Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care: The SUMMIT Randomized Clinical Trial

Abstract

Importance: Primary care offers an important and underutilized setting to deliver treatment for opioid and/or alcohol use disorders (OAUD). Collaborative care (CC) is effective but has not been tested for OAUD.

Objective: To determine whether CC for OAUD improves delivery of evidence-based treatments for OAUD and increases self-reported abstinence compared with usual primary care.

Design, setting, and participants: A randomized clinical trial of 377 primary care patients with OAUD was conducted in 2 clinics in a federally qualified health center. Participants were recruited from June 3, 2014, to January 15, 2016, and followed for 6 months.

Interventions: Of the 377 participants, 187 were randomized to CC and 190 were randomized to usual care; 77 (20.4%) of the participants were female, of whom 39 (20.9%) were randomized to CC and 38 (20.0%) were randomized to UC. The mean (SD) age of all respondents at baseline was 42 (12.0) years, 41(11.7) years for the CC group, and 43 (12.2) yearsfor the UC group. Collaborative care was a system-level intervention, designed to increase the delivery of either a 6-session brief psychotherapy treatment and/or medication-assisted treatment with either sublingual buprenorphine/naloxone for opioid use disorders or long-acting injectable naltrexone for alcohol use disorders. Usual care participants were told that the clinic provided OAUD treatment and given a number for appointment scheduling and list of community referrals.

Main outcomes and measures: The primary outcomes were use of any evidence-based treatment for OAUD and self-reported abstinence from opioids or alcohol at 6 months. The secondary outcomes included the Healthcare Effectiveness Data and Information Set (HEDIS) initiation and engagement measures, abstinence from other substances, heavy drinking, health-related quality of life, and consequences from OAUD.

Results: At 6 months, the proportion of participants who received any OAUD treatment was higher in the CC group compared with usual care (73 [39.0%] vs 32 [16.8%]; logistic model adjusted OR, 3.97; 95% CI, 2.32-6.79; P < .001). A higher proportion of CC participants reported abstinence from opioids or alcohol at 6 months (32.8% vs 22.3%); after linear probability model adjustment for covariates (β = 0.12; 95% CI, 0.01-0.23; P = .03). In secondary analyses, the proportion meeting the HEDIS initiation and engagement measures was also higher among CC participants (initiation, 31.6% vs 13.7%; adjusted OR, 3.54; 95% CI, 2.02-6.20; P < .001; engagement, 15.5% vs 4.2%; adjusted OR, 5.89; 95% CI, 2.43-14.32; P < .001) as was abstinence from opioids, cocaine, methamphetamines, marijuana, and any alcohol (26.3% vs 15.6%; effect estimate, β = 0.13; 95% CI, 0.03-0.23; P = .01).

Conclusions and relevance: Among adults with OAUD in primary care, the SUMMIT collaborative care intervention resulted in significantly more access to treatment and abstinence from alcohol and drugs at 6 months, than usual care.

Trial registration: clinicaltrials.gov Identifier: NCT01810159.

Conflict of interest statement

Conflict of Interest Disclosures: Some of the authors are employees of The RAND Corporation (“RAND”), a nonprofit institution that helps improve policy and decision making through research and analysis. Within the past three years, RAND has received funding for research projects from Alkermes plc (Alkermes) relating to the pharmaceutical Vivitrol, which is manufactured and sold by Alkermes. Dr Watkins participated in RAND research projects funded by Alkermes and served as a principal investigator. Dr Ober participated in RAND research projects funded by Alkermes. To the extent this paper suggests benefits to patients who received any evidence-based practice, which includes Vivitrol, this finding may have a positive financial effect on Alkermes. Prior to submission, RAND conducted additional internal quality reviews of this article with a particular focus on the possibility of bias. Dr Pincus reported serving on committees without compensation for the National Quality Forum, National Committee on Quality Assurance, American Psychiatric Association, and the National Academy of Medicine. Dr Pincus has had research support from the Substance Abuse and Mental Health Services Administration. Dr Heinzerling reported receiving research funding from Alkermes (different funding than was provided for SUMMIT), as well as from Gilead and Medicinova (which are also unrelated to SUMMIT), and has received small honoraria from Reckitt Benkiser (maker of Suboxone). No other disclosures were reported.

Figures

Figure.. CONSORT Diagram