Substance use disorder (SUD) is increasingly prevalent in the United States with sharp increases in overdose mortality rates. Many overdose deaths involve opioids and, more recently, stimulants like methamphetamine. The problem has worsened since the COVID-19 pandemic, in addition to the recent increase of fentanyl, which is being laced into the street drug supply in communities. Despite this, few people with SUD receive the addiction treatment they need. Barriers to care include the difficulty of navigating complex treatment systems and fears related to perceived stigma in health care settings that result from societal attitudes surrounding substance use. Also, people with SUD often have complex needs, such as homelessness or medical and psychiatric comorbidities, which makes the treatment gap even more challenging to cross.
In response, researchers, providers, and policymakers are exploring models in addiction care designed to meet people with SUD “where they are at.” People with SUD frequently use or are transported to emergency departments (EDs) for medical complications of substance use. These treatment episodes can be both costly and chaotic. The period after discharge, too, can be overwhelming for people with SUD, who are at higher risk for hospital readmissions and people with opioid use disorder (OUD) face greater likelihood for drug-related mortality during this vulnerable period. Some addiction care models make better use of these initial medical encounters by offering same-day access to medications for addiction treatment (MAT) and connections with community-based interdisciplinary addiction care teams — including mental health specialists and peer recovery coaches. These evidence-based models provide an important alternative to more traditional approaches to SUD care, such as residential treatment, which can have long waiting lists, is costly, and provides inconsistent quality.
The Better Care Playbook recently developed an Addiction Care Collection of resources to provide a broad (though not exhaustive) overview of some of these innovative models for providers and policymakers interested in understanding: (1) the growing evidence for these models; and (2) case studies and implementation tools on developing such programs. This blog post walks through the findings from the Collection, including emerging evidence for innovative addiction care approaches and considerations for implementation.
Evidence Behind Different Approaches to Addiction Care
Medication First
The Medication First principle describes models that prioritize rapid delivery of MAT, alongside offering other patient-centered psychosocial services or other supports. There are several types of FDA-approved MAT for alcohol and opioid use disorders, all proven to be clinically safe and effective for treating these types of dependencies. The Medication First approach has shown positive outcomes, particularly in EDs for initiating MAT for people with OUD. A seminal randomized controlled trial studied patients with OUD who were initiated on buprenorphine (a type of medication for OUD), demonstrating:
- Significantly higher rates of formal SUD treatment engagement at 30-days post-intervention;
- Reduced rates of self-reported illicit opioid use; and
- Decreased use of inpatient addiction treatment services.
Bridge Clinics
As awareness of the Medication First and ED-initiated MAT approach has grown, some hospitals are offering this within their EDs or establishing bridge clinics. Bridge clinics, which are often adjacent to hospital EDs, are designed to support high-risk, post-discharge patients with SUD. They are staffed with interdisciplinary teams, which can look like addiction medicine specialists, nurses, mental health specialists, and peer recovery coaches. An evaluation of a hospital-wide SUD initiative, which included a low-threshold bridge clinic, found both high rates of clinic referral and MAT induction, indicating a significant need for this type of model in medical settings.
Inpatient Addiction Consult Teams
Inpatient addiction consult teams are another model of addiction care showing positive outcomes. These are interdisciplinary teams composed of medical providers (who are trained in addiction medicine), mental health specialists, and peer recovery coaches and who comprehensively assess patients with SUD or suspected SUD and offer the initiation of treatment, including MAT, behavioral therapies, and follow-up. An evaluation of an inpatient addiction consult team found that patients who received the intervention were twice as likely to engage in post-discharge SUD treatment (compared to their utilization history prior to hospitalization). Another study examines outcomes of a navigation component added to an inpatient addiction consult team called Navigation Services to Avoid Rehospitalization (NavSTAR). NavSTAR provides proactive case management and care coordination for aftercare SUD services with a focus on both SUD and social needs. The study demonstrated reduced rates of hospital re-admission and ED use over a 12-month period as well as higher likelihood of outpatient SUD treatment engagement in the three months after discharge.
Using Data to Design Interventions
Many of the addiction care models explored in the Playbook Collection are designed to reach people with SUD where they already commonly come into contact with the medical system (e.g., EDs, inpatient settings). This study takes this design concept even further. It examined sets of Massachusetts state government agency data to understand other common touchpoints, including “opioid prescribing touchpoints” (e.g., high opioid dosage, multiple providers/pharmacies) and “critical encounter touchpoints” (e.g., nonfatal overdose episode, release from incarceration) and found that up to 50 percent of the state’s opioid overdose deaths had the potential to be averted if addiction care interventions were delivered at these touchpoints.
Facilitating Connections to Primary Care
Many patients with SUD visit EDs as opposed to primary care to address chronic conditions, in part due to fears related to stigma from providers. This study looked at a group intervention embedded in an outpatient SUD clinic that trains participants in engaging with primary care, such as practicing and facilitating de-stigmatizing conversations with primary care physicians about health-related recovery goals. The study found that that the patients had increased health care engagement in primary care and decreased ED-usage for up to five years post-intervention.
Considerations for Implementing Addiction Care Models
As awareness about evidence-based models for addiction care grows, more providers are considering adapting them for their own health system. Here are a few successful examples as well as practical toolkits:
- In Oregon, one hospital-based SUD intervention called the Improving Addiction Care Team (IMPACT) released this toolkit describing the design of their program model to help medical providers and staff considering an inpatient addiction consult team model. This program helped the Oregon-based hospital’s patients engage in SUD treatment in the community at twice the prior rate.
- In Connecticut, a program known as the Connecticut Community for Addiction Recovery (CCAR) launched one of the nation’s first peer recovery coaching services in an ED back in 2017. In their model, recovery coaches meet with patients admitted to the ED for nonfatal overdose or other SUD-related crisis and connect the patients to addiction treatment and community supports. CCAR has served over 10,000 people in the last five years. Medical staff credit the program with successfully engaging patients with SUD to aftercare and for helping shift the culture of the ED to one of compassion and empathy.
- People with SUD are disproportionately more likely to have justice system involvement. Despite some existing local diversion initiatives around the country, many people with SUD will be booked into jails and prisons at some point in time, where medical and behavioral health care is severely lacking. This implementation toolkit describes how health care providers and their correctional agency partners can design MAT programs for people with OUD in these settings, which can help safeguard against deaths from withdrawal and overdose.
- Finally, this toolkit for payers and policymakers describes strategies to strengthen the use of the American Society for Addiction Medicine (ASAM) Criteria in states to improve addiction care delivery and coverage across the country. The ASAM Criteria is the most widely used set of evidence-based criteria for patient assessment and placement. It is designed to consider individualized needs of a patient and ensure placement into the appropriate level of care that is right for that person at that time. Although the ASAM Criteria is increasingly used in states, this toolkit can help address lingering barriers to fidelity such as greater standardization of practice in delivering and authorizing SUD treatment. Providers can also access this free ASAM Criteria Assessment Interview Guide to support implementation.
The Future of Addiction Care
As the health care system and policymakers look to better serve people with SUD, we can expect to see a proliferation of innovative models like the ones described in this Collection cropping up across the health care landscape. Not only do many of these models address the substance use-related needs of the patients they serve, but many also tackle the daily realities of people with SUD, including the need for:
- Supportive housing for people with SUD experiencing or at-risk of experiencing homelessness;
- Telehealth, which can be particularly valuable for those who lack access to transportation or have inflexible work schedules;
- Facilitated connections to primary care to address chronic conditions;
- Examinations of how these models may reduce racial and health inequities; and
- Behavioral health interventions for certain SUD for which there is not yet any medication available (contingency management).
The Playbook team encourages readers to send promising practices or questions about addiction care models to playbook@chcs.org.