Addiction treatment intervention linked to greater long-term health care engagement

A patient activation intervention along with addiction treatment was associated with long-term improvements in primary care engagement, a study found.

More than 20 million people in the U.S. struggle with substance use (SU) disorder, Esti Iturralde, PhD, a research scientist at the Kaiser Permanente Northern California Division of Research, and colleagues wrote in JAMA Network Open. While regular visits to primary care physicians following addiction treatment have shown to reduce medical costs and improve SU outcomes, “psychosocial and systemic barriers” make that engagement difficult to achieve, they added.

“Patients may have difficulty establishing rapport with primary care practitioners due to self-stigma or fears of discrimination due to stigma surrounding SU problems,” they wrote.

Additionally, privacy laws and policies restricting health information sharing can also hinder coordination between PCPs and patients, according to the researchers.

Seeking to improve engagement, the researchers examined the LINKAGE intervention, which involves six group-based sessions that are embedded into outpatient addiction treatment. The intervention focuses on “patient agency, skill and motivation in navigating health care services,” Iturralde and colleagues wrote. It includes a “facilitated connection” through phone or email with PCPs, where patients can talk to their providers about recovery and health goals.

The trial was based at a single addiction treatment clinic over 30 months. Every 3 months, the clinic alternated new patients to receive LINKAGE or usual care. Participants who entered during a LINKAGE period were assigned to the LINKAGE group, and participants who entered during a usual care period were assigned to the usual care group.

The researchers noted that both groups had a 10-day stabilization program followed by a 6-week period of individual counseling, psychotherapy groups and medical education.

The researchers collected baseline and follow-up data from 2011 to 2018. Of the 503 participants, 69% (n = 346) were men and 61% (n = 306) were white. The mean age was 42 years.

The majority of patients (n = 329; 65%) had alcohol use disorder, while 46% (n = 232) had drug use disorder. More than 50% (n = 214) had visited the ED in the last year.

Iturralde and colleagues found that compared with usual care participants, LINKAGE participants were more likely to discuss their substance abuse problems with a PCP (RR = 1.3; 95% CI, 1.03-1.65), though the difference was “only statistically significant at 1 year.”

LINKAGE participants saw higher rates of electronic patient portal usage across years, specifically at 1- and 2-year follow-up periods (RR = 1.24; 95% CI, 1.04-1.47). At 5-year follow-up periods, the LINKAGE group was more likely to:

• log onto the patient portal (RR = 1.18; 95% CI, 1.08-1.29);
• refill medications (RR = 1.38; 95% CI, 1.22-1.56); and
• send secure messages to PCPs (RR = 1.18; 95% CI, 1.05-1.33).

The LINKAGE group also produced small but statistically significant 5-year annual increases in primary case usage (RR = 1.03; 95% CI, 1.003-1.067) and annual declines in substance-related ED use compared with usual care participants (RR = 0.79, 95% CI, 0.64-0.97).

Iturralde and colleagues wrote that while usual care participants “had declining primary care use and stable substance-related ED use over the same time frame,” LINKAGE participants saw gradual improvements in health care usage, consistent with previous studies examining addiction treatment with health care outcomes.

The researchers acknowledged potential bias stemming from use of the alternating 3-month strategy rather than through randomization. However, they wrote it was necessary to prevent contamination across groups while controlling clinical effects.

Further research was also recommended, particularly on the potential benefits of increasing health care engagement among individuals with SU disorders and understanding how to improve SU outcomes as part of efforts to improve health care engagement.

Iturralde and colleagues pointed out that the LINKAGE system could be easily implemented thanks to electronic health records being tied to patient portals across health systems, while concluding addiction treatment “offers a critical opportunity to engage patients in recovery-focused health goals, with potential to improve health care quality and outcomes.”