance existing efforts to expand rural medication-based OUD treatment using telehealth tools. Investing in easy access to mentorship can cultivate clinicians such as our resident to become effective clinical champions.

After discussing the details of the case, we called the resident’s colleague and reviewed a plan for a hospital-based buprenorphine initiation and rapid follow-up with an X-waivered provider at our clinic. The patient arrived for follow-up as anticipated. It was clear that both the resident and his colleague were proud of their respective growth—one as a mentor, the other having officially joined the ranks of frontline clinicians battling the opioid epidemic.

As we confront the tragic loss of life over the past year in an epidemic that has not abated despite widespread public health messaging and substantial investments in treatment infrastructure, new strategies are desperately needed to avert further unnecessary deaths. While a multi-pronged effort is required to accomplish this goal, training local OUD treatment champions has already shown promise as a powerful tool to create the type of culture change necessary to increase acceptance and adoption of medication-based OUD treatment among primary care providers. With the right training, support, and infrastructure, we can harness the talents and dedication of the champions waiting among us.