Talk About It! Evaluation of a Shared Decision-Making–Based Implementation Strategy to Increase Opioid Agonist Therapy

As opioid use disorder (OUD) continues to claim lives, some EDs across the US have begun offering life-saving opioid agonist therapy (OAT: buprenorphine and/or methadone). Implementation of OAT has had varied success. The objective of this study was to evaluate the pilot of a novel shared decision-making-based implementation strategy to increase trust and conversations about OAT initiation at a single site with high OUD burden.

“Talk About It” (TAI) was designed via community-based participatory research to foster compassionate conversations around OAT initiation via training, ongoing support via clinical champions, and the use of a physical conversation aid (CA). Implementation outcomes were collected at baseline and 12 months after implementation started, and included clinician report of receipt of training; validated measures of feasibly, acceptability, and appropriateness; reported use of the CA; actual distribution of the CA (counts); and report of frequency of conversations about OAT (measured by clinician report before and after implementation, compared via test of proportions).

45 and 47 clinicians completed pre- and post-implementation surveys, respectively, and 45 of 47 (96%) reported completing training. Median scores for feasibility, acceptability, and appropriateness were all 4 with means >4 for each (scale range 1-5, with higher scores indicating better potential for successful implementation). The majority (37, 79%) reported handing the CA to a patient at least once in the past 12 months, with 27(58%) reporting sharing it 2+ times, and 32(68%) reported using it to start a conversation. Distribution increased over time, with 16 English and Spanish CAs distributed in the first 6 months and 99 distributed in the second 6 months. Regarding increases in conversations about OAT (by clinician report), 42 (89%) reported having a conversation about starting buprenorphine within the past 12 months, as compared to 35/45(78%) at baseline (p=0.1). Forty (85%) reported having a conversation about starting methadone within the past 12 months, as compared to 27/45 (60%) at baseline (p<0.001).

Pilot implementation results suggest that a novel SDM-based implementation strategy is feasible, meets acceptability criteria, and may increase conversations about OAT. Further evaluation of patient-oriented outcomes such as changes in OAT initiation rates is needed.