Provider talking to woman

Goal: The goal of low-barrier buprenorphine, a new and growing model of care for opioid use disorder (OUD), is to reduce opioid overdose deaths and improve health and quality of life for all people with OUD.

Strategy: Increase access to buprenorphine for people with OUD by creating patient-centered programs that are easy to access, offer a high quality of care, and eliminate hurdles to access or stay in care for OUD.

Rationale: Medications are the front-line treatment for opioid use disorder and are underutilized.

In Washington State, data that helped motivate this model of care included:

  • No significant impact of an overdose prevention intervention on people at high risk for overdose (most with opioid use disorder and homeless/unstably housed).
  • Syringe service client data that indicate:
    • Most people (78%) who use opioids want to stop or reduce their use,
    • The number one intervention of interest is treatment medication (69%),
    • The majority of respondents  (59%) needed medical care and didn’t get it, often because of being treated poorly by health care providers.

Other names for this model include: Medication first; Meds First; Rapid Access; Low Threshold; Med first, more later.

Underlying this model are core beliefs about OUD:

  • Addiction is not a moral failing, it is a medical condition with important psychosocial components,
  • OUD is treatable,
  • Medications are the front-line treatment,
  • People get better,
  • Relapse is expected,
  • Language matters.

These beliefs guide the low-barrier model and influence how and where care is delivered.

Hallmarks of low-barrier buprenorphine programs
  • Short time to medication start (same day for most).
  • Polysubstance use allowed initially and ongoing.
  • Counseling always offered, not mandated.
  • Urine drug screens are used to inform clinical care, not primarily as a basis for discharge.
  • Duration varies: Time-limited or on-going care.
  • Settings vary: Services delivered in the community at trusted locations e.g. syringe service program; Addiction treatment program; Primary care clinic; Behavioral health agency.

Drop-in visit

Some people with OUD may have complicated lives and may not be able to keep or desire appointments. Drop-in visits mean that someone can access care when they’re ready and without additional restrictions. This helps improve access for people who are homeless or others who may find it difficult to keep an appointment.

Short time to medication start

The sooner someone is able to start on medication, the sooner they reduce their risk of dying from overdose. Home inductions are standard, observed can be done when warranted.

Polysubstance use allowed initially and ongoing

A patient on MOUD is less likely to die from overdose than a patient not on MOUD, even if they continue to use other substances. In addition, FDA does not encourage providers to withhold buprenorphine from patients who continue to use benzodiazepines.

If a patient continues to use other substances like methamphetamine, alcohol, or benzodiazepines, it should be an indication that someone needs more care, not less. Low-barrier programs work with patients to understand why they continue to use, and do not discontinue medications due to the use of other substances. Preliminary evidence indicates that many patients will stay on buprenorphine even as they use methamphetamine and some will decrease their methamphetamine use.

Counseling offered, but not required

Many people benefit from counseling for their mental health or OUD while on buprenorphine. However, requiring counseling can be an unnecessary and counter-productive barrier to care for some patients who do not want to participate in counseling as a condition of treatment.

Research, including a Cochrane Review, shows that counseling did not provide additional benefit in reducing mortality among people on medications for opioid use disorder.

Regular urine drug screens

Urine drug screens can be used to determine if patient is taking their buprenorphine or other substances and to improve quality of care.

Time-limited or on-going care

Programs should decide if they are an initial location where people can access care, and then be transitioned to a longer-term program or if they are a place where people can start and continue care on an ongoing basis.

Services delivered in the community at trusted locations

Syringe services programs, programs serving unhoused people, and community health centers are examples of trusted locations that have low-barrier buprenorphine programs. People who use opioids may already have relationships and trust with the staff at these organizations.

Shorten time between treatment episodes

Relapse is a part of any chronic condition, including opioid use disorder. Low-barrier programs encourage people to return to care as soon as possible if they have a relapse, rather than end their treatment. Relapse is a sign that someone needs more care, not less.

Research on low-barrier buprenorphine programs

Evaluation of low-barrier models is ongoing and this model shows promise for engaging patients in care and reducing deaths related to OUD.

Watch a webinar about the Medication-First Model for low-barrier buprenorphine

Presenters: Mark Duncan, MD and Caleb Banta-Green, PhD, MPH, MSW

During the presentation Mark Duncan, MD and Caleb Banta-Green, PhD, MPH, MSW discussed the Medication-First Model. This model aims to address the underlying issues around why less than a quarter of people with OUD are on medications. Many programs are designed to serve the clients most “motivated” to reduce/stop their illicit opioid use. But these criteria have the perverse effect of excluding large proportions of people who DO want to reduce/stop use, but cannot initiate or sustain care in traditional appointment based health care settings. (November 2020)