What Contributes to Sustainability? Examining Access to Medications for Opioid Use Disorder in Low-Adopting VHA Facilities

Princess E. Ackland, Marie E. Kenny, Barbara A. Clothier, Hope A. Salameh, Natassia Boening, Adam J. Gordon, Siamak Noorbaloochi, Allison M. Gustavson, Wendy Miller, Hildi J. Hagedorn

Research output: Contribution to journalArticlepeer-review


Background: Successful implementation can increase the availability of evidence-based treatments but continued patient access can be threatened if there is not deliberate focus on sustainment. Real-world examples are needed to elucidate contributors to sustainability. Objective: We examined sustainability of outcomes of a study which tested a 12-month external facilitation intervention. The study evaluated change in access to medications for opioid use disorder (MOUD) in Veterans Health Administration (VHA) facilities in the lowest quartile of MOUD prescribing. Design: Convergent mixed-methods design. Participants: Thirty-nine providers and leaders from eight VHA facilities. Approach: Thirty-minute post-implementation telephone interviews explored whether barriers identified pre-implementation were successfully addressed, the presence of any new challenges, helpfulness of external facilitation, and plans for sustaining MOUD access. Interviews were analyzed using a rapid turn-around approach. VHA administrative data were used to characterize the facilities and assess their ratio of patients with an OUD diagnosis receiving MOUD (MOUD/OUD ratio) at the end of a 9-month sustainability period. Key Results: Commonly reported contributors to sustained MOUD access included national attention on the opioid epidemic, accountability created by study participation, culture shift in MOUD acceptability, leadership support, and plans to build on initial progress. Frequently reported barriers included staffing issues and lack of MOUD-devoted time; the need to overhaul existing policies, practices, and/or processes; and fear and anxiety about MOUD prescribing. All facilities either maintained MOUD/OUD ratio improvement (n = 2) or further improved (n = 6) at the end of sustainability. Facilities with the highest and lowest ratio at the end of sustainability used a team-based approach to MOUD delivery; however, organizational setting differences may have impacted overall MOUD access. Conclusions: Ensuring stable and consistent staff, and sufficient time dedicated to MOUD are critical to sustaining access to evidence-based treatment in low-adopting facilities. This study highlights the importance of investing in local, system-level changes to improve and sustain access to effective treatments.

Original languageEnglish (US)
Pages (from-to)2647-2654
Number of pages8
JournalJournal of general internal medicine
Issue number12
StatePublished - Sep 2023

Bibliographical note

Funding Information:
This study was funded by the Veteran Administrations Health Services Research and Development Investigator Initiated Research Project #16–145; Minneapolis Center of Innovation, Center for Care Delivery and Outcomes Research (CIN 13–406); Veteran Administrations Health Services Research and Development Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation (CIN 13–414) [AJG]; and the Veterans Health Administration Office of Academic Affiliations Advanced Fellowship in Clinical and Health Services Research (TPH 67–000). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.

Publisher Copyright:
© 2023, This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.


  • Sustainability; access; medications for opioid use disorder; Veterans


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