Table 2 Malleable components to GBOT implementation

I. Approach to slips and lapses

Approaches range from abstinence-only to relapse prevention to harm reduction (see below for further details)

II. Where and how buprenorphine prescription distribution occurs

Prescriptions can be distributed in or outside of the group session. Prescriptions may be provided as paper copies or e-prescribed directly to pharmacy. Patients may be required to attend every group or a certain percentage of groups/month in order to get a prescription

III. Whether or not individual appointments are offered in association with GBOT

Group patients may be offered individual appointments associated with the group visit before or after the group session on an as needed or scheduled basis. Alternatively, individual appointments may not be associated with the group session, and the patient is encouraged to schedule a separate appointment with an onsite provider, such as their primary care provider or psychiatrist

IV. Mix of patients based on status in recovery

Patients may attend groups with others in similar stages of recovery (“leveled groups”) [67] in which they graduate from one level to enter a different level (weekly, bi-weekly or monthly group). Or they may attend with patients in various stages of recovery (“mixed groups”)

V. Mix of patients based on other factors (SUD/psychiatric diagnoses, MAT, gender, and other identities): homogenous versus heterogeneous groups

Some groups may be exclusively for patients with OUD on B/N or XR-naltrexone, while other groups may include patients with non-OUD substance use disorders, such as alcohol use disorder (AUD). Some groups are for people with certain types of psychiatric symptoms, e.g., bipolar [68], PTSD [69] groups. Some groups are gender specific [70] and others are tailored to other group identities, such as LGBTQ or ethnicity, since having a shared identity and background has demonstrated improved SUD-related outcomes [71,72,73,74,75,76]

VI. Type of provider facilitating group, their associated background, training, and skill set

Groups may be facilitated by primary care providers (physicians, physician assistants, nurse practitioners) and/or licensed behavioral health care providers (social workers, certified addiction registered nurses, psychologists).

VII. Psycho-educational approach

Based on their experience and background training and the needs of the group participants, facilitators can run various types and mixes of psycho-educational approaches: support, cognitive behavioral therapy, educational, skills-based, and interpersonal processing groups (see below for further details)

VIII. Buprenorphine dosing

Dosing typically ranges between 2–24 mg buprenorphine/day (see below for further details)

IX. Duration and frequency of groups

Group visits can last from 30 to 120 min. They can be offered several times a week, such as in an intensive outpatient setting or less frequently in other settings

X. Enrollment scheduling and size of group

Group visits can enroll patients through various practices, including fixed membership (with a stable cohort of participants over time) or rolling admissions (with new members continuously entering and leaving the group). Groups can also use partial rolling admission (with a new cohort entering together every 4 weeks) to minimize impact on group cohesion [77, 78]

Participation may be time-limited, with a defined number of sessions or a defined curriculum, or it may be ongoing, lasting until members meet specific goals, such as reduced drug use or stabilization of medical and mental health issues. or last indefinitely

Size of groups can range from 9 to 16 patients (based on best practice recommendations [15]) but are often smaller due to patient absences and CMS billing restrictions for group psychotherapy. Group size might be limited by B/N-prescriber’s capacity [8]

XI. Admissions process

Patients can enter GBOT programs either without recent prior addiction treatment or after completing a more intense program of recovery. All patients have individual appointments with B/N-prescribing providers before beginning group-based treatment

XII. Inductions and observed dosing

Sites can offer in-office inductions or home induction with phone call follow-up based on patient desires, medical necessity, and provider safety concerns [79,80,81,82,83]

XIII. Contingency management

Sites may or may not offer rewards (positive reinforcement) or remove negative stimuli (negative reinforcement) in response to patient behaviors. For example, sites may reward patients doing well (which can be variably defined based on criteria such as attendance rates, toxicology results, social/functional outcomes) by spacing them out to less frequent groups [82, 83]. Some programs may also use monetary rewards to encourage attendance or abstinence [84, 85], using direct payments or a fishbowl system [86, 87]. The rewards can be removed when people do not meet the agreed upon expectations. Contingency management works best when the rewards are given at a high frequency rate for small, manageable behaviors and occur as close in time to the targeted behavior as possible (for example, during group right after each toxicology result rather than after a month of toxicology results) [62]

XIV. Monitoring for illicit and non-prescribed drug use and diversion: type of screening test and frequency of screening

All sites should monitor for drug use. However, the type of screening and frequency can vary: Sites can use urine screens, oral fluid swabs, and/or pill counts to monitor illicit and non-prescribed drug use and diversion. These can be employed regularly at every group visit and/or patients can be called to come in randomly in between group visits or both. The tests can be employed at the group visit itself and/or at individual appointments associated with the group, based on attendance frequency expected for each patient