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Collaborative care improves outcomes for opioid, alcohol use disorders

Integrating a collaborative care intervention for opioid and/or alcohol use disorders in primary care settings significantly increased access to treatment and abstinence from drugs and alcohol compared with usual care, according to research published in JAMA Internal Medicine.

“Mortality rates are rising from increases in drug overdoses, suicides, and alcohol-related liver disease, yet substance use disorders continue to be underidentified and undertreated,” Katherine E. Watkins, MD, MSHS, from The RAND Corporation, and colleagues wrote. “The consequences of this unmet need are great, including increased risk of disease, injury, disability and death, and large social and health care costs. Opioid and alcohol use disorders are of particular concern owing to their high rates of morbidity and mortality and the increasing prevalence of prescription opioid misuse.”

“Although treatment in specialty settings is important for individuals with severe dependence, limited availability and stigma mean that specialty care alone is insufficient to address treatment needs,” they added. “Primary care offers an important and underutilized setting for [opioid and alcohol use disorders] treatment.”

“Collaborative care is an effective strategy for increasing the delivery of evidence-based treatment and improving outcomes, but, to our knowledge, has not been tested for [opioid and alcohol use disorders],” they continued.

Watkins and colleagues conducted a randomized clinical trial (SUMMIT) in two clinics in a federally qualified health center to analyze whether collaborative care for opioid and alcohol use disorders increases delivery of evidence-based treatments and self-reported abstinence compared with usual primary care. They enrolled 377 primary care patients with an opioid and/or alcohol use disorder (20.4% female; mean age, 42 years) and randomly assigned them to receive either collaborative care (n = 187) or usual care (n = 190).

Patients in the collaborative care group met with care coordinators who evaluated their motivation, encouraged them to meet with a therapist for evaluation and treatment planning and regularly performed assessments of their substance use. These patients were input into a registry that monitored their treatment progress. The registry also prompted care coordinators to follow up with patients who missed scheduled visits. Patients in the usual care group were informed that the clinic offered treatment and were given a phone number to schedule an appointment, as well as a list of community referrals. These patients did not receive any further contact or outreach.

Results indicated that more patients in the collaborative care group received any opioid and/or alcohol use disorders treatment at 6 months than those in the usual care group (39% vs. 16.8%; aOR = 3.97; 95% CI, 2.32-6.79). In addition, patients receiving collaborative care were more likely to report abstinence from opioids or alcohol at 6 months than those receiving usual care (32.8% vs. 22.3%; after linear probability model adjustment for covariates: beta = 0.12; 95% CI, 0.01-0.23). Secondary analyses revealed that there were also more patients in the collaborative care group who met the Healthcare Effectiveness Data and Information Set initiation and engagement measures (initiation, 31.6% vs 13.7%; aOR = 3.54; 95% CI, 2.02-6.2; engagement, 15.5% vs. 4.2%; aOR = 5.89; 95% CI, 2.43-14.32) and who abstained from opioids, cocaine, methamphetamines, marijuana and any alcohol (26.3% vs. 15.6%; effect estimate, beta = 0.13; 95% CI, 0.03-0.23), compared with the usual care group.

“Among adults with [opioid and alcohol use disorders] seen in primary care, the SUMMIT intervention resulted in significantly more evidence-based treatment and abstinence from alcohol and drugs at 6 months, compared with usual care,” Watkins and colleagues concluded. “These findings suggest that treatment for [opioid and alcohol use disorders] can be integrated into primary care, and that primary care-based treatment is effective for [opioid and alcohol use disorders].”

The CDC has previously published guidelines for opioid use, which include that treatment of acute pain with opioids should be for the shortest duration possible, and that primary care providers should use caution when prescribing opioids and closely monitor all patients receiving them. – by Alaina Tedesco

Disclosure: Some authors are employees of The RAND Corporation. Please see full study for complete list of individual author’s relevant financial disclosures.