Introduction to Opioid and Substance Use Treatment

In 2017, over 72,000 individuals died in the USA due to opioid overdose while over 2 million individuals were estimated to meet diagnostic criteria for an opioid use disorder (OUD) [1]. The staggering increase in death rates and other health complications related to the misuse of opioids has prompted the national recognition of OUD as a public health crisis. An opioid use disorder is defined as problematic use of opioid including heroin, fentanyl, and other pain-relieving drugs leading to clinically significant impairment or distress while misuse of opioids is defined as “use of a psychotropic medication without a prescription; for a reason other than as directed by a physician; or in greater amounts, more often, or longer than prescribed” [2]. Often, OUD is experienced as a comorbid diagnosis to other physical, mental, and behavioral health diagnoses, exacerbating the complexity of the treatment needs in these cases.

One component of this public health epidemic includes a lack of an adequately trained healthcare workforce to provide opioid case management, prescribing, and dispensing. Primary care providers (PCPs) who are at the forefront of caring for patients with OUD have no specialized training in treating or managing addiction [3, 4]. Medication assisted treatment (MAT) by extended maintenance on an opioid agonist such as buprenorphine is a standard of care for the treatment of opioid use disorder (OUD). As of 2016, only 4% of licensed physicians were approved to prescribe buprenorphine for opioid use disorder. Further, 47% of all US counties and 72% of rural counties lacked a buprenorphine-waivered physician [5]. Although the advent of Office-based opioid treatment (OBOT) has expanded the reach of treatment for individuals with OUD to include the primary care setting, the increase in buprenorphine-credentialed providers has fallen sharply behind the exponential growth of individuals in need of such treatment services. A number of barriers have been cited by providers. Regulatory barriers associated with securing and maintaining the buprenorphine waiver status is perceived as excessively demanding. Additional obstacles include concerns regarding adequacy of training (and subsequent provider capacity) to treat individuals with OUDs, institutional, and collegial infrastructural supports available to clinicians, provider stigma, lack of behavioral health services/care coordination, and difficulty receiving reimbursement for services provided [6,7,8]. Provider time constraints, prohibiting the acceptance of additional patients, and lack of provider knowledge regarding the required training/credentialing to obtain a waiver are cited as top reasons for not receiving the waiver for prescribing buprenorphine among physicians [9]. Furthermore, a large percentage of physicians that are waivered to prescribe MAT do not prescribe buprenorphine at capacity. “At capacity” is defined as 30 patients in the first year and 100 patients in subsequent years [9]. Physicians reported a willingness to become waivered or prescribe to capacity if they were better informed of local counseling resources, were paired with an experienced provider, and had access to additional training (e.g., CME courses) related to treating individuals with OUD [9].

Several systemic and community educational models have emerged in response to the increasing demand for PCP-delivered treatment for OUD, including the Medicaid health home model, ED, and inpatient initiations of OBOT and MAT programs, online Providers Clinical Support System (PCSS), and state-specific programs in Maryland, Vermont, Massachusetts, and Oregon [10•]. The aim of a systems-based program is to connect primary care patients directly with providers trained in treating substance and opioid use disorders. Four key components are addressed to some degree within these models which are pharmacological therapy, psychosocial services, integration of care, and education and outreach [10•]. One promising model that focuses on education and outreach is Project ECHO (Extension for Community Healthcare Outcomes). Project ECHO is a program developed to promote the workforce development for clinicians working with people with SUDs by providing ongoing support and education to clinicians when addressing the range of medical and psychiatric comorbidities that often accompany individuals presenting for SUD treatment. This paper will summarize the evidence to-date regarding the available Project ECHO programs tailored for treatment of individuals with Opioid Use Disorders (OUD).

Project ECHO is a tele-mentoring, medical education, and care delivery model, which uses hub-and-spoke knowledge-sharing networks, led by expert teams at academic medical centers who use telehealth multi-point videoconferencing to conduct virtual clinics with community providers. Every clinic involves a short didactic session given by an expert in the group that hosts the meetings (or “the hub” team), followed by case-based discussions of de-identified real cases presented by practitioners in the community (or “the spokes”). The case discussion involves conversation, suggestions, and consultation around the patient cases, including discussions of clarifying questions and recommendations [11]. Through access to experts for medical consultation and collaboration, existing community providers can provide more specialized care, ultimately diminishing barriers that patients often face when needing treatment for chronic and complex health conditions. Primary care providers participate in didactic sessions and have ability to present cases in de-identified fashion to seek specialty input. In this guided practice model, primary care doctors, nurses, and other clinicians learn to provide skilled specialty care to patients in their own communities. The first Project ECHO clinic focused on the treatment of hepatitis C but has since grown to include a myriad of health issues such as cancer, addiction and substance use, chronic pain, palliative care, and infectious disease. Project ECHO operates more than 220 hubs for more than 100 diseases and conditions in 31 countries [12]. At its core, Project ECHO seeks to increase both the quality and quantity of trained medical providers, particularly in rural and otherwise underserved communities.

Methods

The authors searched PubMed, MEDLINE, Academic Search Complete, PsycINFO, and Project ECHO internal databases to identify results from studies targeting opioid or substance-use-focused tele-ECHO clinics. The keywords used in our search were “Project ECHO,” “Project Extension for Community Healthcare Outcomes,” “opioid,” and or “substance use disorder.” The authors limited the search to literature published from January 2007 to October 2019. Three authors (C.H, L.KM, B.D.) independently reviewed each of the identified abstracts to remove duplicates. Additional studies were identified through searches of the reference lists of reviewed articles.

PRISMA guidelines were utilized for conducting a systematic review. A total of 216 articles were originally identified pertaining to Project ECHO delivery or implementation, and 184 were screened after removing duplicates. Thirty articles were assessed for eligibility, and 15 were included in the review and met the full inclusion criteria. Full inclusion criteria included the following: (1) English-language source; (2) peer-reviewed journal article or indexed abstract; (3) published between January 2007 and October 2019; (4) qualitative or quantitative data collection; and (5) primary focus on opioid Project ECHOs. Chronic pain-focused studies were included if the treatment and management of patients who used opioids were discussed in the findings. See Fig. 1 for a complete chart.

Fig. 1
figure 1

Literature search and selection process for systematic review of opioid-focused Project ECHO studies.

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Data were extracted by the researchers (C.H, L.KM, B.D.) Data extraction categories included the location of Project ECHO sites, author, year, population studied, disease focus, type of conferencing, schedule of sessions, study design, measures used, number of participants, and conclusions. See Fig. 1 for a visual of the process used for data classification.

As Project ECHO seeks to provide continuing education to health care providers, Moore’s framework is used as a guide to evaluating the level of impact on individual practitioners and the patient community [3]. See Table 1 for an overview of the levels of Moore’s framework.

Table 1 Moore’s evaluation framework for assessing outcomes of continuing medical education [13]
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Results

The systematic review of the evidence for opioid-focused Project ECHO assessed a total of 15 studies. The results are represented in Table 2. The location of the studies included the USA (n = 8), Ontario, Canada (n = 4), and India (n = 3). The studies located in the USA included state programs in New Mexico, New York, California, and Ohio, along with multi-state programs. Participants included a wide range of health professions including primary care providers, nurse practitioners, social workers, and pharmacists. Findings from the review noted substantial benefits to participants, including increases in provider knowledge (from pre to post) (n = 11), self-reported improvements in provider self-efficacy (n = 7), and positive changes in provider attitude toward patients (n = 1). Findings suggest an overall satisfactory evaluation of Project ECHO from participants (n = 11). Additionally, data show that opioid-focused Project ECHOs showed an increase in the perception of community building and a reduction in professional isolation (n = 3). Several studies indicated that providers changed their behavior when working with patients with OUD as a result of participation in Project ECHO (n = 3).

Table 2 Summary table of 15 included studies in a systematic review of the literature on the outcomes of opioid-focused Project ECHO programs, 2007–2019
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Quality Assessment Results Through Moore’s Framework

Out of 15 included studies, all but one reported at least one level of Moore’s framework [4, 14,15,16,17, 18, 19•, 20, 21•, 22,23,24,25,26,27].

Level 1: Participation

Eleven studies reported the number of participants [4, 14, 15, 17, 19•, 22,23,24,25,26,27]. The range of participants ranged from 12 to 1079, with a mean of 163 and a median of 36. One study reported the number of participating sites (n = 47) rather than the number of participating individuals [16].

Level 2: Satisfaction

Eleven studies reported provider satisfaction after participation in Project ECHO sessions. These results were collected via surveys and qualitative interviews [4, 14, 15, 17, 19•, 20, 21•, 24,25,26,27]. All of these studies reported satisfaction in the post-tests and interviews. Some frequently reported barriers were lack of reimbursement, reduced the clinical time allocated to participating in the sessions, not enough time dedicated to didactic presentations, and technology issues [4, 15, 21, 26, 27]. Some limitations reported were low number of participants in some studies [4, 15, 19, 20, 26]. Some studies also reported skewed results due to participant populations [14, 25]. Some selection bias may exist as participants volunteered to participate in the ECHO clinics.

Level 3: Learning

Eleven studies reported results of pre- and post-knowledge tests completed by participants and one study reported post-test only results indicating positive findings [4, 14, 15, 17, 19•, 20, 22,23,24,25,26,27]. These studies discussed the overall improvement of baseline knowledge of topics discussed during sessions. Many of these studies conducted initial needs assessments to evaluate what topics are of interest and necessary to learn for participants [4, 24, 26]. All studies used multiple-choice post-tests to evaluate change in knowledge as a result of participation in the ECHO sessions. Self-report of knowledge can contain inherent bias, which is a limitation.

Level 4: Competence

Twelve studies reported self-efficacy or self-confidence of participants who participated in Project ECHO sessions [4, 14, 15, 17, 19•, 20, 22,23,24,25,26,27]. Competence was evaluated using either multiple-choice or semi-structured interview methods. All studies reported increases in self-efficacy after attending sessions. Some study participants noted increased knowledge of resources and a sense of community for OUD treatment providers [15, 17, 20, 23, 24]. Self-report data of self-efficacy or confidence can contain inherent bias, which is a limitation.

Level 5: Performance

Four studies focused on the impact of Project ECHO on delivery of outpatient care [14, 15, 23, 26]. Two of the studies reported an increase in communication with specialty care providers and provided examples of how these interactions informed changes in patient care practices [14, 15]. One study described the impact of ECHO case study presentations on subsequent improvements in patient care [26] while another discussed the impact that participation in ECHO had on increased referrals to behavioral health [23].

Level 6: Patient Health

One study directly correlated patient outcomes to participation in Project ECHO sessions by evaluating the overall number of opioid prescriptions, MME dosages per patient, the number of co-prescribed opioids and benzodiazepines, and the percent of opioid users [16]. This study compared data from sites that participated in Project ECHO and those that did not. This was an observational cohort study to determine systemic effects on patient health as a result of site-based participation in Project ECHO clinics. It was noted that although both the control and experimental groups had declined, a sharper decline existed for those participating in Project ECHO.

This study recognizes the limitations that the decreases observed in ECHO participating sites can also be attributed to changes in policy and guidelines for reduction in opioid prescriptions. Other limitations to this study were the skewed results towards men and active duty patients, the inability to analyze individual patient and provider data, specific reasons for declines in MME doses, opioid prescriptions, and number of co-prescriptions.

Level 7: Community Health

There were no studies that addressed the change in the health status of a community due to provider behaviors directly affected by participation in Project ECHO. However, a concomitant decline in total drug overdose deaths was noted in one study after the institution of a year-long tele-ECHO project focused on chronic pain and addiction [16, 23]. Three studies indicated an increase in DATA-waivered physicians as a result of participation in Project ECHO, which may ultimately lead to a positive change in community health [17, 19•, 21•].

Discussion

To the best of our knowledge, this is the first systemic review of published literature on outcomes of Opioid Project ECHO programs. Opioid education-focused Project ECHO outcomes are predominantly limited to levels 1 through 4 of Moore’s framework representing evaluation on participation, satisfaction, self-reported learning, and competence. Most studies report improvement in self-efficacy, knowledge, and attitudes toward patients with OUD while reporting a decrease in feeling of professional isolation. A study noted reductions in co-prescribing of benzodiazepines due to participation in Project ECHO. Another study noted concomitant declines in total drug overdose deaths after a year-long tele-ECHO project focused on chronic pain and addiction. Three Project ECHO focused on SUDs in New Mexico, New York, and Pennsylvania showed an increase in the number of buprenorphine-waivered following ECHO implementation. Given the current health epidemic in the lack of trained medical providers to manage opioid use and misuse, these findings highlight an important opportunity for the healthcare field. Opioid-focused Project ECHO also bridges a significant need for primary care clinicians to be paired with an experienced provider for guided practice, learn about local counseling resources, and receive CME courses on OUD.

An inherent limitation of the current review is the small number of studies available on this topic. Several studies suffered from selection bias, and none used a randomized control methodology. Although the current review utilized extensive search methods, the studies represented here could suffer from publication bias. This review highlighted a need for more research on tele-ECHO clinics focused on OUD which has been identified by other researchers [3]. An extensive amount of data exists on other types of ECHO projects. Few opioid Project ECHO programs have evaluated provider, patient, community, and cost-related outcomes, which is a critical area of future research. Opioid-focused Project ECHO is one of several systems-based approaches focused on education and the development of a skilled workforce. Other models to support workforce development, connect providers, and enhance patient treatment include PCSS, state-based models (Vermont, Maryland, Massachusetts, Oregon), and other models that integrate behavioral health (e.g., Medicaid health home model). However, widely generalizable data on education, provider, patient, and cost outcomes are not available. Future research to determine superiority or inferiority of a particular model over others relative to context should be evaluated. Clinicians conducting and participating in Project ECHO engage with tele-ECHO clinics during business hours, which results in loss of revenue for them and their practices. The lack of financial incentives is a significant concern for initial and continued participation [21]. For improvement in overall delivery and sustainability of opioid- and substance use-focused Project ECHO clinics, incentives for academic medical centers as well as providers presenting at Project ECHO clinics need to be evaluated.

With the intensifying need for trained providers in opioid and substance use treatment, this type of tele-ECHO clinic would benefit from more research to show the benefit for both provider and patient in order to ensure continued funding and sustainability.

Conclusion

Project ECHO for opioid use disorder has the potential to build an expert workforce, improve access to expert specialist care in isolated communities, disseminate information in a timely manner, increase current and relevant medical knowledge, reduce health disparities, promote evidence-based and high-quality care for complex conditions, create a community of practice, and increase job satisfaction in providers. Few studies have been published to date regarding the impact of OUD-specific tele-ECHO clinics on provider and patient. Given the documented need for highly trained providers and range of comorbid conditions that prevail in patients with OUD and SUD, the dissemination and provision of Project ECHO focused in this area should be a priority.