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Background  The Veterans Health Administration (VHA) is invested in expanding access to medication treatment for opioid use disorder (MOUD) to save lives. Access varies across VHA facilities and, thus, requires implementation strategies to promote system-wide adoption of MOUD. We conducted a 12-month study employing external facilitation that targeted MOUD treatment among low-adopting VHA facilities. In this study, we sought to evaluate the patterns of perceived barriers over 1 year of external implementation facilitation using the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework.    Methods  We randomly selected eight VHA facilities from the bottom quartile of the proportion of Veterans with an OUD diagnosis receiving MOUD (< 21%). The 1-year external implementation intervention included developmental evaluation to tailor the facilitation, an on-site visit, and monthly facilitation calls. Facilitators recorded detailed notes for each call on a structured template. Qualitative data was analyzed by coding and mapping barriers to the constructs in the i-PARIHS framework ( Innovation ,  Recipients ,  Context ). We identified emerging themes within each construct by month.    Results  Barriers related to the  Innovation,  such as provider perception of the need for MOUD in their setting, were minimal throughout the 12-month study. Barriers related to  Recipients  were predominant and fluctuated over time.  Recipient  barriers were common during the initial months when providers did not have the training and waivers necessary to prescribe MOUD. Once additional providers ( Recipients ) were trained and waivered to prescribe MOUD,  Recipient  barriers dropped and then resurfaced as the facilities worked to expand MOUD prescribing to other clinics.  Context  barriers, such as restrictions on which clinics could prescribe MOUD and fragmented communication across clinics regarding the management of patients receiving MOUD, emerged more prominently in the middle of the study.    Conclusions  VHA facilities participating in 12-month external facilitation interventions experienced fluctuations in barriers to MOUD prescribing with contextual barriers emerging after a facilitated reduction in recipient- level barriers. Adoption of MOUD prescribing in low-adopting VHA facilities requires continual reassessment, monitoring, and readjustment of implementation strategies over time to meet challenges. Although i-PARIHS was useful in categorizing most barriers, the lack of conceptual clarity was a concern for some constructs.    Supplementary Information  The online version contains supplementary material available at 10.1186/s13722-021-00259-1.

Fluctuations in barriers to medication treatment for opioid use disorder prescribing over the course of a one-year external facilitation intervention