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Background: Medications for opioid use disorder (MOUD) are shown to improve quality of life while reducing risk for overdose and death among people with OUD. The Veterans Health Administration has supported numerous efforts to increase MOUD availability, but a treatment gap persists: among Veterans with OUD, half do not receive MOUD, and over 5000 died from overdose between 2016 and 2021. To improve MOUD adoption in a large VA health system, we developed a care model to identify and proactively engage Veterans with untreated OUD. Methods: The Virtual Outreach Low-Threshold MOUD care initiative (VOLT), a multi-faceted implementation bundle to support MOUD adoption, had 3 core elements: (1) an electronic health record-powered case-finder to identify individuals with untreated OUD and recent OUD-related clinical events (new OUD diagnosis, nonfatal opioid-involved overdose, acute care encounter for OUD, or referral to residential treatment for OUD), (2) case-finder result reconciliation by a physician champion, and (3) proactive tele-outreach to validated cases of untreated OUD by an MOUD prescriber. Results: The Case-Finder identified 526 encounters over a 2-year evaluation period. Most were either flagged for an inaccurate OUD diagnosis corrected by the physician champion (163, 31%), or validated as appropriate for tele-outreach (107, 20%). Of tele-outreach cases, 67 (63%) were contacted, and 37 (55%) were deemed MOUD-eligible. Of these, 28 (76%) initiated MOUD, all opting for buprenorphine. Retention on MOUD was 71% at 3 months and 57% at 6 months. The proportion of health system Veterans with OUD receiving MOUD increased from 44% pre- to 54% post-implementation. Conclusion: VOLT engaged Veterans with untreated OUD and recent OUD-related clinical events in buprenorphine care with high 3- and 6-month retention and was associated with a 10-percentage point increase in system-wide MOUD adoption. This novel care model may complement existing efforts to close the MOUD treatment gap.

In a drug landscape dominated by the highly potent synthetic opioid fentanyl, traditional methadone initiation protocols increasingly fail people with opioid use disorder (OUD). While “low” initial dose selection and “slow” dose adjustment rates reduce risk for methadone-associated toxicity, they also result in weeks to months of unrelieved withdrawal symptoms and cravings, especially for people with high opioid tolerance from routine fentanyl use. For this growing population, “low-and-slow” forces a choice between 3 poor options: suffer weeks to months of withdrawal, self-manage withdrawal through non-prescribed substance use, or give up on treatment. Our commentary combines a Peer Support Specialist’s lived experiences with methadone initiation and evidence from the peer-reviewed literature to illustrate this problem and the role of one potential solution: rapid methadone initiation (RMI), defined here as reaching a methadone dose of 80 mg or more within the first 7 days of treatment. For appropriately selected patients, RMI is associated with positive outcomes, including improved patient satisfaction, reduced readmission rates, and increased retention in care. Though regulations permit and growing evidence supports RMI, adoption remains limited. Our commentary, therefore, concludes by sharing frameworks to support providers in implementing RMI as a potential treatment option for people with OUD across applicable care settings. Methadone’s life-saving potential depends on dosing that matches the physiological reality of fentanyl use. Collectively, addiction clinicians define the community standard of care. In the face of a transformed drug landscape, it is time for that standard to evolve to ensure that the option for rapid and effective relief becomes the rule, rather than the exception.