Interdisciplinary Management of Opioid Use Disorder in Primary Care

THE INNOVATION

Primary care clinics are developing treatment models for opioid use disorder, but few are integrating comprehensive behavioral health strategies to improve outcomes. Although Medication Assisted Treatment (MAT) models that emphasize medications may be effective,¹ failure to offer robust psychosocial services can yield suboptimal outcomes, especially in complex patients. We implemented a behavioral health-focused model for MAT to expand access, better engage patients in treatment, and improve health outcomes. This was built on concepts of harm reduction and improvement in functioning, emphasizing behavioral health counseling in addition to medications.

WHO & WHERE

We created a multidisciplinary team at a rural health clinic and a federally qualified health center in the Pacific Northwest to address the biopsychosocial needs of patients, with the goal of expanding access, improving retention, reducing relapse, and supporting primary care providers in treating addictions. Masters- and doctoral-level mental health clinicians are integrated into the primary care team to address psychosocial needs, teach coping skills and relapse prevention, and build resilience. This is a valuable benefit to improve abstinence over existing models focused on physician-only care.

HOW

Implementing this model required notification to all patients of the additional behavioral health visits, hiring of additional staff, and consideration that increased cost may be offset by decreased use-related emergency room visits, hospitalizations, and overdose-related morbidity and mortality.

The program uses a risk-stratified registry to determine level of support and visit frequency. Patients complete assessments with behavioral health clinicians to assess readiness for treatment. This replaces the traditional model in which primary care providers initiated or denied buprenorphine treatment without a thorough psychosocial evaluation. Patients sign an agreement which includes education about the medication and requirements of the program, compliance with call-ins, and behavior. The team monitors stability and intensifies support when needed, which is distinct from punitive approaches.

Patients initially have semiweekly contact with behavioral health clincicians and alternate between weekly visits with the nurse and clinician. As patients stabilize, the frequency of visits decreases, alternating among the 3 care team members, at least monthly. Behavioral health clinicians address underlying mental health conditions, coping skills, and relapse prevention using person-centered and cognitive-behavioral techniques. This emphasizes that factors contributing to substance abuse have psychosocial underpinnings and that as mental health improves substance use decreases and medications alone may not be adequate in long term relapse prevention. The nurse performs care management visits with prescription management and drug screening measures. The primary care provider monitors medication side effects, doses, and mental and physical health to prevent segregation of care.

LEARNING

Integration of behavioral health in primary care has increased access to addiction treatment, particularly in communities where services are sparse. Emphasizing behavioral health services in MAT increases clinician confidence to provide primary care based MAT and can help expand care to more patients. Thus far, the addition of behavioral health to our MAT program has streamlined the process and improved access for this care, reduced barriers for primary care clinicians, and increased patients’ feelings of support. We recommend implementing this model to address underlying psychosocial needs of patients and take pressure off of primary care clinicians to manage addictions treatment on their own.