Integrating peer support services into primary care-based OUD treatment: Lessons from the Penn integrated model.

Opioid use disorder (OUD) is a major public health emergency in the United States. In 2020, 2.7 million individuals had an OUD. Medication for opioid use disorder is the evidence-based, standard of care for treating OUD in outpatient settings, especially buprenorphine because it is effective and has low toxicity. Buprenorphine is increasingly prescribed in primary care, a setting that provides greater anonymity and convenience than substance use disorder treatment centers. Yet two-thirds of people who begin buprenorphine treatment discontinue within the first six months. Treatment dropout elevates the risks of return to use, infections, higher levels of medical care and related costs, justice system involvement, and death. One promising form of retention support is peer service programs. Peers combine their lived experience of substance use and recovery with formal training to help patients engage and persist in OUD treatment. They provide a range of services, including health education, encouragement and empathy, coping skills, recovery modeling, and concrete assistance in overcoming the situational barriers to retention. However, guidance is needed to define the peer role in primary care, the specific tasks peers should perform, the competencies those tasks require, training and professional development needs, and peer performance standards. Guidance also is needed to integrate peers into the care team, allocate and coordinate responsibilities among care team members, manage peer operations and workflow, and facilitate effective team communication. Here we describe a peer support program in the University of Pennsylvania Health System (UPHS or Penn Medicine) network of primary care practices. This paper details the program's core components, values, and activities. We also report the organizational challenges, unresolved questions, and lessons for the field in administering a peer support program to meet the needs of patients served by a large, urban medical system with an extensive suburban and rural catchment area. CLINICAL TRIALS REGISTRATION: www.clinicaltrials.gov registration: NCT04245423.

Collaborative care in the treatment of opioid use disorder and mental health conditions in primary care: A clinical study protocol.

BACKGROUND: People with opioid use disorder (OUD) often have a co-occurring psychiatric disorder, which elevates the risk of morbidity and mortality. Promising evidence supports the use of collaborative care for treating people with OUD in primary care. Whether collaborative care interventions that treat both OUD and psychiatric disorders will result in better outcomes is presently unknown. METHODS: The Whole Health Study is a 3-arm randomized controlled trial designed to test collaborative care treatment for OUD and the psychiatric disorders that commonly accompany OUD. Approximately 1200 primary care patients aged ≥18 years with OUD and depression, anxiety, or PTSD will be randomized to one of three conditions: (1) Augmented Usual Care, which consists of a primary care physician (PCP) waivered to prescribe buprenorphine and an addiction psychiatrist to consult on medication-assisted treatment; (2) Collaborative Care, which consists of a waivered PCP, a mental health care manager trained in psychosocial treatments for OUD and psychiatric disorders, and an addiction psychiatrist who provides consultation for OUD and mental health; or (3) Collaborative Care Plus, which consists of all the elements of the Collaborative Care arm plus a Certified Recovery Specialist to help with treatment engagement and retention. Primary outcomes are six-month rates of opioid use and six-month rates of remission of co-occurring psychiatric disorders. DISCUSSION: The Whole Health Study will investigate whether collaborative care models that address OUD and co-occurring depression, anxiety, or PTSD will result in better patient outcomes. The results will inform clinical care delivery during the current opioid crisis. CLINICAL TRIALS REGISTRATION: www.clinicaltrials.gov registration: NCT04245423.

Coercion or Caring: The Fundamental Paradox for Adherence Interventions for HIV+ People with Mental Illness.

To determine if an escalating HIV treatment adherence intervention would be considered by participants from a caring or coercive perspective, perceived coercion was examined in 238 community-based dually diagnosed individuals (HIV+ and a serious mental illness) randomized to a treatment-as-usual (TAU) control group or preventing AIDS through health for HIV+ persons (PATH+) Intervention that increased intervention intensity when adherence fell below 80 %. Minor differences were observed in perceived coercion between the PATH+ Intervention and Control groups with perceived coercion marginally higher in the PATH+ group. Latent growth curve analyses indicate that perceived coercion was not related to duration of the intervention for either the PATH+ or Control group. The experience of coercion by HIV+ individuals receiving community-based mental health services was not related to the intensity or duration of delivered services.

Randomized trial outcomes of a TTM-tailored condom use and smoking intervention in urban adolescent females.

Smoking and sexual risk behaviors in urban adolescent females are prevalent and problematic. Family planning clinics reach those who are at most risk. This randomized effectiveness trial evaluated a transtheoretical model (TTM)-tailored intervention to increase condom use and decrease smoking. At baseline, a total of 828 14- to 17-year-old females were recruited and randomized within four urban family planning clinics. Participants received TTM or standard care (SC) computerized feedback and stage-targeted or SC counseling at baseline, 3, 6 and 9 months. Blinded follow-up telephone surveys were conducted at 12 and 18 months. Analyses revealed significantly more consistent condom use in the TTM compared with the SC group at 6 and 12, but not at 18 months. In baseline consistent condom users (40%), significantly less relapse was found in the TTM compared with the SC group at 6 and 12, but not at 18 months. No significant effects for smoking prevention or cessation were found, although cessation rates matched those found previously. This TTM-tailored intervention demonstrated effectiveness for increasing consistent condom use at 6 and 12 months, but not at 18 months, in urban adolescent females. This intervention, if replicated, could be disseminated to promote consistent condom use and additional health behaviors in youth at risk.

Who benefits from extended continuing care for cocaine dependence?

The goal of this study was to determine which cocaine dependent patients engaged in an intensive outpatient program (IOP) were most likely to benefit from extended continuing care (24 months). Participants (N=321) were randomized to: IOP treatment as usual (TAU), TAU plus Telephone Monitoring and Counseling (TMC), or TAU plus TMC plus incentives for session attendance (TMC+). Potential moderators examined were gender, stay in a controlled environment prior to IOP, number of prior drug treatments, and seven measures of progress toward IOP goals. Outcomes were: (1) abstinence from all drugs and heavy alcohol use, and (2) cocaine urine toxicology. Follow-ups were conducted at 3, 6, 9, 12, 18, and 24 months post-baseline. Results indicated that there were significant effects favoring TMC+ over TAU on the cocaine urine toxicology outcome for participants in a controlled environment prior to IOP and for those with no days of depression early in IOP. Trends were obtained favoring TMC over TAU for those in a controlled environment (cocaine urine toxicology outcome) or with high family/social problem severity (abstinence composite outcome), and TMC+ over TAU for those with high family/social problem severity or high self-efficacy (cocaine urine toxicology outcome). None of the other potential moderator effects examined reached the level of a trend. These results generally do not suggest that patients with greater problem severity or poorer performance early in treatment on the measures considered in this report will benefit to a greater degree from extended continuing care.

An adaptive approach for identifying cocaine dependent patients who benefit from extended continuing care.

OBJECTIVE: Study tested whether cocaine dependent patients using cocaine or alcohol at intake or in the first few weeks of intensive outpatient treatment would benefit more from extended continuing care than patients abstinent during this period. The effect of incentives for continuing care attendance was also examined. METHOD: Participants (N = 321) were randomized to treatment as usual (TAU), TAU and telephone monitoring and counseling (TMC), or TAU and TMC plus incentives (TMC+). The primary outcomes were (a) abstinence from all drugs and heavy alcohol use and (b) cocaine urine toxicology. Follow-ups were at 3, 6, 9, 12, 18, and 24 months. RESULTS: Cocaine and alcohol use at intake or early in treatment predicted worse outcomes on both measures (ps ≤ .0002). Significant effects favoring TMC over TAU on the abstinence composite were obtained in participants who used cocaine (odds ratio [OR] = 1.95 [1.02, 3.73]) or alcohol (OR = 2.47 [1.28, 4.78]) at intake or early in treatment. A significant effect favoring TMC+ over TAU on cocaine urine toxicology was obtained in those using cocaine during that period (OR = 0.55 [0.31, 0.95]). Conversely, there were no treatment effects in participants abstinent at baseline and no overall treatment main effects. Incentives almost doubled the number of continuing care sessions received but did not further improve outcomes. CONCLUSION: An adaptive approach for cocaine dependence in which extended continuing care is provided only to patients who are using cocaine or alcohol at intake or early in treatment improves outcomes in this group while reducing burden and costs in lower risk patients.

Does mandating offenders to treatment improve completion rates?

While it is known that community-based outpatient treatment for substance abusing offenders is effective, treatment completion rates are low and much of the prior research has been conducted with offenders in residential treatment or therapeutic communities. The aim of the present study was to assess whether offenders who are mandated to community-based outpatient treatment have better completion rates compared to those who enter treatment voluntarily. The 160 research participants were a heterogeneous group of substance abusers who were under various levels of criminal justice supervision (CJS) in the community. The participants were enrolled in an intensive outpatient program and were recruited into the study between July 2007 and October 2010. All offenders received weekly therapy sessions using a cognitive problem solving framework and 45% completed the 6 month treatment program. Interestingly, those who were mandated demonstrated less motivation at treatment entry, yet were more likely to complete treatment compared to those who were not court-ordered to treatment. While controlling for covariates known to be related to treatment completion, the logistic regression analyses demonstrated that court-ordered offenders were over 10 times more likely to complete treatment compared to those who entered treatment voluntarily (OR=10.9, CI=2.0-59.1, p=.006). These findings demonstrate that stipulated treatment for offenders may be an effective way to increase treatment compliance.

A multisite pilot study of extended-release injectable naltrexone treatment for previously opioid-dependent parolees and probationers.

A feasibility study was conducted to pilot test the ability of 5 sites to recruit, treat, and retain opioid-dependent offenders in a trial of extended-release injectable naltrexone (XR-NTX). The participants, 61 previously opioid-dependent individuals under legal supervision in the community, received up to 6 monthly injections of Depotrex brand naltrexone and completed a 6-month follow-up interview. Six-month outcomes showed that those who completed treatment had significantly fewer opioid-positive urines and were less likely to have been incarcerated than those who had not completed treatment. The findings indicate that XR-NTX holds promise as a feasible, effective treatment option for opioid-dependent offenders.

Extended telephone-based continuing care for alcohol dependence: 24-month outcomes and subgroup analyses.

AIMS: To determine whether 18 months of telephone continuing care improves 24-month outcomes for patients with alcohol dependence. Subgroup analyses were performed to identify patients who would benefit most from continuing care. DESIGN: Comparative effectiveness trial of continuing care that consisted of monitoring and feedback only (TM) or monitoring and feedback plus counseling (TMC). Patients were randomized to treatment as usual (TAU), TAU plus TM or TAU plus TMC, and followed quarterly for 24 months. SETTING: Publicly funded intensive out-patient programs (IOP). PARTICIPANTS: A total of 252 alcohol-dependent patients (49% with current cocaine dependence) who completed 3 weeks of IOP. MEASUREMENTS: Percentage of days drinking, any heavy drinking and a composite good clinical outcome. FINDINGS: In the intent-to-treat sample, group differences in alcohol outcomes out to 18 months favoring TMC over TAU were no longer present in months 19-24. There was also a non-significant trend for TMC to perform better than usual care on the good clinical outcome measure (60% vs. 46% good clinical outcome in months 19-24). Overall significant effects favoring TMC and TM over TAU were seen for women; and TMC was also superior to TAU for participants with social support for drinking, low readiness to change and prior alcohol treatments. Most of these effects were obtained on at least two of three outcomes. However, no effects remained significant at 24 months. CONCLUSIONS: The benefits of an extended telephone-based continuing care programme to treat alcohol dependence did not persist after the end of the intervention. A post-hoc analysis suggested that women and individuals with social support for drinking, low readiness to change or prior alcohol treatments may benefit from the intervention.

Comparing intervention strategies among rural, low SES, young adult tobacco users.

OBJECTIVE: To evaluate 3-month tobacco quit rates of young adult tobacco users randomized to 2 intervention conditions. METHODS: Overall 192 non-treatment-seeking 18-to-24-year-old tobacco users received educational information and advice to quit smoking. Participants were then block randomized to 2 brief intervention conditions: (1) a telephone quitline (TQ) N = 90; or (2) a brief direct treatment intervention (BDTI) N = 102. RESULTS: A 90-day follow-up evaluation found that 19.6% of BDTI and 10.2% of TQ participants reported 30-day point prevalence tobacco quit rates (chi-square = 2.37, P = .09). CONCLUSIONS: BDTI can help non-treatment-seeking, low SES, young adult tobacco users quit smoking.

Characteristics and 9-month outcomes of discharged methadone maintenance clients.

This study is a secondary data analysis of a clinical trial assessing the effectiveness of outreach case management (OCM) in linking discharged methadone patients back into treatment. The original trial assessed the effectiveness of the OCM intervention compared to a passive referral among methadone clients who needed treatment postdischarge but had not reengaged. The purpose of this study was to assess the characteristics and long-term outcomes of all clients who were discharged from methadone maintenance treatment including those who had reengaged in treatment. A total of 230 methadone clients were interviewed 3 months and then again at 9 months following discharge from treatment. Compared with participants who needed treatment but had not reengaged (NoTx: 56%), those who had successfully reenrolled in treatment (Tx; 44%) were more likely to be female, not married, and unemployed; had a longer history of sedative use; reported more psychiatric hospitalizations; and were originally enrolled in a community-based rather than a Veterans Administration program. Despite having more severe problems, the Tx group had fewer opioid-positive urines and reported less IV drug use at 9 months postdischarge compared to the NoTx group. The findings highlight the importance of rapid treatment reengagement.

Relationship of Mental Health and Illness in Substance Abuse Patients.

This study examined the latent structure of a number of measures of mental health (MH) and mental illness (MI) in substance use disorder outpatients to determine whether they represent two independent dimensions, as Keyes (2005) found in a community sample. Seven aspects of MI assessed were assessed - optimism, personal meaning, spirituality/religiosity, social support, positive mood, hope, and vitality. MI was assessed with two measures of negative psychological moods/states, a measure of antisociality, and the Addiction Severity Index's recent psychiatric and family-social problem scores. Correlational and exploratory factor analyses revealed that MH and MI appear to reflect two independent, but correlated, constructs. However, optimism and social support had relatively high loadings on both factors. Antisociality and the family-social problem score failed to load significantly on the MI factor. Confirmatory factor analysis supported the existence of two obliquely related, negatively correlated dimensions. Study findings, although generally supporting the independence of MH and MI, suggest that the specific answers to this question may be influenced by the constructs and assessments used to measure them.

A randomized trial of extended telephone-based continuing care for alcohol dependence: within-treatment substance use outcomes.

OBJECTIVE: The study tested whether adding up to 18 months of telephone continuing care, either as monitoring and feedback (TM) or longer contacts that included counseling (TMC), to intensive outpatient programs (IOPs) improved outcomes for alcohol-dependent patients. METHOD: Participants (N = 252) who completed 3 weeks of IOP were randomized to up to 36 sessions of TM (M = 11.5 sessions), TMC (M = 9.1 sessions), or IOP only (treatment as usual [TAU]). Quarterly assessment of alcohol use (79.9% assessed at 18 months) was corroborated with available collateral reports (N = 63 at 12 months). Participants with cocaine dependence (N = 199) also provided urine samples. RESULTS: Main effects favored TMC over TAU on any alcohol use (odds ratio [OR] = 1.88, CI [1.13, 3.14]) and any heavy alcohol use (OR = 1.74, CI [1.03, 2.94]). TMC produced fewer days of alcohol use during Months 10-18 and heavy alcohol use during Months 13-18 than TAU (ds = 0.46-0.65). TMC also produced fewer days of any alcohol use and heavy alcohol use than TM during Months 4-6 (ds = 0.39 and 0.43). TM produced lower percent days alcohol use than TAU during Months 10-12 and 13-15 (ds = 0.41 and 0.39). There were no treatment effects on rates of cocaine-positive urines. CONCLUSIONS: Adding telephone continuing care to IOP improved alcohol use outcomes relative to IOP alone. Conversely, shorter calls that provided monitoring and feedback but no counseling generally did not improve outcomes over IOP.

Measurement of mental health in substance use disorder outpatients.

Few studies have examined mental health (MH) attributes of patients with substance use disorder (SUD). This study examines the internal consistency, concurrent validity, and comparative level of MH attributes (i.e., optimism, life attitudes, spirituality/religiousness, social support, positive mood, hope, and vitality) in patients with SUD compared with the instrument development group. The internal consistency of optimism, spirituality/religiousness, positive mood, hope, and vitality were similar in both groups. Some subscales of the social support and life attitude measures had lower internal consistency than was found for the original samples, although internal consistency of more global constructs were comparable. Patients with SUD had higher positive mood, spirituality/religiousness, and hope scores, whereas social support, life attitudes, and optimism scores were lower than in the original sample. Correlations between MH attributes and recent life problems of patients with SUD generally supported the concurrent validity of the MH measures.

A randomized trial of oral naltrexone for treating opioid-dependent offenders.

Offenders with a history of opioid dependence are a particularly difficult group to treat. A large proportion of offenders typically relapse shortly after release from prison, commit drug-related crimes, and then are arrested and eventually re-incarcerated. Previous research demonstrated that oral naltrexone was effective in reducing opioid use and preventing recidivism among offenders under federal supervision. The 111 opioid-dependent offenders in this study were under various levels of supervision that included county and federal probation/parole, a treatment court, an alternative disposition program, and an intermediate punishment program. Subjects were randomly assigned to receive 6 months of either 300 mg per week of oral naltrexone plus standard psychosocial treatment as usual (n = 56) or standard psychosocial treatment as usual (TAU) without naltrexone (n = 55). While the TAU subjects who remained in treatment used more opioids than the naltrexone subjects who remained, the high dropout rate for both groups made it difficult to assess the effectiveness of naltrexone. The study provides limited support for the use of oral naltrexone for offenders who are not closely monitored by the criminal justice system.

Moderators of response to telephone continuing care for alcoholism.

OBJECTIVES: To evaluate potential moderators of the effect of adding extended telephone monitoring (TM) and telephone monitoring and counseling (TMC) continuing care to treatment as usual (TAU) for alcoholism. Continuing care was predicted to be more effective for patients with severe substance-use histories, poor initial response to treatment, and other risk factors for relapse. METHODS: Randomized study with 18-month follow-up. Outcomes were frequency of drinking and any drinking. RESULTS: Main effects favored TMC over TAU on alcohol outcomes. However, none of the 11 variables examined moderated these effects. Conversely, main effect and moderator analyses indicated TM was more beneficial than TAU only for women and for participants with lower readiness to change. CONCLUSIONS: TMC improves drinking outcomes when added to standard care, regardless of alcohol use history, early response to treatment, or other risk factors for relapse. TM is recommended for women and less motivated patients.

Randomized trial of continuing care enhancements for cocaine-dependent patients following initial engagement.

OBJECTIVE: The effects of cognitive-behavioral relapse prevention (RP), contingency management (CM), and their combination (CM + RP) were evaluated in a randomized trial with 100 cocaine-dependent patients (58% female, 89% African American) who were engaged in treatment for at least 2 weeks and had an average of 44 days of abstinence at baseline. METHOD: The participants were from intensive outpatient programs, which provide 10 hr per week of group counseling. The CM protocol provided gift certificates (maximum value $1,150; mean received = $740) for cocaine-free urines over 12 weeks on an escalating reinforcement schedule, and weekly individual RP sessions were offered for up to 20 weeks. Average number of RP sessions attended was 3 in RP and 13 in CM + RP. RESULTS: Generalizing estimation equation analyses over 18 months postrandomization showed significant effects for CM (but not RP) on urine toxicology and self-reported cocaine use (p = .05), with no significant CM x RP interactions. Secondary analyses indicated CM + RP produced better cocaine urine toxicology outcomes at 6 months than treatment as usual, odds ratio [OR] = 3.96 (1.33, 11.80), p < .01, and RP, OR = 4.89 (1.51, 15.86), p < .01, and produced better cocaine urine toxicology outcomes at 9 months than treatment as usual, OR = 4.21 (1.37, 12.88), p < .01, and RP, OR = 4.24 (1.32, 13.65), p < .01. Trends also favored CM + RP over CM at 6 months, OR = 2.93 (0.94, 9.07), p = .06, and 9 months, OR = 2.93 (0.94, 9.10), p = .06. Differences between the conditions were not significant after 9 months. CONCLUSIONS: These results suggest CM can improve outcomes in cocaine-dependent patients in intensive outpatient programs who have achieved initial engagement, particularly when it is combined with RP.

Predictors of drug treatment completion among parole violators.

This study examined the predictors of treatment completion among 380 state parole violators consecutively admitted to a comprehensive 12-month drug treatment program in lieu of reincarceration. Offenders were placed on intensive parole supervision throughout the 12-month treatment protocol and received three months of residential substance abuse treatment followed by nine months of outpatient counseling. Overall 123 (32.4%) of the offenders completed the 12-month treatment protocol. The primary reason for noncompletion was a positive drug screen. Bivariate analyses were performed to determine independent predictors of program completion. Four variables (age, past 30-day heroin use, total months incarcerated, and significant problems with mother) from the baseline Addiction Severity Index were found to be correlated with treatment completion (p <.10). These factors and other demographics (race, marital status, education) and variables found predictive of program completion in previous studies were entered into a multiple logistic regression model. Overall the final model found that only two factors--older age (p < .03) and no heroin use in the past 30 days (p < .02) significantly predicted treatment completion. These findings suggest that among parolees with moderate to extensive criminal justice histories younger individuals and those with recent heroin use respond less favorably to comprehensive substance abuse treatment services and intensive parole supervision.

An integrated drug counseling and employment intervention for methadone clients.

After drug use stabilization, employment has long been considered an important goal for clients enrolled in Methadone Maintenance Treatment Programs (MMTPs). The integrated counseling and employment intervention described here is a manualized treatment based on interpersonal cognitive problem solving (ICPS) theory. The six-month intervention utilized a problem-solving framework to help methadone clients obtain a job and manage employment within the context of drug treatment. In this pilot study, 23 subjects were randomly assigned to either integrated ICPS drug and employment counseling (n = 12) or to an ICPS drug counseling control condition (n = 11). While there were no differences between the integrated and control conditions, both groups showed a significant improvement in employment outcomes and reduction in HIV risk behaviors at the six-month follow-up. Although there may be concerns regarding the generalizability of the findings, overall, the problem solving framework may be an improvement over standard methadone counseling. The intervention may be beneficial when implemented with a larger group of motivated ex-offenders who are mandated to drug treatment as a condition of their parole.

The effectiveness of outreach case management in re-enrolling discharged methadone patients.

BACKGROUND: Heroin dependence is a chronic relapsing disease often requiring multiple treatment experiences. Despite this knowledge, few methadone programs follow-up with discharged patients who frequently continue to engage in risky behaviors. The aim of this project was to evaluate the effectiveness of outreach case management for post-discharged methadone patients. METHODS: At 90 days post-discharge 128 active out of treatment heroin users were randomly assigned to receive either a passive referral (PR) for drug treatment (n=52) or were provided with 6 weeks of outreach case management (OCM), an intervention designed to help motivate and coach patients to re-enter treatment (n=76). RESULTS: At 6 months post-baseline 29% of the OCM participants had successfully re-enrolled in drug treatment compared to 8% of the PR participants (chi(2)=7.6, d.f.=1, p=0.006). A logistic regression analysis showed that OCM participants were nearly six times more likely than PR participants to re-engage in MMT (OR=5.8, CI=1.6-20.8, p=0.008). Moreover, OCM subjects had fewer opiate and cocaine positive urines at the 6-month follow-up compared to PR subjects. CONCLUSIONS: The findings highlight the importance of engaging former patients in treatment and actively assisting in treatment re-entry. OCM is a simple approach to reduce the number of out-of-treatment drug users, although availability of treatment funding limits enrollment opportunities.