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The nation has been confronted with an opioid crisis for several years. According to the Centers for Disease Control and Prevention (CDC), nearly one million people have died since 1999 from a drug overdose; and in 2020 alone, nearly 75% of drug overdose deaths involved an opioid (n=69,000). These overdose deaths are attributed to prescription opioids, heroin, and synthetic opioids (i.e., fentanyl).1 VA has invested in several initiatives to encourage the “gold standard” treatment for Veterans with opioid use disorder (OUD) – medication treatment, including methadone, buprenorphine, and naltrexone. Despite these efforts, by 2017, just more than one-third of all Veterans diagnosed with OUD received medications for opioid use disorder (MOUD).2 Thus, VA’s Office of Mental Health and Suicide Prevention (OMHSP) launched the Stepped Care for Opioid Use Disorder, Train-the Trainer (SCOUTT) initiative to facilitate access to MOUD in VA non-substance use disorder (SUD) care settings. In 2018, 18 VA healthcare networks each sent one multidisciplinary healthcare team from either primary care, general mental health, or pain to the SCOUTT kick-off conference.
Improving the Implementation and Spread of SCOUTT
Two QUERI initiatives are dedicated to the implementation and evaluation of the SCOUTT Initiative. Led by Drs. Adam Gordon, Hildi Hagedorn, Princess Ackland, and Amanda Midboe, the SCOUTT Facilitation team works to implement a comprehensive plan to train interdisciplinary teams in VA primary care, general mental health, and pain clinics to offer SCOUTT to Veterans with OUD. As part of this effort, each VISN is assigned an external facilitator (modeled on the Behavioral Health QUERI implementation strategy), who works closely with the SCOUTT clinic teams through regular monthly contacts to develop action plans, address barriers, and provide resources. In addition, the SCOUTT Facilitation team provides regular monthly cross-site community of practice calls and didactic educational opportunities. Through a three-day virtual conference in September 2020 sponsored by OMHSP, an additional 18 “phase 2” SCOUTT clinics were added to the initiative. [See response to conference in section on VA SCOUTT Teams.]
Led by Dr. Eric Hawkins, the Evaluating Implementation of SCOUTT QUERI team works closely with OMHSP to assess whether the SCOUTT program improves access to OUD care – and to identify barriers that inhibit and facilitators that promote its success. Their research shows that since the launch of the SCOUTT initiative in 2018, the number of Veterans with an opioid use disorder receiving care in a dedicated SCOUTT clinic who received buprenorphine has increased 267% (from 202 per month to 740 per month). The number of clinicians prescribing buprenorphine also has increased 240% (from 35 per month to 119 per month).
Research Building Blocks
The QUERI partnered national implementation and evaluation initiative enabled the rapid deployment of SCOUTT using strong implementation strategies derived from HSR&D research. For example, an HSR&D-funded study titled “Testing a Novel Strategy to Improve Implementation of Medication-Assisted Treatment for Veterans with Opioid Use Disorders in Low Performing Facilities,” (also referred to as ADAPT-OUD) led by Drs. Hagedorn and Gordon, greatly informed the facilitation of the SCOUTT initiative.3,4 In addition, lessons learned from another study funded by HSR&D titled “A Multi-Faceted Intervention to Improve Alcohol Dependence Pharmacotherapy Access,” led by Drs. Hagedorn and Alex Sox-Harris, informed the successful implementation strategy for ADAPT-OUD, which, in turn, helped the implementation of the SCOUTT initiative.5
The SCOUTT intervention was based on randomized controlled trials showing the effectiveness of stepped care for substance use disorder – and was grounded in a long-term commitment by HSR&D and QUERI to identify and mitigate multi-level barriers to the uptake of SUD care for Veterans. They also committed to further study on how best to optimize strategies to ensure successful implementation and sustainment of MOUD in real-world practice.
VA SCOUTT Teams Discuss Effects of Initiative on their Facility
SCOUTT investigators recently surveyed 37 “Stepped Care for Opioid Use Disorder Train-the-Trainer (SCOUTT) Initiative” Phase 1 and 2 teams about their models of care, facilitators, and barriers to implementation, in addition to their general impressions of the Initiative. So far, they have received responses from SCOUTT teams at 29 facilities across the VA healthcare system. Following are just some of the very positive responses to the question: “Please indicate your overall impression of the SCOUTT Initiative at your facility and nationally.”
It [SCOUTT] has been a tremendous success in changing the culture, expanding access, and providing care in step-down (“more common”) settings. Prior to SCOUTT, our VISN was the lowest in the nation in providing MOUD, now we are better than the national average within the VA.
Overall, [the] SCOUTT initiative has significantly improved MOUD awareness and recognition within our facility. Our pain team is very thankful for the information and support we have had via the SCOUTT initiative – and hope to continue using this initiative as a means for further implementation of MOUD at our facility.
SCOUTT has been enormously beneficial at our facility as we start to expand MOUD care for our Veterans to more settings. Nationally, the support has been great.
Overall: Outstanding! I am very grateful to have the opportunity to have participated in the SCOUTT conference, as it was a unique opportunity to build relationships with interdisciplinary team members from my own facility and across the country. The SCOUTT conference was well timed and laid the foundation for us to collaborate with one another during the pandemic.
[The] SCOUTT initiative brought together various efforts across the area and gave voice to the struggles of patients with OUD and providers who are trying to treat them. This is not a simple problem that is going to change in a few years. Persistence under the SCOUTT banner is key for change.
Incredible! It is really helpful to have the vocabulary and evidence that SCOUTT provides to do the work.
- Centers for Disease Control and Prevention (CDC). Data Overview. The drug overdose epidemic: Behind the numbers.
- Gordon A, Drexler K, Hawkins E, et al. Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative: Expanding access to medication treatment for opioid use disorder within Veterans Health Administration facilities. Substance Abuse. 2020(41)3:275-282.
- Hagedorn H, Gustavson A, Ackland P, et al. Advancing pharmacological treatments for opioid use disorder (ADaPT-OUD): An implementation trial in eight Veterans Health Administration facilities. Journal of General Internal Medicine. January 2022;3-109.
- Gustavson A, Kenny M, Wisdom J, et al. Fluctuations in barriers to medication treatment for opioid use disorder prescribing over the course of a one-year external facilitation intervention. Addiction Science & Clinical Practice. August 6, 2021. Open Access.
- Hagedorn H, Wisdom J, Gerould H, et al. Alcohol use disorder pharmacotherapy and treatment in primary care (ADaPT-PC) trial: Impact on identified barriers to implementation. Substance Abuse. 2022;43(1):1043-1050.