The first wave of the opioid epidemic began 26 years ago, and it continues to be a major issue for the health care system today.
However, there is one treatment model that shows promise—but it could see progress stunted by future Medicaid cuts.
In 2022, 81,806 opioid-involved overdose deaths occurred in the United States, more than any year prior. However, in 2024, overdose deaths relating to synthetic opioids dropped by almost 37 percent from 2023.
A form of treatment that has proved and could continue to prove beneficial for treating opioid use disorder (OUD) is the collaborative care model (CoCM). In the SUMMIT randomized clinical trial, published in 2017, 32.8 percent of patients in a CoCM displayed abstinence from opioids or alcohol, as compared to 22.3 percent in standard care.
How do collaborative care models work?
The CoCM is depicted as a triangle and involves a behavioral health clinician, a consulting specialist (like a psychiatrist or addiction medicine specialist) and a primary care provider, collaborating to provide behavioral health services to a patient.
This treatment model stems from research conducted at the University of Washington at its Advancing Integrated Mental Health Solutions (AIMS) Center to understand whether it was possible to leverage the power of the relationship between a primary care physician and their patient while also increasing access to mental health services.
Dr. Rachel E. Kishton, a physician at Penn Medicine, headquartered in Philadelphia, was recently named medical director of the Penn Integrated Care (PIC) program, where she oversees Penn’s integrated and collaborative care programs.
“By including everything within the primary care setting and centering that relationship between the primary care physician and the patient, you get over the hump of the fear and stigma related to it but also start from a place of trust,” Kishton told Newsweek.
Collaborative care models have been used to treat individuals with disorders like OUD and alcohol use disorder but are also used to treat mental health disorders. Within this lies the biggest challenge in treating patients for OUD using a CoCM. More often than not, OUD is accompanied by comorbid mental health disorders.
According to Kishton, the need for a shift to more immediate and definitive treatment for mental health disorders is overlooked, compared to other disciplines in medicine.
Kishton provided the metaphor of a patient having a heart attack. In that scenario, the patient should be rushed to the catheterization lab, not kept in an outpatient office and given aspirin. The distinction isn’t always clear when a patient is having a mental health crisis. Physicians need better guidelines to respond to behavioral health patients with the proper level of urgency, the same way they would for a patient experiencing physical symptoms.
“More research is definitely needed to understand when you send someone to the cath lab,” she said, continuing the metaphor. “We need to ensure this research is continued to understand what the next steps are.”
Dr. Tyler Winkelman, a primary care physician at Hennepin Healthcare in Minneapolis, explained that often patients with depression or anxiety come in with the understanding that they have the disorder, whereas OUD patients often have yet to recognize what they’re dealing with.
“We’ve had a lot of success in referring patients with anxiety, depression and alcohol use disorders to the model,” Winkelman said. “It has been trickier to figure out how to adapt the model for people with opioid use disorder.”
As a result of this, Hennepin recently started shifting its CoCM strategy. It previously treated OUD similarly to mental health disorders and is now using the model to prioritize care coordination and access, since that’s what the patient population needs most.
The collaborative care model is a highly evidence-based and adaptable form of treatment. The behavioral health clinician in the model will typically utilize evidence-based therapy modalities, including cognitive behavioral therapy and behavioral activation. The typical progression for these programs is six to eight sessions with a therapist over three to four months.
However, despite the model appearing somewhat formulaic, Kishton emphasized that collaborative care programs vary across institutions.
“If you’ve seen one collaborative care program, you’ve seen one collaborative care program,” Kishton said. “They can be very different, depending on what the goals are, where the funding’s coming from and what the core patient group is that you’re working with.”
How do collaborative care models help build patient trust?
In addition to Penn Medicine, other institutions around the country are working to create collaborative care programs to serve this patient population.
Dr. Gavin B. Bart, who has been a physician of internal and addiction medicine at Hennepin Healthcare for 20 years now, believes the collaborative care model is instrumental in helping people with substance-abuse disorders.
“People with substance use disorders are complicated because they’ve been so marginalized by the health care system,” Bart said. “Having care coordination within a single site helps prevent the fragmentation of care that is sort of the standard right now.”
The CoCM addresses this fragmentation of care by providing patients with direct and immediate access to care within one facility, preventing them from having to find and build trust with a new provider.
“The initial part of treating addiction requires much more upfront management to make sure the patient’s needs are being mapped, their withdrawal is being managed and other medical issues are managed,” said Bart. “And it should be done in a quick manner, otherwise the patients walk away and don’t come back.”
Nurse Practitioner Brenda Bauch works within Hennepin’s addiction clinic and shed some light on the vulnerability patients often come into the clinic with.
“We see patients who often have a distrust of doing something new,” Bauch said. “We have access to effective FDA-approved medications for OUD. That’s wonderful and can be life-changing. But initially, it’s about saying, ‘You’re welcome here in wherever you’re at in your state of transformative change.'”
Could Medicaid cuts limit access to collaborative care?
Hennepin Healthcare provides services through grants provided by the Substance Abuse and Mental Health Services Administration (SAMHSA). However, Minnesota’s state Medicaid agency is yet to adopt the billing codes that cover the cost of a collaborative care program.
Bart and Winkelman from Hennepin Healthcare expressed concern regarding pending Medicare and Medicaid cuts.
“As a public safety net hospital, we’re certainly concerned about the potential cuts,” Bart said. “The best we can do to preserve our finances is not squander the knowledge we’ve gathered through research and public health information. There’s data that tells us for every dollar invested in treatment, the amount of savings that occur elsewhere in society in terms of reduced rates of incarceration, increased employment rates and more. We need to not lose touch with that as we create our plans, moving forward, to make America healthy.”
Despite this possible obstacle, Hennepin Healthcare has been largely successful in helping OUD patients transform their lives.
Aside from sharing concerns regarding the financial sustainability of the collaborative care program at Hennepin, Winkelman, too, is “extremely optimistic” about the model’s future in treating OUD and other disorders.
“I’ve had so many patients in the last two years benefit dramatically from these services, and we’ve really been able to help patients get back on their feet,” he said. “It has improved the quality of health care that we’ve provided. And I really see it as the standard of care moving forward in primary care.”
What’s on the horizon for collaborative care models?
Currently, research is shifting to examine not only how the collaborative care model can address substance abuse symptoms but also the co-occurring mental health conditions.
Penn Medicine’s Whole Health Study focused on this with a randomized controlled trial designed to assess collaborative care models and their effectiveness in treating patients for OUD and the comorbid mental disorders that accompany it.
The study utilized three conditions. In the first, primary care doctors were prescribing buprenorphine and referring patients out for mental health care.
Currently, buprenorphine, a Schedule 3 controlled substance, is one of the medications most commonly used to treat OUD and help patients reduce or quit their opioid usage.
In the second condition, a collaborative care model was implemented with a licensed clinical social worker and a psychiatrist who were providing mental health treatment within the primary care practice. The final condition added a peer or certified recovery specialist to increase treatment engagement and retention.
The study’s principal investigator, David Mandell, professor of psychiatry and director of the Penn Center for Mental Health, shared details regarding the initial results the center recently shared with the College on Problems of Drug Dependence (CPDD) organization in New Orleans.
“In all three conditions, there’s a substantial reduction in opioid use, and [use] stays low for the six months they’re in [the CoCM],” said Mandell. “But our collaborative care condition also results in substantial reduction in psychiatric symptoms and even remission from psychiatric disorder, relative to the usual care condition.”
According to the study’s protocol published in 2021, poor treatment retention is relatively common in CoCMs treating OUD. Mandell described a few reasons why this occurs: the location of care sites, which can make it difficult to live one’s life during treatment; punitive measures and caregivers’ refusal to see patients after relapses; and problems that accompany opioid use, like food insecurity and housing instability.
The center recruited participants from among primary care doctors’ existing patients; these patients had either initiated treatment or had been in treatment for some time but were still experiencing psychiatric distress. Hence, convincing patients to begin treatment wasn’t necessarily part of conducting the study.
“One of the really exciting things we see is, across the conditions tested, 80 percent of people stayed in treatment,” Mandell said. “This suggests they liked their doctors, thought the treatment was effective and thought people were meeting them where they were.”
Mandell believes one of the main reasons for this is the harm reduction approach used by Penn primary care doctors, in which they’re more responsive to patients’ needs and don’t use the punitive approach often taken to OUD patients.
When asked about the most rewarding part of the trial, Mandell mentioned seeing how much the primary care doctors loved the model, because they’ve been eager to secure a high level of support for their patients for a long time.
Mandell also enjoyed reading patient testimonials, talking about how much they loved their therapists and benefited from their treatment.
“The emails we get, where they say, ‘You’ve turned my life around. Things are so great,’ relative to what they were. ‘I don’t know what I would’ve done without this social worker.’ That’s very rewarding,” said Mandell.
To ensure success, Mandell had a multidisciplinary team working alongside him, and working with the members has been one of his favorite parts of leading the trial because of their determination to help this patient population.
“This patient population has a lot of stigma around it, and many people are not interested in helping these folks,” he said. “They believe, ‘You could stop if you wanted,’ and ‘You get what you deserve.’ But these are people really committed to helping OUD patients and figuring out the best way to support them. And that has just absolutely restored my faith in humanity.”
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