Overview

• A randomized control trial examined the impact of a collaborative care intervention in primary care patients with opioid and alcohol use disorders (OAUD) vs. primary care alone on the delivery of treatment and self-reported abstinence related to OUAD.

Organization Name

Venice Family Clinic

Organization Type

• FQHC

National/Policy Context

• While the prevalence of OAUD is increasing in the United States, identification and treatment of OAUD continues to be overlooked in many communities. As a result, many of those with OAUD continue to be at heightened risk of related morbidity and mortality, and they are vulnerable to incurring significant healthcare costs from complications related to their disease.
• There has been an increase in federal coverage for substance use disorder (SUD) treatments. OAUD is often treated in the primary care setting due to being treatable with medications (unlike other SUDs). Collaborative Care (CC) has not yet been tested for delivering treatment and improving results for OAUD.

Patient Population Served and Payor Information

• Of the over 100,000 patients seen each year at Venice Family Clinic, 58% are of Hispanic origin and 11% are African American.

Leadership

• Dr. Katherine E. Watkins was the principal investigator for this study.

Funding

• This project was funded by a grant from the National Institute on Drug Abuse (NIDA): “R01DA034266 (PI: Watkins)”

Tools or Products Developed

• Chronic care model: a model combining behavioral health and primary care, which was adopted for this project.
• Baseline assessment: an interview that collected the demographics of the participants including:homeless status, DSM diagnosis of alcohol/heroin/prescription opioid use or dependence, past 30-day use of alcohol and opioids, 30-day use of methamphetamines/cocaine/marijuana, typicaly number of drinks per day in the past 12 months, number of heavy drinking days (defined as 4+ drinks for women, 5+ drinks for men), consequences of alcohol or opioid use using the Short Inventory of Problems Alcohol and rugs, depression screening using PHQ-8, health-related quality of life using the SF-12 Health Survey, ED or overnight hospital stays in the past 90 days, and self-reported receipt of lifetime and past year SUD treatment.
• Registry: electronically tracked treatment progress and reminded care coordinators to reach out to patients who missed visits.

Training

• The seven therapists from the clinics received an hour of training about the program. The five of those therapists who were randomly chosen for the CC condition were given an additional two days of training.
• Care coordinators received two days of motivational interviewing training.
• Clinicians received their Drug Enforcement Agency waiver to prescribe buprenorphine/naloxone (BUP/NX).

Tech Involved

• Statistical software

Team Members Involved

• MAs
• NPs
• PAs
• Physicians
• Psychologist

Workflow Steps

• During a primary care visit, partipants were screened for substance use in the past 3 months using a three question screener (based on the National Institute on Drug Abuse quick screen) given to them by a medical assistant.
• Consenting patients who screened positive for risky use were referred for assessment by the research team. Participants gave written informed consent and were compensated for research activities ($5 for eligibility screener, $50 for baseline assessment, $50 for follow-up assessment).
• Participants in the CC group were enlisted in a registry. The registry allowed for tracking of treatment progress and reminded care coordinators to contact patients who missed appointments.
• Care coordinators made regular evaluations, in person, at every visit made to the clinic (as scheduled through appointments) of substance use (with results being entered into the registry). Data was reviewed during team meetings. The number of appointments that patients attended varied on their time availability and commitment of coming in for scheduled appointments.
• Six months after baseline assessment, participants take part in a follow-up assessment over the phone.
• Team meetings were conducted weekly. Supervision for the CC condition was led by the clinical psychologist. Care coordinators and therapists attended the meetings. All sessions were audiotaped and uploaded to site for review during supervision.

Budget Details

• Cost of pharmacotherapy consultation provided by a board-certified addiction medicine physician affiliated with a local academic medical center.
• 28 care coordinators, seven therapists
• Patient compensation for study ($5 for screener, $50 for baseline assessment, and $50 for follow-up assessment).

Where We Are

• The project has been completed (June 3, 2014-September, 2016).

Outcomes

• Medical engagement: after the six months of the study, participants in the CC group received more treatment (measured by appointment time) with care members including clinicians, and psychologists in comparison to the regular care group.
• Substance abstinence: at six months, CC participants had higher abstinence from alcohol and opioids compared to the control arm.

Benefits

• Those who participated in the CC group had a decreased likelihood of substance use relapse in comparison to the other group.
• The study proved that implementation of a CC program into the primary care system in communities is feasible and effective.

Unique Challenges

• Almost half of the participants were homeless, which was an added challenge. It was difficult to get in touch with them to schedule appointments and follow up.
• Many of the participants had been hospitalized for OAUD use before participating in this treatment, and  many had never received professional guidance or treatment regarding OAUD.
• Study limitations:
  • Generalizability: the FQHC being used for this project was linked to behavioral health, so the results may not be the same for other facilities not linked to the same type of care being administered.

Sources

Watkins KE, Ober AJ, Lamp K, Lind M, Setodji C, Osilla KC, Hunter SB, McCullough CM, Becker K, Iyiewuare PO, Diamant A, Heinzerling K, Pincus HA. Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care: The SUMMIT Randomized Clinical Trial. JAMA Intern Med. 2017 Oct 1;177(10):1480-1488. doi: 10.1001/jamainternmed.2017.3947. PubMed PMID: 28846769; PubMed Central PMCID: PMC5710213.