Alicia Ault

June 01, 2017

SAN DIEGO, California – Collaborative care may provide a new supply of clinicians to meet the need for substance use disorder treatment, new research suggests. However, the model is just beginning to be tested.

The vast majority of people with substance use disorders are not receiving treatment, said Katherine Watkins, MD, MSHS, a senior physician policy researcher at the RAND Corp. She discussed the development and implementation of a collaborative care model to help primary care physicians deliver treatments for alcohol and opioid use disorders here at the American Psychiatry Association (APA) 2017 Annual Meeting.

"This is a way of increasing access for those patients who maybe don't need specialty care, or who aren't going to go to specialty care, or who would go, but there's no capacity," Dr Watkins told Medscape Medical News.

Patients may also feel more comfortable talking about substance use and treatment with a primary care physician, with whom they might have a more-established relationship, said Dr Watkins. "Primary care is an important and underutilized resource," she said.

Although the long-term care model — which gave rise to collaborative care — has been used for a decade or so for patients with conditions such as diabetes, asthma, heart disease, depression, and anxiety, it has not been extended into substance use disorders, said Dr Watkins.

The RAND researchers focused on adapting the model for alcohol and opioid use disorders because both can be treated with evidence-based medications that are readily available in primary care, she said.

The Substance Use, Motivation, Medication and Integrated Treatment (SUMMIT) study was conducted at the two sites of the Venice Family Clinic, a federally qualified health center that has about 20,000 patient visits a year. RAND has published the protocol for the study, and two papers on how it was implemented and the outcomes achieved are currently in press, said Dr Watkins.

The data indicate that at 6 months, patients who participated in the collaborative care model were more likely to be abstinent and to have received treatment than those who received usual care, she said.

Identifying Barriers Key

It took 2 years of planning to get the model up and running, but newcomers who want to adopt it should be able to implement it faster, because they have the benefit of learning from the RAND researchers' experience, said Dr Watkins.

The researchers first held focus groups with Venice Family Clinic healthcare providers, administrators, and support staff to identify potential barriers to implementing collaborative care. They then met to find ways to address the barriers.

Patients were seen as an initial barrier — it was not clear they would admit to having or being aware that they had a substance use disorder, they might not be ready for treatment, or they might not be aware that treatment existed. A key was to hire and train care coordinators to conduct motivational interviewing. Clinicians also were not ready — for psychological or behavioral reasons ― to deliver treatment, said Dr Watkins. And treatment protocols were not specific to primary care.

Clinician-champions were identified to help get peers on board. In addition, RAND developed treatment protocols aimed at primary care (which can be downloaded without cost from the organization's website).

Information systems had to be tweaked to track utilization and outcomes for patients with substance use disorders; a registry report was created for that purpose. A formalized care protocol was created that established a workflow. The lengths of visits were adjusted to accommodate patients. Clinic administrators decided to foot the bill for brief therapy sessions, which were not reimbursed.

The Venice clinic was linked to nearby inpatient detoxification providers to ensure patients who were referred for the service would be seen in a timely manner.

Under the model, a medical assistant would conduct universal screening to identify patients who had substance use disorders. About 6% of patients were identified as having a disorder — fewer than the 10% to 15% reported in most studies, which indicates that some with addiction were not being detected, said Dr Watkins.

The physician would conduct a brief intervention and connect the patient with a care coordinator, usually during that visit. The coordinator would tell the patient what kinds of treatment were available, assess motivation, and encourage the individual to seek an assessment by the social worker.

If patients chose treatment, they were randomly assigned to receive either treatment as usual ― which could include behavioral therapy and medication-assisted treatment (naltrexone for alcohol use disorder and buprenorphine for opioid use disorder), or treatment facilitated by the collaborative care process.

Most physicians were on board with prescribing naltrexone, which simply required a nurse to give an injection, said Dr Watkins. Only about half of the physicians said they would receive the special training required to prescribe buprenorphine.

Exciting Opportunity

Commenting on the RAND model for Medscape Medical News, Anna Ratzliff, MD, PhD, director of the University of Washington's Integrated Care Training Program, called it "really exciting."

In the past 2 years, Dr Ratzliff has trained more than 1500 psychiatrists in how to deliver collaborative care, thanks to grants the APA received from the Centers for Medicare & Medicaid Services' Transforming Clinical Practices Initiative.

Substance use treatment "is one of the critical areas that we needed additional studies to see what's possible...[and] to see how we can support primary care teams to deliver more treatment," said Dr Ratzliff, who is associate professor of psychiatry at the University of Washington, Seattle.

Collaborative care has the potential to enhance primary care's capacity for treatment, but it also helps identify patients for whom treatment in primary care may not be sufficient. Psychiatrists can act as consultants and can support colleagues in primary care, sharing the evidence base, providing guidance on outcomes measurement, and answering questions about patients, said Dr Ratzliff.

At the University of Washington, a large-scale implementation of collaborative care has shown that patients with anxiety and depression "can get better with the primary care approach," she said. It is more likely to result in referrals for care, she said.

Adapting the collaborative care model to deliver substance use disorder treatment in a primary care setting is not only possible but will likely produce better outcomes, Dr Ratzliff said.

"Patients will benefit from a more systematic approach to the delivery of mental health in a primary care setting," said Dr Ratzliff.

For psychiatry and primary care practices that want to test the waters, the APA has created a financial workbook that helps in estimating visit volume and the number of patients served; to define and analyze how much time staff will be engaged in key integrated care tasks; and to estimate potential fee-for-service and G-code revenues.

Beginning in January 2018, practices can possibly receive a monthly fee from Medicare for participating in collaborative care.

The SUMMIT study was funded by the National Institute on Drug Abuse. Dr Watkins has received grant and/or research support from Acadia Pharmaceuticals, Actavis, Alkermes, Assure RX, Avanir Corp, the Crohns and Colitis Foundation, Embera Neuro Therapeutics, Inc, Janssen, Lundbeck, Novartis Pharmaceuticals Corp, Otsuka Pharmaceuticals, Servier, Sprout Pharmaceuticals, Takeda Pharmaceuticals, and Teva Pharmaceuticals. She has received funding and/or honoraria from AB-Biotics, AstraZeneca, Bial, BMS, Dainippon Sumitomo, Elan, Eli Lilly, Farmaindustria, Ferrer, Forest Research Institute, Gedeon Richeter, GSK, Janssen, Lundbeck, Otsuka, Pfizer, Roche, Sanofi-Aventis, Servier, Shire, Solvay, Sunovion, Takeda, Telefonica, Institute de Salud Carlos III, ENBREC, NARSAD and Stanley Medical Research Institute. Dr Ratzliff's spouse works for Allergan.

American Psychiatric Association (APA) 2017 Annual Meeting. Abstract 3, Rapid-Fire Talks: Focus on Integrated and Collaborative Care. Presented May 23, 2017.

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