The MOUD “PLUS” Study: Collaborating with Recovery Peers to Support Opioid Use Disorder Treatment In Primary Care

Summary

In the US, many people with opioid use disorder (OUD) do not engage with or remain in treatment.^1–3 People with OUD face barriers to care engagement and retention including healthcare related stigma toward individuals with OUD and toward medications for opioid use disorder (MOUD), fragmented care, and logistical challenges associated with MOUD prescribing (e.g., accessing care, need for frequent visits, and procedures).¹ Further, as more people with OUD are seen in primary care settings additional barriers arise. Barriers include lack of provider time or resources to deliver evidence-based counseling interventions and lack of social support to adhere to treatment plans. These barriers can be addressed using low threshold prescribing of MOUD⁴ (e.g., prescribing MOUD on same day as initial visit) and the use of integrated counseling and peer recovery specialists (“peers”). Peers with lived experience of addiction can reach people using drugs and keep them engaged in specialty treatment, but there is a lack of evidence showing the effectiveness of peers in primary care.^5-7

The MOUD PLUS study aims to improve care engagement and retention for people with OUD seen in primary care. The study pilots implementation of addiction counseling navigators with peer referral in a collaborative care model.⁸ Prescribers will refer patients to navigators who are certified alcohol and drug counselors during clinic visits. Navigators build rapport with patients, conduct brief screening and counseling interventions, and refer patients to community-based peer services. Peers will work with clients outside the walls of the clinic to support patients in overcoming barriers to treatment and recovery. Peer activities include outreach to patients, accompanying patients to recovery group meetings, and advocating for patient needs.

The MOUD PLUS study was co-designed and adapted by a community engagement council, including study team members, patients, and family representatives. The study team introduced the council to the Gelberg-Andersen behavioral model adapted for vulnerable populations⁹ to brainstorm barriers and facilitators patients with addictions face when seeking care at our community clinic. The Consolidated Framework for Implementation Research (CFIR)¹⁰ guided intervention and implementation design. We used CFIR to identify the need for building coalitions between clinic and community peer organizations, and to develop practice facilitation through “tests of change” to make modifications to how prescribers and patients interact with the counselors and peer interventions.

Significance

The goal of the MOUD PLUS study is to improve engagement with and retention on medications for people with OUD seen in primary care. We hypothesize that the involvement of peers and counselors can increase patient-clinic trust, bolster social support, and reduce stigma that leads to improved engagement and retention. Our group has previously shown that team-based clinic interventions can increase social support to improve care,¹¹ but are difficult to implement at scale. MOUD PLUS integrates counseling and peers with lived experience to overcome distrust from the system, the provider, and the individual patient levels.¹² This study assesses feasibility and acceptability of the intervention to our provider and clinic staff and preliminary treatment retention efficacy for patients.

Benefits

Demonstrated benefits are those that have been observed and are verifiable.

Potential benefits are those logically expected with moderate to high confidence.

Clinical & medical benefits

Increase screening for OUD and other addictions by task-shift screening and discussion of OUD from physicians to peers or counselors. potential.

Diagnostic procedures

Improve treatment engagement and retention for patients with OUD by assessing the acceptability and feasibility of integrating peer recovery specialists and addiction counseling navigators into primary care settings. potential.

Therapeutic procedures

Community & public health benefits

Integrate peers and recovery counselors into primary care settings. potential.

Health care delivery

Improve recovery capital and social support for people with OUD. potential.

Health care quality

Increase uptake of evidence-based treatment for OUD by supporting prescribers and patients via care coordination, counseling, and peer engagement. potential.

Health care quality

Improve quality of life for people with OUD. potential.

Life expectancy & quality of life

Economic benefits

Expand economic opportunities for those with lived experience. potential.

Diverse healthcare workforce (New TSBM benefit)

Policy & legislative benefits

Provided evidence to guide future policy adoption. demonstrated.

Policies

This research has clinical, community, economic, and policy implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.¹³

Clinical

The primary outcome is percentage of patients who are still on medications for opioid use disorder at 3 months compared to care as usual. We use the RE-AIM (reach effectiveness adoption implementation and maintenance) evaluative framework¹⁴ in order to identify facilitators and barriers to future uptake and sustainability. For example, there are usually time constraints during office visits that limit additional counseling interventions. Other outcomes we examined included improved adherence to medications, improved recovery capital (i.e., knowledge and ability to access resources to support recovery), social support, quality of life, and decreased perceived stigma.¹⁵

Community

As integrating peers into primary care settings is novel, understanding the impact of this work is pivotal. We assess potential community and public health benefits qualitatively through interviews with patients, clinic staff, community partners, and policymakers/stakeholders. Anticipated benefits include decreased drug use, overdose, and improved community engagement and collaboration. As more and more patients with OUD seek MOUD in primary care, peers could improve successful clinic engagement and retention on MOUD.

Economic

There is evidence that expanded access to and retention on medications for opioid use disorder is associated with cost-saving reductions in morbidity and mortality.^16,17 If the MOUD Plus study is successful, the intervention has potential for wider adoption to improve retention in treatment and reduce opioid-related healthcare and societal costs.

Policy

If successful, future study would look at existing barriers to implementation (e.g., payment of peer facilitated services) and potential policy solutions. In addition, this study may guide future adoption of novel measures (e.g., access to care, improvements in recovery capital such as ability to obtain employment, sustain meaningful relationships, and functional status/quality of life) as important predictors and outcomes of addiction care quality.

Lessons Learned

The importance of designing for implementation and selection of implementation strategies (developing coalitions, conducting educational meetings, and testing change to refine the intervention) have been invaluable in moving the project forward. Finally, community impacts not studied here but important in future study would be assessing the impact of the program on reduction in overdose rates for a community and increased reduction in harms due to OUD including hospitalization and its associated costs.