Collaborative care to treat opioid abuse

Is collaborative care effective for the treatment of opioid abuse?

Every day, 91 Americans die from an opioid overdose, and every year, the number of opioid-involved deaths increases.

With the estimated economic burden of prescription opioid misuse in the United States totalling $78 billion a year, state and local governments have been tasked with finding cost-effective ways to expand access to treatment services. However, deciding how to expand access in individual communities and what treatments to offer are not always clear.

An emerging trend in opioid treatment

Opioid use disorders (OUDs) have traditionally been treated with psychosocial, abstinence, or detoxification interventions. There is an emerging trend toward the implementation of collaborative care models to treat OUDs, particularly those that combine medication-assisted therapy (MAT) with counseling and behavioral services.

As part of the waiver to prescribe MAT to patients with OUDs, the physician must have other therapy available; however, this is not often formalized. Sometimes MAT is added to counseling and behavioral therapy, and sometimes it is not. According to a scoping review published in the Annals of Internal Medicine, greater integration of MAT for OUDs in U.S. primary care settings would expand access to treatment. MAT may also be more cost effective than traditional interventions. The state of Vermont commissioned a study to assess the treatment and medical service expenditures for Medicaid beneficiaries with opioid addiction who received MAT treatment compared to those who received substance abuse treatment without medication. Results of the study suggest that MAT is associated with reduced general healthcare expenditures and utilization.

Improved outcomes, growing adoption

There are an increasing number of clinical trials designed to assess the effectiveness of collaborative care to treat OUD. Recent research indicates that collaborative care interventions may result in improved outcomes.

  • A randomized clinical trial that followed 377 primary care patients with opioid and/or alcohol use disorders at two health centers for six months found that a higher proportion of patients in the collaborative care group reported abstinence from opioids or alcohol at six months than those who received usual care.
  • A study of 45 opioid dependent or chronic pain patients who were treated with buprenorphine in a collaborative care management program found that patients who remained in the program for six months had a lower number of aberrant urine toxicology reports and lower craving scores compared to baseline.

Promising results like these have prompted the American Academy of Pediatrics to recommend that pediatricians consider MAT for adolescents with severe opioid disorders. The use of medication in combination with counseling and behavioral therapies is also a recommended best practice for the care of pregnant women with OUDs.

Barriers to implementation

While collaborative care models that incorporate MAT have been shows to be effective in treating OUD in primary care and other office-based settings, there are a number of barriers to implementation:

  • Insufficient institutional support
  • Knowledge gaps in the area of addiction among primary care physicians
  • Lack of buprenorphine-waivered physicians
  • Stigma toward MAT among physicians, clinic staff, and patients
  • Insufficient time and inadequate office space
  • Reimbursement issues

Despite the barriers to MAT, clinicians with experience treating OUDs, as well as those with expertise in policy and implementation, note that the most promising models of care are those that emphasize the integration of OUD with primary care and other medical and psychological needs.

YOUR TURN: Do you think that MAT implemented in a collaborative care model is effective for the treatment of OUDs?

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