Confidentiality protections versus collaborative care in the treatment of substance use disorders

A scoping review of barriers and facilitators to the integration of substance use treatment services into US mainstream health care

Background

Following the national implementation of the Affordable Care Act (ACA) in 2014, barriers still exist that limit the adoption of substance use treatment (SUT) services in mainstream health care (MHC) settings in the United States. This study provides an overview of current evidence on barriers and facilitators to integrating various SUT services into MHC.

Methods

A systematic search was conducted with the following databases: "PubMed including MEDLINE", "CINAHL", "Web of Science", "ABI/Inform", and "PsycINFO." We identified barriers and/or facilitators affecting patients, providers, and programs/systems.

Results

Of the 540 identified citations, 36 were included. Main barriers were identified for patients (socio-demographics, finances, confidentiality, legal impact, and disinterest), providers (limited training, lack of time, patient satisfaction concerns, legal implications, lack of access to resources or evidence-based information, and lack of legal/regulatory clarity), and programs/systems (lack of leadership support, lack of staff, limited financial resources, lack of referral networks, lack of space, and lack of state-level support). Also, we recognized key facilitators pertaining to patients (trust for providers, education, and shared decision making), providers (expert supervision, use of support team, training with programs like Extension for Community Health Outcomes (ECHO), and receptivity), and programs/systems (leadership support, collaboration with external agencies, and policies e.g., those expanding the addiction workforce, improving insurance access and treatment access).

Conclusions

This study identified several factors influencing the integration of SUT services in MHC. Strategies for improving SUT integration in MHC should address barriers and leverage facilitators related to patients, providers, and programs/systems.

The Dobbs Double Bind: Lessons From Substance Use Disorder on the Conflict Between Privacy and Quality Care

The Dobbs decision overturned the right to abortion in the United States and allowed states to enact total abortion bans. In addition to restricting access to abortion, laws criminalizing pregnancy outcomes deter providers from offering timely, appropriate care for pregnancy complications. To avoid litigation or prosecution, providers are under pressure to strictly guard the privacy of patient health information related to pregnancy. Perinatal care is at risk of repeating the experience of similar enhanced privacy rules for substance use disorders, which have impeded information sharing and care coordination that improves outcomes.

Strategies to recruit rural primary care providers to implement a medication for opioid use disorder (MOUD) focused integrated care model

Background

Access to providers and programs that provide medications for opioid use disorder (MOUD) remains a systemic barrier for patients with opioid use disorder (OUD), particularly if they live in rural areas. The Rural Access to Medication Assisted Treatment (MAT) in Pennsylvania Project (Project RAMP) addressed this problem with a multisystem partnership that recruited, trained, and supported rural primary care providers to provide MOUD and implement an integrated care model (ICM) for patients with OUD. Given the demonstrated efficacy of Project RAMP, this article summarizes our recruitment strategies, including feasibility concerns for further expansion into other regions.

Methods

The approach for recruiting implementation sites included two phases: partner outreach and site identification. Once recruited, the Systems Transformation Framework guided planning and implementation activities. Recruitment and implementation activities were assessed with implementation trackers and evaluated by providers via key informant interviews (KIIs).

Results

Project RAMP recruited 26 primary care practices from 13 counties, including nine health systems and two private practice groups—exceeding the original target of 24 sites. There was a median of 49 days from first contact to project onboarding. A total of 108 primary care practices spanning 22 health systems declined participation. Findings from the KIIs highlighted the value of engaging PCPs by connecting to a shared vision (i.e., improving the quality of patient care) as well as addressing perceived participation barriers (e.g., offering concierge technical assistance to address lack of training or resources).

Conclusion

Findings highlight how successful recruitment activities should leverage the support of health system leadership. Findings also emphasize that aiding recruitment and engagement efforts successfully addressed prescribers’ perceived barriers to providing MOUD as well as facilitating better communication among administrators, PCPs, behavioral health professionals, care managers, and patients. Plain Language Summary: Opioid use disorder (OUD) is one of the leading causes of preventable illness and death. The standard of care for OUD is the provision of medications for opioid use disorder (MOUD) and the application of an integrative integrated care model (ICM) where behavioral health is blended with specialized medical services. Unfortunately, access to providers and healthcare facilities that provide MOUD or apply an ICM remains a systemic barrier for patients with OUD, particularly if they live in rural areas. Although there is no one-size-fits-all approach to implementing MOUD in primary care, findings from Project The Rural Access to Medication Assisted Treatment (MAT) in Pennsylvania Project (Project RAMP) highlight strategies that may improve future MOUD and ICM implementation efforts in similar rural contexts. Specifically, future efforts to increase MOUD capacity by recruiting new providers should be prepared to leverage health system leadership, address provider barriers via training and expert consultation, and facilitate connections to local behavioral health providers. This approach may be helpful to others recruiting health systems and primary care practices to implement new care models to use MOUD in treating patients with OUD.

Outpatient follow-up and use of medications for opioid use disorder after residential treatment among Medicaid enrollees in 10 states

BACKGROUND

Follow-up after residential treatment is considered best practice in supporting patients with opioid use disorder (OUD) in their recovery. Yet, little is known about rates of follow-up after discharge. The objective of this analysis was to measure rates of follow-up and use of medications for OUD (MOUD) after residential treatment among Medicaid enrollees in 10 states, and to understand the enrollee and episode characteristics that are associated with both outcomes.

METHODS

Using a distributed research network to analyze Medicaid claims data, we estimated the likelihood of 4 outcomes occurring within 7 and 30 days post-discharge from residential treatment for OUD using multinomial logit regression: no follow-up or MOUD, follow-up visit only, MOUD only, or both follow-up and MOUD. We used meta-analysis techniques to pool state-specific estimates into global estimates.

RESULTS

We identified 90,639 episodes of residential treatment for OUD for 69,017 enrollees from 2018 to 2019. We found that 62.5% and 46.9% of episodes did not receive any follow-up or MOUD at 7 days and 30 days, respectively. In adjusted analyses, co-occurring mental health conditions, longer lengths of stay, prior receipt of MOUD or behavioral health counseling, and a recent ED visit for OUD were associated with a greater likelihood of receiving follow-up treatment including MOUD after discharge.

CONCLUSIONS

Forty-seven percent of residential treatment episodes for Medicaid enrollees are not followed by an outpatient visit or MOUD, and thus are not following best practices.

Addressing Unhealthy Substance Use in Primary Care

Unhealthy substance use is common in primary care populations and is a major contributor to morbidity and mortality. Two key strategies to address unhealthy substance use in primary care are the process of screening, brief intervention, and referral to treatment (SBIRT), and integration of treatment for substance use disorders into primary care. Implementation of SBIRT requires buy-in from practice leaders, careful planning, and staff and primary care provider training. Primary care-based treatment of opioid and alcohol use disorders can be effective; more data are needed to better understand the benefits of these models and identify means of treating other substance use disorders in primary care.

Possible Alternatives to Diagnosis-Based Denominators for Addiction Treatment Quality Measures

Consumers of healthcare quality measures are often unaware of how measured performance may be driven by diagnosing practices rather than the provision of high quality care. Reliance on quality metrics that depend on documented diagnoses can therefore subvert comparisons between clinicians, facilities or systems. In this study, three versions of an alcohol use disorder (AUD) treatment quality measure were calculated: method 1--the usual denominator including all diagnosed patients; method 2--a "population-based" denominator including the entire facility census; and method 3-an epidemiologically-derived denominator comprising the expected prevalence of AUD based on case-mix characteristics and geographic region. Performance rankings under the three specifications were calculated. Changes in percentile rank of up to 30-45% were observed between methods. Therefore, much of the observed between-facility differences on diagnosis-based quality measures may reflect variation in the propensity to diagnose rather than real differences in performance. Stakeholders must decide which of the validity threats produced by these different methods is least worrisome.

The Affordable Care Act: an opportunity for improving care for substance use disorders?

The Patient Protection and Affordable Care Act (ACA) will greatly increase coverage for treatment of substance use disorders. To realize the benefits of this opportunity, it is critical to develop reliable, valid, and feasible measures of quality to ensure that treatment is accessible and of high quality. The authors review the availability of current quality measures for substance use disorder treatment and conclude there is a pressing need for development, validation, and use of quality measures. They provide recommendations for research and policy changes to increase the likelihood that patients, families, and society benefit from the increased coverage provided by the ACA.