Implementation of a Primary Care Nurse Care Manager Model Increased Opioid Use Disorder Treatment but Did Not Decrease Acute Care Utilization

Medications for opioid use disorders (MOUD) are highly effective, but the optimal model for MOUD delivery in primary care is unknown. This trial tested the Massachusetts Model of nurse care management of OUD with buprenorphine versus usual care in a mixed-methods, implementation-effectiveness, cluster-randomized clinical trial in six diverse health systems in five US states. The intervention included salary for a full-time OUD nurse care manager, ongoing training and technical support, and three or more providers agreeing to prescribe buprenorphine.

  • Intervention and usual care clinics saw an average of 18,485 and 22,557 patients, respectively, with substantially more baseline OUD treatment in the usual care clinics (10.6 versus 6.8 patient-years per 10,000 patients).
  • After implementation, the intervention clinics provided 8.2 more patient-years of OUD treatment per 10,000 primary care patients compared with usual care clinics.
  • Most of the benefit occurred in two of six health systems and in patients new to clinic or newly treated for OUD post-randomization.
  • Acute care utilization among those with documentation of OUD prior to randomization did not differ between intervention and usual care clinics.
  • Qualitative data identified key facilitators of implementation, including: broad institutional commitment to treat OUD, full financial coverage for OUD treatment, and clear pathways for patients to access nurse care managers.

Comments: This trial demonstrated a meaningful increase in primary care OUD treatment using a nurse care manager model. Given that most of the benefit was the result of attracting new patients with OUD to clinic after randomization, it is not surprising that acute care utilization was not reduced in those with OUD identified prior to randomization. The variability in outcomes seen in both trial arms highlights the importance of institutional, financial, and clinic-level factors for successful implementation of primary care OUD treatment.

Joseph Merrill, MD, MPH

References: Wartko PD, Bobb JF, Boudreau DM, et al. Nurse care management for opioid use disorder treatment: the PROUD cluster randomized clinical trial. JAMA Intern Med. 2023;183(12):1343–1354.

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