Variations in evidence-based clinical practices in nine United States Veterans Administration opioid agonist therapy...

Opioid agonist therapy (OAT) for opioid dependence has a strong evidence base, but clinical practice often does not conform to evidence-based practices. The goal of the OpiATE Initiative is to improve patient outcomes by implementing four evidence-based practices in United States Veterans Administration OAT clinics: (1) long-term maintenance orientation, (2) adequate dosing, (3) adequate counseling, and (4) use of contingency management.

The OpiATE monitoring system (OMS) was developed to help clinics assess concordance with evidence-based practices. For each patient, counselors record current agonist dose, recent counseling frequency, length of treatment, and urine toxicology results. For patients with sub-standard agonist doses, an algorithm was used to determine if the current dose was clinically appropriate. Maintenance orientation was assessed using the abstinence orientation scale.

Concordance with counseling recommendations was uniformly high, concordance with maintenance orientation and dosing recommendations varied widely across clinics, and concordance with contingency management principles was low. Abstinence orientation scores were negatively correlated with dose and patient retention. Dose was negatively correlated with percent of urine screens positive for non-medical opioids and other illicit substances.

The OMS was well accepted by clinic staff. Wide variability in clinical practices and outcomes across clinics supports the importance of individualizing quality improvement strategies to address specific performance gaps.