Use of The Collaborative Care Model in Treating Concomitant Opioid Use Disorder (OUD) and Mental Illness

RESEARCH ANALYSIS

Use of The Collaborative Care Model in Treating Concomitant Opioid Use Disorder (OUD) and Mental Illness

Tyler Kung, BS

Philadelphia College of Osteopathic Medicine

SUMMARY POINTS

-        Collaborative Care (CoCM) is a treatment methodology combining behavioral healthcare and primary care directly in the primary care setting via a team of PCPs, psychiatrists, and behavioral healthcare managers

-        Preliminary trials have shown CoCM to be effective in decreasing opioid use and increasing physician prescriptions of highly efficacious medications such as buprenorphine

-        CoCM effects on mental health symptoms in OUD patients are unknown

-        CoCM is a promising solution to simultaneously addressing the opioid and mental health crises in America

ANALYSIS

Background

Currently, there are 2.1 million individuals living in the United States with opioid use disorder (OUD) (1). Of these 2.1 million people, "27% have a serious mental illness, 64% have any mental illness, and approximately 11% to 26% have alcohol use disorder or another substance use disorder." (2). This is problematic, as concurrent OUD and mental illness has been associated with higher probabilities of drug overdose (3). Given the severity of these conditions, there is a dire need to treat both conditions simultaneously. One solution is the Collaborative Care Model (CoCM).

Findings

The Collaborative Care Model is an integrated therapeutic approach where patients receive primary care and behavioral health directly in the primary care setting (Figure 1). The care team is comprised of a primary care physician (PCP), a psychiatrist, and a behavioral health care manager, who all work together to support the needs of the patient (3). The model aims to treat opioid use disorder through medication-assisted therapy as well as treat mental illness through various efficacious psychotherapies. The strength of the model lies in the tight-knit communication between the care team. The critical player in CoCM is the Behavioral Health Care Manager (BHCM), who serves as the liaison between the patient and the care team (4).

First, the BHCM designs the initial mental health treatment plan after evaluating the patient (4). They then consult with the psychiatrist and PCP to fine-tune their diagnostic plan. Once the plan is devised, the BHCM administers the mental health care. The BHCM is also responsible for monitoring patients in the medical database and coordinating care. For example, they may help to improve medication adherence, set up follow-ups, monitor symptoms, and provide referrals. Through continuous follow-ups, the BHCM addresses any issues that may hinder a patient's treatment, such as a lack of transportation or any other obstacles (4).

CoCM is not a new model, as it has been applied in a diversity of populations, including university students, post-partum women, and the elderly. However, it has not been widely utilized in the treatment of OUD (4). To date, there have been two main trials that have piloted CoCM in OUD, with a third currently underway. 

Figure 1: A Schematic Showing The Relationships in the Collaborative Care Model (5)

SUMMIT Trial:

The first major trial was the Substance Use Motivation and Medication Integrated Treatment (SUMMIT) trial (6). This randomized controlled trial, conducted at two federally qualified health centers, enrolled 377 participants with opioid use disorder (OUD) into two groups: 187 in the collaborative care (CoCM) group and 190 in the usual care (UC) group. The study aimed to determine whether implementing collaborative care would increase patient access to evidence-based OUD treatments, such as medication-assisted therapy (MAT) or behavioral health interventions. The authors also assessed changes in opioid abstinence.

After six months, the researchers found that 39% of CoCM participants received evidence-based treatment—either behavioral therapy or MAT—compared to only 16.8% of UC participants (Figure 2) (6). However, the CoCM model did not lead to a significant increase in MAT uptake (25 CoCM vs. 24 UC). The primary driver of the overall treatment increase was behavioral therapy, with 67 CoCM participants receiving BT compared to only 20 in the UC group.

Regarding abstinence (Figure 3), 88.7% of CoCM participants self-reported abstinence six months after treatment, up from 79% at baseline (6). In contrast, 79.9% of UC participants reported abstinence after treatment, compared to 67.9% at baseline. The p-value for this comparison was 0.33, indicating the result was not statistically significant. It is also important to note that the CoCM group began with 187 participants but had 138 at the six-month follow-up, while the UC group started with 190 participants and had 123 remaining at follow-up (6).

The SUMMIT trial led to an increase in evidence-based treatments as well as abstinence for OUD patients. However, the results were underwhelming. The CoCM intervention did not lead to an increase in medication prescriptions or significantly increase abstinence from opioids. Further methodological flaws include a lack of follow-up 6 months after SUMMIT's conclusion and a lack of data indicating the results on mental health outcomes.

Figure 2:Primary Outcomes from the SUMMIT Trial (6)

Figure 3: Secondary Outcomes from the SUMMIT Trial (6)

Dartmouth Study:

A second major study investigating the use of CoCM in OUD occurred at Dartmouth College across their five primary care clinics over two years, from April 1, 2019, to March 31, 2020 (7). The study reported an increase in the number of buprenorphine-waivered clinicians from 11 to 35. Furthermore, the number of patients started on buprenorphine skyrocketed from 4 to 18 per month. The authors also noted a 180-day treatment retention of 53% (49/92), which is notably higher than the national retention rates of 30.3% in primary care and 26.7% in specialty care. Also, 81% of participants consistently had negative drug tests in the sample population. According to the self-report surveys, 91% (~91/101 patients) reported no opioid usage in the week of the survey (7).

While these results are quite promising, the Dartmouth study, like the SUMMIT study, did not report on the effects of CoCM on mental health. However, the study’s insights into the impact of CoCM on opioid use is undoubtedly commendable, as it assisted many patients in scaling back their usage.

CLARO:

            The last major study involving CoCM in treating OUD is the Collaboration Leading to Addiction Treatment and Recovery from Other Stresses (CLARO) trial. CLARO is a multi-site randomized trial utilizing CoCM across 13 rural and urban primary care clinic sites in New Mexico, aimed at improving outcomes for patients with both OUD and depression/PTSD (3). The study is ongoing, as it commenced in October 2019 and is expected to conclude in October 2024. The study aims to enroll 900 participants, with 450 participants each in the CoCM group and the UC model group. Patients are enrolled in the study for six months and are given follow-ups at three and six months. The study's primary outcomes are medications for OUD, MOUD continuity of care, and depression/PTSD symptoms (3).

Discussion

The collaborative care model (CoCM) holds significant potential for treating both opioid use disorder (OUD) and co-occurring mental illness. While preliminary data from the SUMMIT and Dartmouth studies is promising, much work remains to be done in this space. Simultaneously treating both conditions is a logically sound approach and, if successfully implemented, could have a substantial impact. However, numerous challenges remain.

First, provider attitudes continue to pose a significant barrier. The authors of the Dartmouth study describe a reluctance among providers to obtain waivers for prescribing buprenorphine, citing reasons such as the belief that OUD treatment does not belong in primary care settings and persistent stigma surrounding opioid use. Another area for improvement is treatment standardization. The ideal delivery model for CoCM in New Mexico, for example, will likely differ significantly from that in rural New Hampshire due to differences in available resources, healthcare providers, and socioeconomic factors. These contextual variables make a uniform model difficult to establish. Additionally, the shortage of mental health providers in the United States continues to limit access to and delivery of CoCM. Despite these challenges, CoCM remains a pragmatic and promising therapeutic approach for addressing both OUD and mental illness.

REFERENCES

1.     Dydyk AM, Jain NK, Gupta M. Opioid Use Disorder. In: StatPearls. StatPearls Publishing; 2024. Accessed June 25, 2024. http://www.ncbi.nlm.nih.gov/books/NBK553166/

2.     National Institutes of Health HEAL Initiative. Optimizing Collaborative Care for People with Opioid Use Disorder and Mental Health Conditions | NIH HEAL Initiative. Published August 18, 2019. Accessed June 18, 2024. https://heal.nih.gov/research/new-strategies/optimizing-care

3.     Meredith LS, Komaromy MS, Cefalu M, et al. 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. Contemp Clin Trials. 2021;104:106354. doi:10.1016/j.cct.2021.106354

4.     Reist C, Petiwala I, Latimer J, et al. Collaborative mental health care: A narrative review. Medicine (Baltimore). 2022;101(52):e32554. doi:10.1097/MD.0000000000032554

5.     What Is The Collaborative Care Model? | American Psychiatric Association.; 2021. Accessed June 17, 2024. https://www.youtube.com/watch?v=Yb4n-o2oqdA

6.     Watkins KE, Ober AJ, Lamp K, et al. Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care: The SUMMIT Randomized Clinical Trial. JAMA Internal Medicine. 2017;177(10):1480-1488. doi:10.1001/jamainternmed.2017.3947

7.     Brackett CD, Duncan M, Wagner JF, Fineberg L, Kraft S. Multidisciplinary Treatment of Opioid use Disorder in Primary Care using the Collaborative Care Model. Substance Abuse. 2022;43(1):240-244. doi:10.1080/08897077.2021.1932698