Opioid agonist therapy for opioid use disorder in primary versus specialty care.

International agencies recommend integrating addiction treatment into primary care for people who inject drugs (PWID) with opioid use disorder (OUD). Empirical data supporting integration that incorporates comprehensive health outcomes, however, are not known. For this randomized controlled trial in Ukraine, adult PWID with OUD were randomized to receive opioid agonist therapy (OAT) in specialty addiction treatment clinics (SATC) or to primary care clinics (PCCs). For those randomized to PCC, they were subsequently allocated to PCCs where clinicians received pay-for-performance (P4P) incentives (PCC with P4P) or not (PCC without P4P). Participating cities had one of each of the three intervention sites to control for geographic variation. Ongoing tele-education specialty training (OAT, HIV, tuberculosis) was provided to all PCCs. While the primary outcome for the parent trial focuses on patient medical record data, this preliminary analysis focuses on assessment of self-reported achievement of nationally recommended quality health indicators (QHIs) which is summed as a composite QHI score. Secondary outcomes included specialty and primary care QHI subscores. This study occurred from 01/20/2018-11/1/2020 with 818 of 990 randomized participants having complete self-reported data for analysis. Relative to SATC (treatment as usual), the mean composite QHI score was 12.7 (95% CI: 10.1–15.3; p<0.001) percentage points higher at PCCs; similar and significantly higher scores were observed in PCCs compared to SATCs for both primary care (PCC vs SATC: 18.4 [95% CI: 14.8–22.0; p<0.001] and specialty (PCC vs SATC: 5.9 [95% CI: 2.6–9.2; p<0.001] QHI scores. Additionally, the mean composite QHI score was 4.6 (95% CI: 2.0–7.2; p<0.001) points higher in participants with long term (>3 months) experience with OAT compared to participants newly initiating OAT. In summary, PWID with OUD receive greater primary care and specialty healthcare services when receiving OAT at PCCs supported by tele-education relative to treatment as usual provided in SATCs.Clinical trial registration: This trial was registered at clinicaltrials.gov and can be found using the following registration number: NCT04927091.

Opioid use disorder (OUD) drives high morbidity and mortality, but access to opioid agonist therapy (OAT) is limited in low- and middle-income countries. Integrating OAT into primary care may expand access and improve comorbidity management, although provider discomfort remains a barrier. To compare health care use among persons with OUD receiving methadone in specialty clinics versus primary care centers in Ukraine (January 2018 to December 2023). Two-group randomized controlled trial with 2:1 allocation to intervention and control. (ClinicalTrials.gov: NCT04927091). Thirteen cities in Ukraine: Cherkasy, Dnipro, Kramatorsk, Kropyvnytskyi, Kryvyi Rih, Kyiv, Lviv, Mariupol, Mykolaiv, Odesa, Rivne, Sloviansk, and Zhytomyr. A total of 1459 adults with OUD (950 intervention, 509 control) initiating or receiving methadone. Methadone delivered in primary care aided with telementoring, an Extension for Community Healthcare Outcomes-like model that is adapted to the Ukraine context, versus standard specialty clinic care. Primary outcome: difference in composite quality health indicator (QHI) scores between groups at 24 months, representing access to 17 guideline-concordant services (9 primary care and 8 specialty care) received, assessed through surveys and ranging from 0 to 100. Secondary outcomes: domain-specific QHI scores and methadone treatment indicators. Participants in primary care settings achieved higher composite QHI scores than those in specialty clinics, with a mean difference of 9.1 percentage points (95% CI, 6.9 to 11.2 percentage points) at 24 months. Results were similar for primary care QHI (12.3 percentage points [CI, 9.0 to 15.6 percentage points]) and specialty care QHI (5.2 percentage points [CI, 0.2 to 10.3 percentage points]). Methadone retention among new patients at 24 months was 67.2% in primary care versus 64.7% in specialty clinics. Quality health indicators reflect health care use rather than health outcomes. Quality health indicators were equally weighted despite differing clinical significance. Integrating methadone treatment into primary care settings improves adherence to guideline-concordant health care without compromising methadone retention and treatment quality. National Institute on Drug Abuse.

Research Issues for Improving Treatment of U.S. Hispanics With Persistent Mental Disorders

2005 APA Gold Award: Improving Treatment Engagement and Integrated Care of Veterans

Efforts to increase access to highly effective medications for opioid use disorder (MOUD) have largely focused on primary care. Ironically, many specialty addiction treatment programs have yet to adopt MOUD. To bring MOUD access to scale, researchers need to better understand medication practices across these 2 major portals of care for patients with opioid use disorder (OUD). In this study, our team examined baseline prescribing data from 62 primary care clinics and specialty addiction treatment programs (SATPs) participating in MOUD implementation endeavors across 2 states. Our primary outcomes included MOUD prescribing practices, measured by the integrating medications for addiction treatment (IMAT), which includes 7 dimensions of guideline-adherent delivery of MOUD, and an additional subscale on low threshold care. We also measured reach of MOUD to patients and adoption as the number of current MOUD prescribers. Secondary outcomes included community characteristics surrounding each type of organization. Descriptive statistics and bivariate tests explored differences between primary and specialty care settings. SATPs had lower MOUD capacity and implementation as compared with primary care clinics. Specialty settings also had lower organizational support for low threshold prescribing. SATPs were located in counties with higher overdose rates, higher unemployment, fewer MOUD prescribers, and with more opioid prescriptions per capita. SATPs have lower MOUD implementation capacity than their primary care counterparts and are more likely to be in counties with greater OUD-related needs, economic distress, and fewer treatment resources. Selecting more precise implementation support strategies for SATPs that are late adopters of MOUD is a major need.

Back to table of contents Previous article Next article Professional NewsFull AccessCollaborative-Care Models Prove Cost-EffectiveMark MoranMark MoranSearch for more papers by this authorPublished Online:7 Sep 2012https://doi.org/10.1176/pn.47.17.psychnews_47_17_4-aAbstractModels of “collaborative chronic care” can improve mental and physical outcomes for individuals with psychiatric disorders across a wide variety of care settings, and they provide a robust clinical and policy framework for care integration, according to a meta-analysis published July 12 in AJP in Advance.Investigators performing a literature search found 161 analyses from 57 trials involving care of a mental disorder (depression, n=40; bipolar disorder, n=4; anxiety disorders, n=3; multiple/other disorders, n=10). The meta-analysis indicated significant effects across disorders and care settings for depression as well as for mental and physical quality of life and social-role function.Moreover, total health care costs did not differ between collaborative-care models and comparison models.The report was titled “Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty, and Behavioral Health Care Settings: Systematic Review and Meta-Analysis.” The analysis was conducted by Emily Woltman, Ph.D., of the Brown School of Social Work at Washington University, and colleagues.Collaborative care—also known as “integrated care”—is a feature of the delivery-system reforms in the new health care reform law, and policymakers and many clinicians have converged on the idea that the full range of medical services should be brought together in patient-centered locations. Integrated care was the theme of immediate past APA President John Oldham, M.D.’s presidential year. And today, a small but dedicated cadre of psychiatrists is advancing the cause of integrated care and the participation of psychiatrists in collaborative-care models (Psychiatric News, October 21, 2011).Integrated-care models have evolved from the traditional consultative role that consultation-liaison psychiatrists have practiced, to a “co-located” model in which psychiatrists see individual patients in a primary care clinic, to a fully collaborative care model in which a psychiatrist takes responsibility for a caseload of primary care patients and works closely with primary care clinicians and other primary care–based mental health care providers. Though models may differ, the core principles of collaborative care are constant: patient-centered care teams providing evidence-based treatments to a defined population of patients using a measurement-based “treat-to-target” approach. (The latter refers to the use of tested instruments so that symptoms can be measured with numerical targets established for clinical treatment goals.)In the AJP in Advance analysis, randomized, controlled trials comparing collaborative-care models (CCMs) with other care conditions, published or in press by August 15, 2011, were identified in a literature search and through contact with investigators. CCMs were defined as interventions with at least three of the six components of the Improving Chronic Illness Care initiative developed by the Robert Wood Johnson Foundation. Those components include patient self-management support, clinical information systems, delivery-system redesign, decision support, organizational support, and community resource linkages. (Details about the initiative are posed at www.improvingchroniccare.org/.)Articles were included if the CCM effect on mental health symptoms or mental quality of life was reported. Data extraction included analyses of these outcomes plus social-role function, physical and overall quality of life, and costs.An example of a trial of collaborative care that was included in the analysis was a report titled “Collaborative Care Management of Late-Life Depression in the Primary Care Setting: A Randomized, Controlled Trial,” which appeared in the Journal of the American Medical Association (December 11, 2002).In that trial, patients were randomly assigned to a collaborative-care intervention or to usual care. Patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care expert. Services included education, care management, and support of antidepressant management or a brief psychotherapy. The report found that at 12 months, intervention patients had a significantly greater reduction in depressive symptoms from baseline compared with usual-care participants. Intervention patients also experienced greater rates of depression treatment, more satisfaction with depression care, lower depression severity, less functional impairment, and greater quality of life.Woltman and colleagues said that the analysis demonstrates the cost-effectiveness and outcome-enhancing utility of chronic-care models. “CCM effects were robust across populations, settings, and outcome domains, achieving effects at little or no net treatment costs,” they wrote. “Thus, CCMs provide a framework of broad applicability for management of a variety of mental health conditions across a wide range of treatment settings, as they do for chronic medical illnesses.” “Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty, and Behavioral Health Care Settings: Systematic Review and Meta-Analysis” is posted at http://ajp.psychiatryonline.org/Article.aspx?ArticleID=1213771. ISSUES NewArchived

A direct comparison of presenting characteristics of depressed outpatients from primary vs. specialty care settings: preliminary findings from the STAR*D clinical trial

A Path Toward Improving Nonalcoholic Fatty Liver Disease Care Among Non-hepatologists

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.

Using Science to Battle Stigma in Addressing the Opioid Epidemic: Opioid Agonist Therapy Saves Lives

In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with developing strategies to improve the quality of child and adolescent mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health care that pediatricians and other primary care clinicians† provide to children and adolescents will require systemic interventions at the national, state, and community levels to improve the financing of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “ Strategies for System Change in Children's Mental Health: A Chapter Action Kit ” (chapter action kit),1 “Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration,”2 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3 The task force also recognized that enhanced mental health practice will require competencies not currently achieved by many primary care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to outline these competencies and propose strategies for achieving them. This report offers strategies for preparing the primary care practice itself for provision of enhanced mental health care services. The task force proposes incrementally applying chronic care principles to the care of children with mental health and substance abuse problems as primary care clinicians apply them to the care of children with chronic medical conditions such as asthma. Most primary care clinicians will find that significant gaps exist between their current practice and the proposed ideal. The task force offers guidance in … Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu

<h3>Context:</h3> Opioid agonist therapy (OAT) is used worldwide to treat opioid use disorder (OUD). Integrating OAT into primary care has been proposed to improve patient accessibility. The degree of prescribing regulation in primary care varies by country; those with more restrictions may draw upon experiences and outcomes (e.g. overdose mortality reduction) from less restrictive countries to promote relaxed prescribing. However, OAT delivery and any resultant health outcomes may be dependent on broader sociocultural, political, health system, and epidemiological factors. <h3>Objective:</h3> To compare contextual and health system factors between France and the US, and explore how this may affect buprenorphine provision. <h3>Study design &amp; analysis:</h3> The health system dynamics framework takes a system-level approach to examine health systems and the dynamics/interactivity of its components. In this comparative policy analysis, we used it to explore the drug context regarding opioid use and related harms, and health system factors regarding prescriber supply, sector organization, and primary care insurance coverage. <h3>Setting/dataset:</h3> For both countries, we used national reports on health systems and health data, national drug strategies/policies, published scientific reports, and OUD treatment guidelines. <h3>Results:</h3> The different scale and nature of drug use and primary care delivery between France and the US suggest that relaxing restrictions on buprenorphine prescribing is unlikely to achieve the desired reductions in opioid overdose mortality. Rates of buprenorphine prescribing in the US already surpass those achieved nearly a decade into the French model of care. Variations in the drug supply, coordination with pharmacists and specialists, level of health insurance coverage and healthcare costs, and a higher supply of primary care providers in France are likely to affect buprenorphine and OAT prescribing policy and subsequent health outcomes. <h3>Conclusions:</h3> Our analysis showed that contextual factors are crucial to understanding how OUD treatment policies are designed and implemented, and how they may affect outcomes. Using a health system framework allowed us to consider the complex, non-linear dynamics in OUD treatment and the role of primary care. Strengthening the health system by focusing on structural primary care factors such as prescriber supply, coverage, and coordination as policy targets may yield greater change than relaxing OAT prescribing restrictions in isolation.

Differences in buprenorphine initiation and retention for opioid use disorder between primary care and substance use disorder specialty care settings.

Predictors of enrollment in opioid agonist therapy after opioid overdose or diagnosis with opioid use disorder: A cohort study

Predictors of enrollment in opioid agonist therapy after opioid overdose or diagnosis with opioid use disorder: A cohort study