title: Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration.
abstract: Opioid dependence is a chronic, relapsing disorder that deleteriously influences the health of those afflicted. Sublingual buprenorphine opioid agonist treatment (OAT) has been shown to be safe, effective, and cost-effective for the treatment of opioid dependence in nonspecialized, office-based settings, including the Veterans Health Administration (VHA). We sought to examine and describe provider-, facility-, and system-level barriers and facilitators to implementing buprenorphine therapy within the VHA. From June 2006 to October 2007, we conducted semistructured telephone interviews of key personnel at a national sample of VHA facilities with high prevalence of opioid dependence and without methadone OAT programs. Sites were categorized based on the number of veterans receiving buprenorphine prescriptions: More Buprenorphine (MB, >40 prescriptions, 5 sites), Some Buprenorphine (SB, 5-40 prescriptions, 3 sites), and No Buprenorphine (NB, 0-5 prescriptions, 9 sites). Interviews were taped, transcribed, and coded; consensus of coding themes was reached; and data were evaluated using grounded theory. Sixty-two staff members were interviewed. For NB sites, perceived patient barriers included lack of need and attitudes/stigma associated with opioid dependence. Provider barriers included lack of interest, stigma toward the population, and lack of education about buprenorphine-OAT. Prominent facilitators at MB sites included having established need, provider interest, and resources/time available for buprenorphine-OAT. The presence of a champion/role-model for buprenorphine care greatly facilitated its implementation. We conclude that factors that enable or impede buprenorphine-OAT vary by facility. Strategies and policies to encourage implementation of buprenorphine should be adaptable and target needs of each facility.
authors.affiliation: Mental Illness Research, Education, and Clinical Center, and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, 7180 Highland Drive, Pittsburgh, PA 15206, USA. adam.gordon@va.gov
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Gordon
authors.forename: Greg
authors.initials: G
authors.lastname: Kavanagh
authors.forename: Margaret
authors.initials: M
authors.lastname: Krumm
authors.forename: Rajeev
authors.initials: R
authors.lastname: Ramgopal
authors.forename: Sanjay
authors.initials: S
authors.lastname: Paidisetty
authors.forename: Minu
authors.initials: M
authors.lastname: Aghevli
authors.forename: Francine
authors.initials: F
authors.lastname: Goodman
authors.forename: Jodie
authors.initials: J
authors.lastname: Trafton
authors.forename: Joseph
authors.initials: J
authors.lastname: Liberto
mesh_terms: D001291:Attitude of Health Personnel; D002047:Buprenorphine / Q000627:therapeutic use*; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006801:Humans; D009292:Narcotic Antagonists / Q000627:therapeutic use*; D009293:Opioid-Related Disorders / Q000517:prevention & control*; D014481:United States; D014493:United States Department of Veterans Affairs; D058014:Veterans Health
chemical_list: D009292:Narcotic Antagonists; D002047:Buprenorphine