Collaborative Care for Opioid Use Disorder and Mental Illness

The psychosocial pain management to improve opioid use disorder treatment outcomes study: Protocol for a randomized controlled trial.

Impacts of the COVID-19 pandemic on enrollment in medications for opioid use disorder (MOUD) in Vancouver, Canada: An interrupted time series analysis.

The criterion-standard treatment for opioid use disorder (OUD) is medications for OUD (MOUD). However, less than a quarter of people with OUD receive MOUD. The collaborative care model (CCM) is an evidence-based practice that integrates mental and physical health treatment in primary care settings. Expanding CCM to include patients with OUD could improve MOUD initiation. To compare the effectiveness of CCM for OUD and co-occurring mental health symptoms (intervention) with CCM for mental health symptoms only (active control). This hybrid type 2a trial cluster-randomized 24 US primary care clinics to intervention or control. Participants included patients with OUD and mental health symptoms who were not receiving specialty mental health care or specialty substance use treatment. Study data were analyzed from February 2024 to January 2025. The control care team included primary care practitioners, care managers, and psychiatric consultants. Primary care practitioners prescribed psychotropic medications with psychiatric consultation. Care manager activities included patient education, engagement and self-management, shared decision-making, measurement-based care for mental health symptoms, and brief psychotherapy for mental health. The intervention had the same components as the control, with additional MOUD training and psychiatric consultation for primary care practitioners, measurement-based care for OUD, and brief psychotherapy for OUD. Participants completed research assessments at baseline, 3 months, and 6 months. The multiple primary outcomes were past-month number of days of using opioids and the Veterans RAND 12 Mental Health Component Summary score. A total of 254 patients (mean [SD] age, 40.9 [12.4] years; 139 women [59.9%]) participated in the trial. Most participants (172 of 212 [81.1%]) were taking MOUD at baseline. Days using opioids decreased in both the control and intervention groups. The intervention significantly reduced opioid use more than the control with a medium effect size (adjusted ratio of odds ratio, 0.10; 95% CI, 0.03-0.38; Cohen d = -0.44; P < .001). Mental Health Component Summary scores improved slightly in both the control and intervention groups. The intervention did not significantly improve scores more than control (adjusted difference in change, -1.20; 95% CI, -4.97 to 2.57; Cohen d = -0.09; P = .53). Findings of this cluster randomized clinical trial indicate that OUD can be successfully managed in primary care with CCM, especially CCM for OUD and mental health symptoms. Primary care clinics with MOUD prescribers should consider implementing CCM for OUD and mental health. ClinicalTrials.gov Identifier: NCT04600414.

Opioid use disorder (OUD) and posttraumatic stress disorder (PTSD) frequently co-occur. However, there are no psychotherapy treatments intentionally designed for this comorbidity, nor designed to be augmented with medications for OUD. In this open-label pilot trial, we tested Helping Opioid Use Disorder and PTSD with Exposure (HOPE), a novel integrated, trauma-focused treatment for individuals (N = 6) with OUD/PTSD who were stabilized on medications for OUD. HOPE was delivered weekly for 10-12 sessions, and one follow-up visit was conducted ~1-month post-treatment. Primary outcomes included urine drug screens, the Timeline Followback, Desire for Drugs Questionnaire, Clinician-Administered PTSD Scale-5 (CAPS-5), and PTSD Checklist-5 (PCL-5). Boot-strapped linear mixed effect models and generalized estimating equations showed that PTSD symptoms (CAPS-5: B = -7.16, SE = 1.24, p < 0.01; PCL-5: B = -2.04, SE = 0.26, p < 0.01), desire for opioids (B = -0.56, SE = 0.15, p < 0.01), depression symptoms (B = -0.43, SE = 0.09, p < 0.01), and anxiety symptoms (B = -0.50, SE = 0.08, p < 0.01) decreased significantly over time. Client satisfaction increased throughout the study (B = 0.18, SE = 0.08, p = 0.02), and 83.3% of participants completed the therapy and follow-up visit. There were no significant changes in opioid or other substance use from baseline to follow-up. Although preliminary, results show high acceptability and feasibility of the HOPE therapy and demonstrate significant improvements in PTSD and associated symptoms with an integrated, trauma-focused treatment.

Encouraging Improvements to Opioid and Substance Use Disorder Care Quality in Nursing Homes

Leveraging Telehealth in the United States to Increase Access to Opioid Use Disorder Treatment in Pregnancy and Postpartum During the COVID-19 Pandemic.

BackgroundPeople living with HIV (PLWH) and opioid use disorder (OUD) commonly experience criminal justice involvement (CJI). We sought to estimate the impact of CJI on 1) HIV care engagement, 2) antiretroviral therapy (ART) prescription rates, and 3) receipt of medications for opioid use disorder (MOUD), among PLWH and OUD in Vietnam.MethodsParticipants were PLWH enrolled in a 12-month MOUD treatment trial of HIV clinic-based buprenorphine vs. methadone referral in Vietnam. We compared those with CJI (arrest, incarceration, or compulsory “06” drug rehabilitation) during the first 9 months of the study to those with no CJI. To ensure participants with CJI had the opportunity to re-engage in treatment, only those who were released before their 9-month study visit were included; participants still incarcerated at 9 months were excluded. Logistic regression models estimated the association between CJI and HIV care engagement (≥ 1 visit), ART prescription, and receipt of MOUD between 9 and 12 months, controlling for demographics, substance use, past CJI, and HIV history.ResultsAt baseline, 234 of 281 participants (83.6%) had a history of arrest/incarceration, and 172 (61.2%) reported prior 06 detention. During their first 9 months of study participation, 14 participants (5.0%) were arrested and 14 participants (5.0%) were sent to compulsory 06 rehabilitation. Being arrested (OR=0.04, 95% CI= (0.007, 0.25)), sent to compulsory 06 rehabilitation (OR=0.08, 95% CI= (0.02, 0.38)), or either (OR=0.07, 95% CI= (0.02, 0.24)), were negatively associated with receipt of MOUD. CJI involvement was also negatively associated with HIV clinic engagement after release (OR=0.20, 95% CI= (0.05, 0.84)). A similar negative association was noted for ART prescription, though it did not reach statistical significance (OR=0.17, 95% CI= (0.03, 1.22)).ConclusionArrest, incarceration, and compulsory 06 rehabilitation negatively impact HIV and OUD care among people with HIV and OUD in Vietnam. Policies that decrease incarceration, and the impacts of incarceration, for people with OUD and HIV may improve care outcomes in Vietnam and elsewhere.DisclosuresP Todd Korthuis, MD, MPH, Alkermes & Indivior (Other Financial or Material Support, Dr. Korthuis serves at principal investigator for NIH-funded studies that accept donated study medicine from Indivior (buprenorphine) and Alkermes (extended-release naltrexone).)

Developing a cascade of care for opioid use disorder among individuals in jail

Medication-based treatment among rural, primary care patients diagnosed with opioid use disorder and alcohol use disorder

Design of CLARO (Collaboration Leading to Addiction Treatment and Recovery from other Stresses): A randomized trial of collaborative care for opioid use disorder and co-occurring depression and/or posttraumatic stress disorder

Offering patients medications for opioid use disorder (MOUD) is the standard of care for opioid use disorder (OUD), but an estimated 75%-90% of people with OUD who could benefit from MOUD do not receive medication. Payment policy, defined as public and private payers' approaches to covering and reimbursing providers for MOUD, is 1 contributor to this treatment gap. We conducted a policy analysis and qualitative interviews (n = 21) and surveys (n = 31) with US MOUD payment policy experts to characterize MOUD insurance coverage across major categories of US insurers and identify opportunities for reform and innovation. Traditional Medicare, Medicare Advantage, and Medicaid all provide coverage for at least 1 formulation of buprenorphine, naltrexone, and methadone for OUD. Private insurance coverage varies by carrier and by plan, with methadone most likely to be excluded. The experts interviewed cautioned against rigid reimbursement models that force patients into one-size-fits-all care and endorsed future development and adoption of value-based MOUD payment models. More than 70% of experts surveyed reported that Medicare, Medicaid, and private insurers should increase payment for office- and opioid treatment program-based MOUD. Validation of MOUD performance metrics is needed to support future value-based initiatives.

Individuals with opioid use disorder (OUD) may experience worsening sleep quality over time, and a subset of individuals may have sleep disturbances that precede opioid use and do not resolve following abstinence. The purpose of the present study was to (1) collect retrospective reports of sleep across the lifespan and (2) identify characteristics associated with persistent sleep disturbance and changes in sleep quality in persons with OUD. Adults with OUD (n = 154) completed a cross-sectional study assessing current and past sleep disturbance, opioid use history, and chronic pain. Repeated-measures analysis of variance was used to examine changes in retrospectively reported sleep quality, and whether changes varied by screening positive for insomnia and/or chronic pain. Multivariate linear regression analyses were used to identify additional correlates of persistent sleep disturbance. Participants reported that their sleep quality declined over their lifespan. Changes in reported sleep over time varied based on whether the individual screened positive for co-occurring insomnia and/or chronic pain. In regression analyses, female sex (β = 0.16, P = .042), a greater number of treatment episodes (β = 0.20, P = .024), and positive screens for chronic pain (β = 0.19, P = .018) and insomnia (β=0.22, P = .013) were associated with self-reported persistent sleep disturbance. Only a portion of participants who screened positive for sleep disorders had received a formal diagnosis. OUD treatment providers should routinely screen for co-occurring sleep disturbance and chronic pain. Interventions that treat co-occurring OUD, sleep disturbance, and chronic pain are needed. Ellis JD, Mayo JL, Gamaldo CE, Finan PH, Huhn AS. Worsening sleep quality across the lifespan and persistent sleep disturbances in persons with opioid use disorder. J Clin Sleep Med. 2022;18(2):587-595.

The Veterans Health Administration (VA) has prioritized addressing opioid use disorder (OUD) due to rising opioid overdose rates among Veterans, aiming to expand evidence-based OUD treatment in primary care. The purpose of this project was to (1) examine VA provider perspectives regarding OUD treatment in primary care, and (2) explore provider perceptions about stigma related to OUD. From September 2021 to June 2022, we held 6 semi-structured focus groups with multidisciplinary VA primary care providers (n = 91 participants) via Microsoft Teams and in person. Each group, comprising 13 to 24 providers, engaged in interviews lasting 50 to 80 minutes. We employed qualitative interviewing techniques to collect feedback on provider perspectives concerning OUD treatment within VA primary care. Participants viewed 2 to 3 short videos from the Insights Into Recovery series. Focus group interviews were recorded, transcribed, and checked for accuracy. Directed content analysis was used to identify themes and patterns. Participants identified several barriers to treating OUD in primary care. Patient-level challenges reported by providers included establishing clinician-patient trust and differing views on OUD diagnoses. Provider-level barriers included limited experience, discomfort with treatment, and managing complex care needs. System-level obstacles involved time constraints, administrative burdens, and stigma, which affected attitudes toward OUD and opioid medication use. Facilitators of OUD care included satisfaction with patient success, training in buprenorphine prescribing, and the use of motivational interviewing (MI) techniques tailored to the patient's level of readiness. Providers identified barriers to OUD care, including patient trust issues, limited provider experience, lack of support, and stigma from both patients and providers. Facilitators included enhanced training in buprenorphine prescribing and MI. To strengthen OUD care, 3 key strategies are recommended: addressing provider stigma, prioritizing OUD-specific training, and integrating MI. These initiatives could enhance OUD care in primary care settings within the VA, benefiting Veterans with chronic pain and OUD.

Medications for opioid use disorder (MOUD) in youth can reduce harms but many youths do not receive MOUD. Improving quality metrics of MOUD among youth can advance interventions for youth with opioid use disorder (OUD). We relied on 2018 Medicaid claims data from California, Colorado, Massachusetts, and New Mexico. We calculated the percentage of youth with OUD included in the quality metric for initiation, and the percentage who initiated by state. We also calculated the percentage excluded from the quality metric for initiation because they have an existing episode of OUD care and their MOUD receipt. We compared the characteristics of those who initiated/received MOUD to those who did not and compared state estimates after adjusting for age and health conditions. Estimates of initiation exclude about half of the youth with OUD because they were in an existing episode of OUD care and could not be observed initiating. Among youth in a new episode of OUD care, only about 1 in 4 initiated and state estimates varied from 18.9% to 40.1%. Among youth with an existing episode of OUD care, more than half received MOUD and state estimates ranged from 35.2% to 71.3%. Youth who initiated MOUD or received MOUD with an existing OUD had more severe OUD but fewer co-occurring substance use disorders or mental or physical health diagnoses. After adjusting for age and health conditions, MOUD still varied substantially across states. Most youth with a new OUD diagnosis do not initiate MOUD but more than half of the youth in an existing OUD diagnosis receive MOUD. MOUD quality metrics that are disaggregated, adjusted, and inclusive of youth in an existing episode of care provide additional insight into opportunities to better support youth who might choose MOUD. State differences should be further studied for insight into policies that may affect MOUD.

As this issue of The Senior Care Pharmacist focuses on elder abuse, it is critical to recognize that people with opioid use disorder (OUD) are federally protected under the Americans with Disabilities Act (ADA). This was affirmed in 2022 by physician and Director of the Office of National Drug Control Policy, Dr. Rahul Gupta, in a recent public workshop on medications for opioid use disorder (MOUD) hosted by the National Academies of Sciences, Engineering, and Medicine. While the ADA specifies that discrimination against those with OUD is illegal, it also affords legal protection to access to health services and treatment for those with OUD that includes skilled nursing facilities (SNFs). The policy guidance document from the US Department of Justice Civil Rights Division titled “The ADA and Opioid Use Disorder: Combating Discrimination Against People in Treatment or Recovery” explicitly states that if a SNF refuses to admit a patient with OUD predicated on the patient taking a clinician prescribed MOUD or the SNF prohibited any of its patients from taking MOUD, then this exclusion/prohibition would be in violation of the ADA. Refusal to provide care for patients experiencing a drug overdose at emergency departments or to provide health services for a patient with OUD are also in violation of the ADA. The refusal of a city to open an OUD treatment center on the basis of hostility toward people with OUD may also be in violation of the ADA.