Impact of a National Stepped-Care Model of Opioid Use Disorder Treatment on Access to Medication Therapies Among Homeless-Experienced Veterans.

OBJECTIVE

To determine whether the Veterans Health Administration's (VHA) Stepped Care for Opioid Use Disorder Train-the-Trainer (SCOUTT) initiative increased medication treatment for opioid use disorder (MOUD) among persons experiencing homelessness (PEH).

STUDY SETTING AND

DESIGN

We conducted a national retrospective cohort study of MOUD, including buprenorphine, naltrexone, or methadone, in federal fiscal years (FY) 2016-2020. In late FY2018, VHA regional directors nominated facilities to receive SCOUTT implementation support to expand prescribing of MOUD (primarily buprenorphine) in select primary care, pain, and general mental health settings. We used mixed-effects quasi-Poisson regression models with entropy balancing to estimate the Average Treatment Effect on the Treated in the years after SCOUTT was implemented (FY2019-2020), controlling for pre-implementation levels of MOUD. Secondary analyses applied synthetic difference-in-differences (DiD) to estimate changes associated with SCOUTT.

DATA SOURCES AND ANALYTIC SAMPLE: We used yearly pooled cross-sectional data from VHA electronic health records, FY2016-2020. The sample included annual cohorts of PEH with an opioid use disorder diagnosis and ≥ 1 primary care visit in the pre-implementation (FY2016-2018, n = 31,354) or post-implementation (FY2019-2020, n = 20,746) periods.

PRINCIPAL FINDINGS: From FY2016-2020, MOUD receipt increased more in SCOUTT facilities (n = 30, 45.0% to 61.1%) than in non-SCOUTT facilities (n = 811, 41.9% to 49.7%). In post-implementation years, PEH in SCOUTT facilities, compared to non-SCOUTT facilities, were more likely to receive any MOUD (risk difference [RD] = 6.16, 95% CI = 2.33-9.99), including buprenorphine (RD = 7.16, 95% CI = 4.35-9.97). There were no significant differences in methadone (RD = -0.19, 95% CI = -1.03-0.65) or naltrexone (RD = 0.10, 95% CI = -1.85-2.05). Synthetic DiD offered similar results: any MOUD DiD = 7.85, 95% CI = 2.15-13.55; buprenorphine DiD = 9.31, 95% CI = 3.56-15.06.

CONCLUSIONS

A national initiative to advance a stepped-care model that encourages MOUD initiation outside specialty addiction settings improved access to buprenorphine among PEH. Similar initiatives could help to close treatment gaps in health care settings serving PEH.