Adding Nurse Care Managers in Primary Care Boosted OUD Treatment

Integrating nurse care managers into primary care teams significantly increased access to opioid use disorder (OUD) treatment compared with usual care, a cluster randomized trial showed.

In the Primary Care Opioid Use Disorders Treatment (PROUD) trial, clinics that utilized the Massachusetts model of nurse care management provided 8.2 more patient-years of OUD treatment per 10,000 primary care patients compared with usual care clinics (95% CI 5.4 to ∞, P=0.002), reported Paige Wartko, PhD, MPH, of Kaiser Permanente Washington Health Research Institute in Seattle, and colleagues in JAMA Internal Medicine.

Results with the intervention — including salary for a full-time OUD nurse care manager, training and technical assistance for these managers, and three or more primary care clinicians who committed to prescribing buprenorphine — varied across the six included health systems, with most of the improvements seen in two health systems and across two categories of patients: those new to primary care clinics and those new to treatment.

Among patients new to primary care clinics post-randomization, the authors observed 5.8 (95% CI 1.3 to ∞) more patient-years of OUD treatment, and among those who were being newly treated for OUD post-randomization, the authors reported 8.3 (95% CI 4.3 to ∞) more patient-years of OUD treatment.

Despite opioid deaths continuing to climb in the U.S., most people with OUD do not receive treatment, and as few as 10% of primary care physicians currently prescribe medications for OUD.

“Multiple models for increasing [primary care] OUD treatment have been proposed, but none have been shown to increase OUD treatment in a trial previously,” the authors wrote.

Notably, in a post-hoc analysis, they observed a 21 percentage point increase in the share of patients who received OUD treatment from baseline to follow-up at intervention clinics compared with a 2.8 percentage point difference in usual care.

“Eighteen percent of people who weren’t treated before who have opioid use disorder [were] being treated” beyond usual care, Wartko pointed out.

The factors most critical to the intervention’s success, gleaned from surveys, included commitment to treating OUD from system leaders and primary care teams, “full financial coverage for OUD treatment, and straightforward pathways to access nurse care managers,” the authors wrote.

In an accompanying editorial, Michael A. Incze, MD, MSEd, of the University of Utah in Salt Lake City, and colleagues noted that while nurse care managers provide a “bedrock of support,” the study results suggest nurses should not be solely responsible for addressing the problem of primary care-based OUD treatment.

“Like all professionals, nurses require a supportive environment, backing from local leadership, a platform to create change, and colleagues who are open minded and willing to collaborate,” they wrote. “Rather than a ready-made solution, the nurses in the PROUD trial may be better characterized as catalysts of OUD treatment in primary care — added to a receptive environment, their influence can be immense.”

The PROUD trial took place across five states — New York, Florida, Michigan, Texas, and Washington — and six health systems. Two primary care clinics per system were randomly assigned to either the intervention, which utilized the Massachusetts model of nurse care management, or usual care.

Primary care patients were included in the study if they were 16 to 90 years old and visited the clinic from up to 3 years before randomization to 2 years after. OUD treatments included buprenorphine or extended-release injectable naltrexone.

At baseline, 130,623 patients (mean age 48.6, 59.7% women) were randomized to intervention clinics, while 159,459 patients (mean age 47.2, 63% women) were randomized to usual care clinics.

Of note, usual care clinics provided “substantially more” OUD treatment at baseline compared with the intervention clinics, which may have potentially led to “attenuated effect estimates,” Wartko and team noted.

Another limitation of the study was the authors’ uncertainty around whether they had captured all the data on treatment, including OUD treatment, delivered outside the system, Wartko said.

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