Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care

Abstract

IMPORTANCE Primary care offers an important and underutilized setting to deliver treatment for opioid and/or alcohol use disorders (OAUD). Collaborative care (CC) is effective but has not been tested for OAUD.OBJECTIVE To determine whether CC for OAUD improves delivery of evidence-based treatments for OAUD and increases self-reported abstinence compared with usual primary care. DESIGN, SETTING, AND PARTICIPANTSA randomized clinical trial of 377 primary care patients with OAUD was conducted in 2 clinics in a federally qualified health center. Participants were recruited from June 3, 2014, to January 15, 2016, and followed for 6 months.INTERVENTIONS Of the 377 participants, 187 were randomized to CC and 190 were randomized to usual care; 77 (20.4%) of the participants were female, of whom 39 (20.9%) were randomized to CC and 38 (20.0%) were randomized to UC. The mean (SD) age of all respondents at baseline was 42 (12.0) years, 41 (11.7) years for the CC group, and 43 (12.2) years for the UC group. Collaborative care was a system-level intervention, designed to increase the delivery of either a 6-session brief psychotherapy treatment and/or medication-assisted treatment with either sublingual buprenorphine/naloxone for opioid use disorders or long-acting injectable naltrexone for alcohol use disorders. Usual care participants were told that the clinic provided OAUD treatment and given a number for appointment scheduling and list of community referrals. MAIN OUTCOMES AND MEASURESThe primary outcomes were use of any evidence-based treatment for OAUD and self-reported abstinence from opioids or alcohol at 6 months. The secondary outcomes included the Healthcare Effectiveness Data and Information Set (HEDIS) initiation and engagement measures, abstinence from other substances, heavy drinking, health-related quality of life, and consequences from OAUD.RESULTS At 6 months, the proportion of participants who received any OAUD treatment was higher in the CC group compared with usual care (73 [39.0%] vs 32 [16.8%]; logistic model adjusted OR, 3.97; 95% CI, 2.32-6.79; P < .001). A higher proportion of CC participants reported abstinence from opioids or alcohol at 6 months (32.8% vs 22.3%); after linear probability model adjustment for covariates (β = 0.12; 95% CI, 0.01-0.23; P = .03). In secondary analyses, the proportion meeting the HEDIS initiation and engagement measures was also higher among CC participants (initiation, 31.6% vs 13.

Barriers to integrating the continuum of care for opioid and alcohol use disorders in primary care: A qualitative longitudinal study

“…Collaborative care for OAUD was a system-level clinical intervention that used care coordinators and a patient registry to support the delivery of medication-assisted treatment and/or a six-session motivational interviewing- and cognitive therapy- based brief treatment (Ober et al, 2015; Rollnick & Miller, 1991; Watkins et al, In press; Watkins et al, 2017). In the current study, implementation refers to the process of integrating the continuum of care for OAUD using collaborative care into the two primary care clinics, including screening, brief intervention, MAT, and brief therapy.…”

“…Effective integration of OAUD treatment into primary care settings could increase access to treatment for many individuals with OAUDs. However, in order for OAUD treatment to be adopted and integrated within existing practices, organizations must have the capacity to deliver the treatment (Meyer, Davis, & Mays, 2012; Ober et al, 2015; Watkins et al, 2017). …”

Developing an opioid use disorder treatment cascade: A review of quality measures

“…not specific to OUD). These studies found higher rates of initiation and engagement when patients were identified in specialty settings or receiving care in specialty settings (Harris & Bowe, 2008; Harris, Bowe, Finney, & Humphreys, 2009) although primary care (Kim, Saitz, Cheng, et al, 2011) and collaborative care initiatives have also shown to be successful (Watkins, Ober, Lamp, et al, 2017) at engaging patients. Other studies found that patients with greater criminal justice involvement, addiction severity, and racial/ethnic minorities often had relatively lower probabilities of treatment initiation and engagement (Acevedo, Garnick, Dunigan, et al, 2015; Brown, Bennett, Li, & Bellack, 2011; Lee, Garnick, O’Brien, et al, 2012) but this was not always observed (Bensley, Harris, Gupta, et al, 2017), reflecting variation in patient populations across settings.…”

“…Although some patients may receive high quality care for other SUDs that does not involve MAT, the evidence does not currently support this as a first line approach for OUD. Additionally, studies such as Watkins, Paddock, Hudson, et al, 2017 have demonstrated the limitations of general SUD measure reliability for OUD and pitfalls of their misapplication to OUD, limiting clinical validity. For example, in many systems, the initiation of MAT may reflect underlying addiction severity requiring risk adjustment as a confounder for outcomes such as mortality in addition to serving as a process measure approximating quality care.…”

The Costs of Implementing Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care

“…We further describe these below and in Ober et al (2015). During this phase, we developed a collaborative care service delivery protocol in response to identified barriers to delivering OAUD treatment in the FQHC Watkins et al, 2017).…”