Best Practice of the Month
Initiating MOUD

When a person with opioid use disorder (OUD) requests initiation of medication for OUD (MOUD), time is of the essence. Delaying treatment initiation increases the chances that an individual may lose their motivation to initiate care, and every additional day of continued use poses another risk for overdose. Although multi-step assessments prior to initiating care are now recognized as unnecessary barriers, they remain standard in some settings. This best practice advisory will define treatment access as a quality measure and outline tangible steps for reducing wait times.

A “Medication First” Model of Care

Historically, many office-based buprenorphine treatment providers required multiple visits prior to initiation of MOUD, requiring, for example, visits with behavioral health clinicians, psychoeducation, trips to the lab, or completion of treatment agreements. This multi-step process often meant that only the most organized and resourced individuals were able to make it to the appointment initiating MOUD. Because the majority of people with OUD never receive formal treatment, many office-based buprenorphine treatment providers work to eliminate barriers to treatment initiation and have moved to a “Medication First” model (PDF). The four key principals of this model are:

  1. Patients receive MOUD as quickly as possible, prior to lengthy assessments.
  2. Maintenance MOUD is delivered without arbitrary tapering or time limits.
  3. Individual psychosocial services are offered when available but are not required as a condition of MOUD.
  4. MOUD is only discontinued if it appears to be worsening a patient’s condition.

An evaluation found that the Missouri Medication First treatment approach led to increased MOUD use, improved timeliness of MOUD initiation, and improved treatment retention at 1-, 3-, and 6-month timeframes despite the fact that fewer psychosocial services were delivered.  Additional support for these practices may be found in Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Treatment Improvement Protocol (TIP) 63 on Medications for Opioid Use Disorder.

Treatment Access Is a Quality Measure

The Centers for Medicare and Medicaid Services Healthcare Effectiveness Data and Information Set (HEDIS) substance use disorder (SUD) treatment access measure is that individuals who receive a SUD diagnosis should be able to initiate treatment within 14 days of that diagnosis. While an important measure to keep in mind when a patient is being referred from a hospital or other healthcare setting, it is common that individuals self-refer for MOUD treatment in primary care settings, making this outcome measure less useful in these circumstances. The Center for Care Innovations created an Index of Capability PDF assessment tool specifically for primary care practices. This tool offers an access measure that can be used in primary care settings: Patients choosing MOUD, either buprenorphine or naltrexone long-acting injection, may start medication within 72 hours (Dimension 3, metric 12, page 4).  While ensuring every patient requesting MOUD is prescribed buprenorphine within 72 hours may be difficult in some settings, there are multiple steps all clinics can take to reduce wait times.

Practical Tips for Reducing Wait Time for Medication Initiation

  1. Estimate current wait time from point of request until medication initiation (baseline data)
    1. What is the average wait time for a new patient intake visit for MOUD?
    2. Are patients required to have your practice listed as their primary care physician?
      1. If so, is there a lag time in making this change?
      2. Are there ways to expedite this process?
    3. If you require multiple visits prior to initiation, what is the average wait time until medication is prescribed?
    4. Is there a buprenorphine prescriber onsite 5 days per week?
  2. Document current workflows from point of request until medication initiation
    1. If a patient calls to request MOUD initiation, does the call go through the standard scheduling process or is there an MOUD intake coordinator?
    2. Are MOUD initiation requests triaged or expedited in any way?
    3. How many visits do you require before medication initiation?
    4. Are lab results required prior to medication initiation?
    5. Are patients required to engage with a behavioral health clinician prior to starting medication?
  3. Identify whether you can eliminate, expedite, or delay some steps in the process until after medication initiation
    1. Can patient calls requesting MOUD initiation be triaged differently to ensure expedited scheduling?
    2. Are there “same day” or urgent care slots that could be utilized for medication initiation visits?
    3.  If there are multiple steps required before initiating medication, could these be condensed or all occur on a single day?
    4. If counseling is available at your site, could counseling engagement happen after medications have been initiated?
    5. Could labs be recommended, but not required prior to initiation of treatment?
  4. Develop a Plan-Do-Study-Act (PDSA) quality improvement process to reduce wait time
    1. Which team members should be on the test of change team?
    2. How will time from request until medication initiation be measured?