• Denalee M O'Malley, Cilgy M Abraham, Heather S Lee, Ellen B Rubinstein, Jenna Howard, Shawna V Hudson, Autumn M Kieber-Emmons, and Benjamin F Crabtree.
• Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
• Fam Pract. 2022 Mar 24; 39 (2): 282-291.

BackgroundOver the last decade, primary care clinics in the United States have responded both to national policies encouraging clinics to support substance use disorders (SUD) service expansion and to regulations aiming to curb the opioid epidemic.ObjectiveTo characterize approaches to SUD service expansion in primary care clinics with national reputations as workforce innovators.MethodsComparative case studies were conducted to characterize different approaches among 12 primary care clinics purposively and iteratively recruited from a national registry of workforce innovators. Observational field notes and qualitative interviews from site visits were coded and analysed to identify and characterize clinic attributes.ResultsCodes describing clinic SUD expansion approaches emerged from our analysis. Clinics were characterized as: avoidant (n = 3), contemplative (n = 5) and responsive (n = 4). Avoidant clinics were resistant to planning SUD service expansion; had no or few on-site behavioural health staff; and lacked on-site medication treatment (previously termed medication-assisted therapy) waivered providers. Contemplative clinics were planning or had partially implemented SUD services; members expressed uncertainties about expansion; had co-located behavioural healthcare providers, but no on-site medication treatment waivered and prescribing providers. Responsive clinics had fully implemented SUD; members used non-judgmental language about SUD services; had both co-located SUD behavioural health staff trained in SUD service provision and waivered medication treatment physicians and/or a coordinated referral pathway.ConclusionsEfforts to support SUD service expansion should tailor implementation supports based on specific clinic training and capacity building needs. Future work should inform the adaption of evidence-based practices that are responsive to resource constraints to optimize SUD treatment access.© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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