Nurse Care Management for Opioid Use Disorder Treatment
Authors: Wartko Paige D , Bobb Jennifer F. , Boudreau Denise M. , Matthews Abigail G. , McCormack Jennifer , Lee Amy K. , Qiu Hongxiang , Yu Onchee , Hyun Noorie , Idu Abisola E. , Campbell Cynthia I. , Saxon Andrew J. , Liu David S. , Altschuler Andrea , Samet Jeffrey H. , Labelle Colleen T. , Zare-Mehrjerdi Mohammad , Stotts Angela L. , Braciszewski Jordan M. , Murphy Mark T. , Dryden Douglas , Arnsten Julia H. , Cunningham Chinazo O. , Horigian Viviana E. , Szapocznik José , Glass Joseph E. , Caldeiro Ryan M. , Phillips Rebecca C. , Shea Mary , Bart Gavin , Schwartz Robert P. , McNeely Jennifer , Liebschutz Jane M. , Tsui Judith I. , Merrill Joseph O. , Lapham Gwen T. , Addis Megan , Bradley Katharine A. ,   PROUD Trial Collaborators, Ghiroli Megan M. , Hamilton Leah K. , Hu Yong , LaHue Jennifer S. , Loree Amy M. , Murphy Sean M. , Northrup Thomas F. , Shmueli-Blumberg Dikla , Silva Angela J. , Weinstein Zoe M. , Wong Mark TinFook , Burganowski Rachael P. 
Published: October 2023

Importance

Few primary care (PC) practices treat patients with medications for opioid use disorder (OUD) despite availability of effective treatments.

Objective

To assess whether implementation of the Massachusetts model of nurse care management for OUD in PC increases OUD treatment with buprenorphine or extended-release injectable naltrexone and secondarily decreases acute care utilization.

Design, Setting, and Participants

The Primary Care Opioid Use Disorders Treatment (PROUD) trial was a mixed-methods, implementation-effectiveness cluster randomized clinical trial conducted in 6 diverse health systems across 5 US states (New York, Florida, Michigan, Texas, and Washington). Two PC clinics in each system were randomized to intervention or usual care (UC) stratified by system (5 systems were notified on February 28, 2018, and 1 system with delayed data use agreement on August 31, 2018). Data were obtained from electronic health records and insurance claims. An implementation monitoring team collected qualitative data. Primary care patients were included if they were 16 to 90 years old and visited a participating clinic from up to 3 years before a system’s randomization date through 2 years after.

Intervention

The PROUD intervention included 3 components: (1) salary for a full-time OUD nurse care manager; (2) training and technical assistance for nurse care managers; and (3) 3 or more PC clinicians agreeing to prescribe buprenorphine.

Main Outcomes and Measures

The primary outcome was a clinic-level measure of patient-years of OUD treatment (buprenorphine or extended-release injectable naltrexone) per 10 000 PC patients during the 2 years postrandomization (follow-up). The secondary outcome, among patients with OUD prerandomization, was a patient-level measure of the number of days of acute care utilization during follow-up.

Results

During the baseline period, a total of 130 623 patients were seen in intervention clinics (mean [SD] age, 48.6 [17.7] years; 59.7% female), and 159 459 patients were seen in UC clinics (mean [SD] age, 47.2 [17.5] years; 63.0% female). Intervention clinics provided 8.2 (95% CI, 5.4-∞) more patient-years of OUD treatment per 10 000 PC patients compared with UC clinics (P = .002). Most of the benefit accrued in 2 health systems and in patients new to clinics (5.8 [95% CI, 1.3-∞] more patient-years) or newly treated for OUD postrandomization (8.3 [95% CI, 4.3-∞] more patient-years). Qualitative data indicated that keys to successful implementation included broad commitment to treat OUD in PC from system leaders and PC teams, full financial coverage for OUD treatment, and straightforward pathways for patients to access nurse care managers. Acute care utilization did not differ between intervention and UC clinics (relative rate, 1.16; 95% CI, 0.47-2.92; P = .70).

Conclusions and Relevance

The PROUD cluster randomized clinical trial intervention meaningfully increased PC OUD treatment, albeit unevenly across health systems; however, it did not decrease acute care utilization among patients with OUD.

Trial Registration

ClinicalTrials.gov Identifier: NCT03407638