Explaining Variation in VA Opioid Treatment Program Clinical Practice Following Regulatory Reform: A Qualitative Study

Abstract

Background:

Federal rules governing opioid treatment programs (OTPs)—altered during and in the aftermath of the COVID-19 public health emergency—granted OTPs greater flexibility in clinical care (eg, take-home methadone doses, telehealth). Revised rules have not appeared to impact patient safety and were largely welcomed by patients and clinicians. Despite this, OTPs varied in adoption, and some have returned to pre-pandemic practice. In this qualitative study, we examined variation in clinical practices across U.S. Department of Veterans Affairs (VA) OTPs following the opportunity for reform, as well as the beliefs and perspectives of OTP administrators that may shed light on variability in decisions to adopt programmatic changes.

Methods:

We contacted OTP administrators (medical directors, program managers) at all 33 VA OTPs nationally. We conducted semi-structured interviews from September 2023 to June 2024. Data were analyzed using an inductive-deductive analytic approach employing the framework method. Transcripts were coded and charted into a framework matrix that included site characteristics, clinical practices and requirements, and summaries of domains developed during the coding stage, allowing for comparison across sites.

Results:

Administrators from 28/33 VA OTPs completed interviews. Participants described diverse clinic policies regarding take-home schedules, frequency and response to toxicology testing, and requirements to attend groups. Telehealth utilization increased in almost all locations. Decisions to adopt more flexible clinical requirements appeared to reflect differential perceptions of patient and community risks and beliefs about the effects of the regulations on the therapeutic environment. While leaders appreciated the opportunity to individualize treatment, they also expressed a need for guidance to ensure consistent, equitable care.

Conclusions:

This study reveals variation in OTP clinical practice across VA in the wake of regulatory reform. To inform decision-making in the new regulatory environment, research examining the effects of OTP clinical practices on patient engagement, retention, and quality of care should be prioritized.