OUD Care Improved with Nurse Support, Use of Opioid Agonists

Employing a nurse care manager to work with patients who have an opioid addiction and prescribing partial or full opioid agonists can help more people enter treatment in primary care settings, according to new research published in JAMA Network Open.

The addition of a nurse who helped clinicians check urine screens, address patient social needs and related conditions, and follow up with those who discontinued treatment, led to clinics providing more addiction care to those who needed it, the study found.

“There’s an ‘Aha’ moment when you realize that this is a treatable medical condition,” said Katharine Bradley, MD, MPH, of Kaiser Permanente Washington Health Research Institute in Seattle, and an author of the study. The intervention “takes away the blame people put on the patient and helps them understand that this is a brain disorder resulting from genetically predisposed people using a substance that takes over their reward system.”

Intervention clinics demonstrated 19.7 more total days of treatment per 10,000 patients over 3 years of the trial than clinics offering usual care (95% CI, 11.1-28.4), Bradley and her colleagues found.

The study required at least three clinicians per intervention site to prescribe either full or partial opioid antagonists.

Treatment for opioid use disorder (OUD) historically has been viewed by the medical community as a nonmedical issue and addiction, the result of poor patient willpower, Bradley said. The intervention helped normalize prescribing opioid antagonists among primary care clinicians. She said many clinicians are shocked to see drastic changes after they prescribe the drugs to patients.

Lucinda Grande, MD, a clinical assistant professor of family medicine at the University of Washington School of Medicine in Seattle, said she has cared for many patients who said they “wouldn’t even bother” telling their primary care physician about their OUD because they “know they’ll be judged.”

But the findings illustrate that “if there’s good, destigmatized care that’s specific for addiction treatment, it’s going to draw in more people,” Grande, who was not associated with the study, said.

The Intervention

Physicians, nurse practitioners, or physician assistants prescribed medication to patients with OUD, while intervention clinics also hired a full-time nurse care manager to screen and support patients with the condition. The nurse assisted clinicians in assessment, diagnosis, and initiation of either opioid antagonist, among other duties.

Nurses also received training in destigmatizing the condition, including eliminating blaming and negative language, such as use of the terms, “dirty urine” and “drug abuse,” Bradley said. 

In a 1-year extension of a 2-year trial, researchers compared treatment rates for OUD — defined as receiving buprenorphine or extended-release naltrexone — between intervention clinics and those providing conventional care. The usual care clinics were told they could improve OUD care, but were directed to not use intervention model.

The clinics were part of safety net, community health, integrated health, or university systems in New York, Florida, Michigan, Texas, and Washington State. Each system was given funding to hire a full-time nurse, which ranged from $76,673 to $147,590.

The study included 290,071 patients aged between 16 and 90 years, of whom 130,618 were seen in the intervention clinics (mean age, 48.6 years; 59.3% women), and 159, 453 in clinics providing usual care (mean age, 47.2; 64% women). Approximately 14% of patients at each clinic had a diagnosis of OUD.

At the end of the third year, three of the six intervention clinics had increased the total days of treatment per 10,000 patients with statistical significance, providing between 9.5 and 45.6 patient years of treatment than their counterpart clinics providing usual care. Only one usual care site showed a large increase in treatment, due to the clinic getting X waivers for all of their prescribing clinicians on their own.

No new patients were enrolled in year 3 of the trial because of COVID-19. Bradley said had they been able to enroll new patients, the difference between the intervention and usual care may have been even higher.

The model “creates a sort of ‘magnet’ clinic that attracts people with OUD because they hear they can get the care they need in a positive environment,” Bradley said.

Prescribing buprenorphine during the trial required clinicians to obtain an X-waiver, which required specialized training. The waiver was eliminated in January 2023, but many clinicians are still hesitant to provide the drugs because of reluctance to treat patients with OUD, time constraints, concerns about overreach from the Drug Enforcement Administration, and a lack of insurance coverage for treatment.

Opioid prescriptions have decreased by 51.7% since 2012, according to the American Medical Association. Meanwhile, state prescription drug monitoring programs were used by healthcare workers over 1.4 billion times in 2023, up from about 61 million times in 2014.

Mortality from drug overdoses involving prescription opioids decreased from a peak of 17,029 deaths in 2017 to 14,716 in 2022. But deaths involving synthetic opioids — primarily illicitly-manufactured fentanyl — more than doubled during the same time frame, to 73,838 Americans overdosing in 2022, according to the National Institute on Drug Abuse.

The study was funded by the National Institute on Drug Abuse. Various authors reported receiving grants from the National Institute on Alcohol Abuse and Alcoholism, the Agency for Healthcare Research and Quality, Syneos Health, GlaxoSmithKline, and Bayer.

Brittany Vargas is a medicine, mental health, and wellness journalist.