Developing a Medication for Opioid Use Disorder Workforce in Primary Care Training

Introduction

The opioid epidemic and rising overdose rate has spurred increasingly urgent calls for expanded access to addiction medicine in office-based settings with medication for opioid use disorder (MOUD).¹ One of the biggest barriers to expanded MOUD care is lack of trained providers with the necessary clinical expertise.^{2, 3} Currently, within most Internal and Family Medicine residency programs, the majority of addiction medicine training is didactics, role play, and observed standardized clinical interactions.⁵ A 2018 survey of Internal Medicine, Family Medicine, and Psychiatry program directors found that few programs taught office-based opioid treatment with buprenorphine.⁵

In response to the recognized need, there is interest among training programs to help build the necessary future work force to address this public health crisis.⁴ To achieve this goal, it is critical to understand how best to structure clinical experiences to make residents comfortable treating patients with SUD. However, there is limited data on what type and amount of exposure to MOUD practice is needed to do so.

Our aim was to understand whether limited experience in a clinic caring for individuals with OUD would impact residents’ attitudes toward providing care to this population and the motivation and tools to engage in MOUD care as part of their future clinical practice.

Methods

At the University of Pennsylvania, a novel MOUD curriculum is delivered to PGY-2 and PGY-3 primary care track Internal Medicine and Family Medicine residents. The program incorporates x-waiver training, in-person didactics, and an immersive clinical experience within a MOUD clinic embedded within the main primary care clinics in both programs. The clinics are staffed by waivered attending preceptors with clinical expertise in SUD. Each clinical session has between 12-16 patients who are being seen specifically for MOUD.

To ascertain if this “dose” of training was enough to change resident perceptions, we designed a survey based on literature review and administered it before and after resident’s spent time in MOUD clinic. The survey was reviewed by Medical Education and MOUD content experts and then piloted with a small group of residents for clarity prior to administration to the larger study population. Questions were designed to assess resident comfort with prescribing buprenorphine, likelihood of future prescribing, and impact on resident wellness using a 5-point Likert scale ranging from strongly disagree to strongly agree. An additional question asked respondents to rate perceived barriers to prescribing buprenorphine in their future practice both before and after participating in the clinic.

Twenty-five PGY-2 and PGY-3 primary care track Internal Medicine and Family Medicine residents were surveyed following their time in clinic between 2017 and 2019. Results from the survey were analyzed using the Wilcoxon signed-rank test to assess whether perception on a Likert scale increased (towards strongly agree) after the clinical experience. The study was reviewed by the Institutional Review Board at the University of Pennsylvania and approved as a quality improvement project. Additionally, we conducted a follow up survey in January 2022 to understand how many residents had gone on to receive their DEA with x-waiver upon graduation, how many were prescribing buprenorphine in their clinical practices, and how their experience in MOUD clinic as resident’s influenced their comfort in prescribing on their own.

Results

Twenty-five of thirty-three (75.7%) residents completed the survey. Of these 25, 76% agreed with the statement “I have more empathy for patients with addiction” (median Likert response = 4) after their clinical experience. Residents felt uncomfortable prescribing buprenorphine prior to their clinical experience. Median ratings went from 2 to 4 (p<0.001) for likelihood to recommend MOUD to patients and identifying candidates for therapy.

Median ratings also went from 2 to 4 (p<0.001) in response to the statement, “I feel empowered to care for patients with addiction disorders.” Prior to the clinical experience, the top three perceived barriers to prescribing were lack of mental health resource availability, complex clinic logistics, and not enough ancillary staff support. These perceived barriers stayed consistent following the clinical experience. Prior to the clinical experience, 12 respondents answered that for them, a barrier was fear of causing patient harm from lack of expertise. After the pilot program, this decreased to four respondents. Prior to the clinical experience, nine respondents also answered that a barrier to prescribing MOUD was that patients are difficult, which decreased to one respondent following the pilot program.

For our follow up survey, 29 of 41 residents (70.7%) completed the survey. Of the respondents, 21 (72.4%) reported that they had their DEA license with X waiver, 13 (44.8%) reported prescribing buprenorphine in their clinical practice, and 28 (96.6%) somewhat agreed or strongly agreed with the statement “My experience in buprenorphine clinic in training made me comfortable prescribing on my own.”

Discussion

Overall, this study demonstrates that limited exposure to treating patients with SUD increased residents self-reported comfort with prescribing buprenorphine. The response to our follow-up survey lends further strength to this signal as (44.5%) of respondents reported prescribing buprenorphine as part of their independent clinical practice and (96.6%) agreed that their experience with the MOUD curriculum during training was the reason. This study also showed that residents felt that they had made a significant impact in the care of these vulnerable patients.

Our study is limited by being at a single center with primary care Internal Medicine and Family Medicine residents who may have more baseline interest in caring for patients with SUD. It was also conducted in Philadelphia, Pennsylvania, and thus our residents have exposure to patients with SUD in the inpatient setting on a regular basis, no doubt impacting their perceptions of this patient population in various ways.

While our initial survey was designed to measure perceptions and it is not known if perceptions translate into prescribing in the future, our follow up survey indicates that many of our graduates go on to provide MOUD care as part of their clinical practice.

Conclusion

We know that a first step to expanding the provider base engaged in providing MOUD care requires a workforce that is passionate and has the necessary clinical skills. This study provides a signal that a small, immersive clinical experience with MOUD during training may be enough to start to move the needle.