TABLE OF CONTENTS
- Retention and Continuity of Care Defined
- Influences on Retention
- Literature Review
- Key Informant Interviews
- Case Studies
- Settings and Retention in Treatment
- Client-Related Factors Influencing Retention in Treatment
- Evidence or Practice-Based Approaches to Addressing Retention
- Psychosocial Supports
- Reimbursement Approaches
IBM Watson Health prepared this report under contract to the Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services (HHS) (HHSP2332016000231HHSP23337004T). The authors appreciate the guidance of Joel Dubenitz and Laurel Fuller (ASPE). Mary Beth Schaefer and Paige Jackson (IBM Watson Health) provided editorial support. Mustafa Karakus and Amy Windham (formerly IBM Watson Health) provided early guidance. Ashley Palmer and Brendan Leonard (IBM Watson Health) contributed to data collection. The authors also wish to acknowledge and thank our key informants (Colette Croze, MSW, Principal, Croze Consulting; Rick Harwood, Deputy Executive Director, National Association of State Alcohol and Drug Abuse Directors; Brendan Saloner, PhD, Assistant Professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health; Peter Thomas, Quality Assurance Officer, National Association of Addiction Treatment Providers; Melanie Whitter, Director of Research and Program Applications, National Association of State Alcohol and Drug Abuse Directors; Arthur Robin Williams, MD, Assistant Professor/Addiction Psychiatrist at Columbia University. We also very gratefully thank all the individuals who participated in or facilitated the case study site visits at our five sites.
The views and opinions expressed here are those of the authors and do not necessarily reflect the views, opinions, or policies of ASPE or HHS. The authors are solely responsible for any errors.
The following acronyms are mentioned in this report and/or appendices.
|ACS||New York Administration for Children's Services|
|ADHD||Attention Deficit Hyperactivity Disorder|
|AHRQ||HHS Agency for Healthcare Research and Quality|
|APG||Ambulatory Patient Group|
|ASAM||American Society of Addiction Medicine|
|ASPE||HHS Office of the Assistant Secretary for Planning and Evaluation|
|AUD||Alcohol Use Disorder|
|BHIVES||Buprenorphine-HIV Evaluation and Support study|
|BHO||Behavioral Health Organization|
|CBT||Cognitive Behavioral Therapy|
|CCC||Oregon Central City Concern|
|CCO||Coordinated Care Organization|
|CDP||Chemical Dependency Professional|
|CEO||Chief Executive Officer|
|CEP||Community Engagement Program|
|CFS||Child and Family Services|
|CJS||Criminal Justice System|
|CMO||Chief Marketing Officer|
|CMS||HHS Centers for Medicare & Medicaid Services|
|COO||Chief Operating Officer|
|COR-12||Comprehensive Opioid Response with the Twelve Steps|
|COWS||Clinical Opiate Withdrawal Scale|
|CPT||Cognitive Processing Therapy|
|CRT||Cognitive Rehabilitation Treatment|
|CSI||Contracting with Staff Incentives|
|CVAM||Central Vermont Addiction Medicine|
|CVMC||Central Vermont Medical Center|
|DBT||Dialectical Behavior Therapy|
|DSM-V||Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition|
|ETS||Washington Evergreen Treatment Services|
|FDA||HHS Food and Drug Administration|
|FFS||Fee For Service|
|FQHC||Federally Qualified Health Center|
|HHS||U.S. Department of Health and Human Services|
|HIV||Human Immunodeficiency Virus|
|ICER||Institute for Clinical and Economic Review|
|KEEP||Key Extended Entry Program|
|LADC||Licensed Alcohol and Drug Counselor|
|LGBT||Lesbian, Gay, Bisexual, and Transgender|
|MPR||Medication Possession Ratio|
|MSBI||New York Mount Sinai Beth Israel Gouverneur Clinic|
|MTC||Maryland Treatment Centers|
|NIATx||Network for the Improvement of Addiction Treatment|
|NQF||National Quality Forum|
|OAT||Opioid Addiction Treatment|
|OBOT||Office-Based Opioid Treatment|
|OBOT-B||Office-Based Opioid Treatment with Buprenorphine|
|OTC||Oregon Old Town Clinic|
|OTP||Opioid Treatment Program|
|OUD||Opioid Use Disorder|
|PCP||Primary Care Provider|
|PDMP||Prescription Drug Monitoring Program|
|POATS||Prescription Opioid Addiction Treatment Study|
|PTSD||Post-Traumatic Stress Disorder|
|RAM||Rapid Access to Medication-Assisted Treatment|
|RCT||Randomized Controlled Trial|
|SAMHSA||HHS Substance Abuse and Mental Health Services Administration|
|SBIRT||Screening, Brief Intervention, and Referral to Treatment|
|SUD||Substance Use Disorder|
|UDS||Urine Drug Screen|
|VA||U.S. Department of Veterans Affairs|
|WCSARP||Washington County Substance Abuse Regional Partnership|
Retention in medication-assisted treatment (MAT) for opioid use disorder (OUD) results in better outcomes, including reduced rates of mortality (Ma et al., 2018), reduced utilization of high-intensity treatment (Lo-Ciganic et al., 2016; Shcherbakova et al., 2018), and other benefits. This study sought to identify best practices for retaining individuals in treatment and for achieving continuity of care between settings.
This three-part study included a literature review of peer-reviewed and gray literature that addressed retention in substance use disorder (SUD) treatment, key informant interviews with six subject matter experts, and five case studies of sites or models that show promise for improving retention in treatment. The objectives of the case studies were: (1) to obtain an in-depth understanding of different models of specialty SUD treatment that are thought to be successful in retaining individuals in treatment; and (2) to determine the programmatic and financial structures required to support retention in treatment and sustained recovery.
The five settings for case studies were as follows:
Multiple providers in central Vermont that are part of the statewide hub-and-spoke system, including a pilot involving buprenorphine induction in the emergency department with guaranteed follow-up in a hub or a spoke, and a state initiative to require MAT in all Vermont jails.
A multifaceted service provider in Portland, Oregon, with a clientele that is 90 percent homeless or exiting homelessness, that offers a variety of services and supports that address physical and behavioral health treatment needs; the provider's SUD treatment spectrum includes withdrawal management and stabilization, intensive outpatient, and outpatient treatment, as well as housing and employment services that help address social determinants of health.
A large, well-resourced health system in New York City that includes ten opioid treatment programs (OTPs), including the oldest methadone clinic in the country; the health system collaborates closely with the criminal justice system (CJS) to ensure continuity of treatment and is using telehealth for Hepatitis C treatment.
An SUD treatment provider in Baltimore, Maryland, that, among other things, has piloted home-delivery of extended-release naltrexone (XR-NTX) for young adults and is about to pilot home-delivery for XR-buprenorphine.
An SUD treatment system in Washington State that includes a mobile methadone clinic to serve specific neighborhoods without a fixed clinic and that has used telehealth to facilitate buprenorphine prescribing.
Many variables affect retention in SUD treatment, including treatment for OUD. It is the interaction of those variables that is critical--whether they are client characteristics, provider or service delivery characteristics, setting-based factors, or external variables such as cross-system collaboration or payment policies. Retention depends on those interactions and the ability of domains such as providers, payers, or clients to adjust. One primary adjustment within the realm of OUD treatment has been gradual movement away from abstinence-based treatment toward MAT, reflecting the fact that "people were dying and it had to change," as one interviewee said.
The literature provides us with excellent background regarding certain factors that may influence treatment retention. Relevant patient characteristics that often are found to impede retention include being younger (Saloner et al., 2017), having co-occurring mental disorders and SUDs (Kumar et al., 2016), using multiple substances (Franklyn et al., 2017), having less robust social determinants of health in areas such as employment and housing (Choi et al., 2015; Cui et al., 2016), and facing geographic impediments to care (Saloner et al., 2017).
The programs and key informants we interviewed confirmed much of what the literature indicates about client characteristics, including that younger adults are more difficult to retain in treatment, that polysubstance use and co-occurring mental illness are major factors reducing retention, and that lack of housing and geographic impediments can hinder retention. In addition, these interviews expanded prior research and identified diagnostic complexity such as pregnancy or benzodiazepine use, lack of client understanding of the treatment process, stigma and shame, CJS involvement, and lack of social supports, transportation, and childcare as other impediments.
Evidence or Practice-Based Approaches to Addressing Retention
MAT is the foremost evidence-based practice for OUD, including treatment with buprenorphine, methadone, or naltrexone (Substance Abuse and Mental Health Services Administration, 2018), and a proper dose is very important for retention (Institute for Clinical and Economic Review, 2015; Samples et al., 2018). Seldom, however, do providers offer a meaningful choice between these three medications, particularly methadone and buprenorphine. Yet qualitative research is starting to suggest that having access to and a choice between both methadone and buprenorphine or all three medications may enhance adherence to treatment and outcomes (Yarborough et al., 2016). Treatment system structure and approach also can positively influence retention. Some examples from the literature include the Massachusetts-originated Collaborative Care Model, which uses a nurse care manager for induction and other supports (LaBelle et al., 2016; Weinstein et al., 2017); efforts to streamline receipt of care (e.g., Gauthier et al., 2018); treatment in inpatient or emergency department settings (Bhatraju et al., 2017; D'Onofrio et al., 2017); home-delivery of XR-NTX (Vo et al., 2018); buprenorphine treatment in HIV clinics (Fiellin et al., 2011); and use of telehealth (Weintraub et al., 2018).
Our case studies revealed a wealth of information on evidence or practice-based approaches that facilitate retention (i.e., approaches supported either by research or by experience in settings with higher rates of retention). The primary evidence-based approach to treating OUD is use of one of the three approved medications. Steps taken to enhance the benefits of those medications on retention include providing multiple OUD medication options at the same site and providing MAT at effective doses as quickly as is safely possible. Two critical clinical approaches are: (1) focusing on the need to develop a solid therapeutic relationship early in treatment; and (2) using team-based approaches, such as the multidisciplinary team used in a dual diagnosis program at one of the sites.
Among the practice-based approaches are ones based on the philosophy that patients should not be refused treatment because of certain missteps or complexities relating to their treatment. Two primary examples of how this philosophy translates into practice are policies not to discharge people simply because of relapse and policies not to refuse treatment to individuals with OUD who also use benzodiazepines.
Finally, we discovered a wide range of innovative approaches to facilitate patient engagement and monitoring, with evidence of flexibility at many stages of treatment. These approaches include service flexibility at intake to simplify and expedite access to treatment as well as to make the treatment process more transparent. Examples include providing treatment on demand with guaranteed follow-up and orienting new clients to treatment. Processes also are established to facilitate ongoing treatment engagement. For instance, embedding SUD treatment in physical health settings provides greater flexibility for intake, providing an open-door between physical and behavioral health providers where "warm hand-offs" can occur. It also allows individuals to receive behavioral health treatment in a setting where their receipt of such services can be more discreet than in a behavioral health-specific clinic. Other ongoing engagement and retention supports include flexible dosing times for methadone; client tracking and outreach; use of peer providers, particularly early in treatment; client "contracting" and motivational incentives; use of unobserved urine drug screens; and use of telehealth. Retention in treatment also can be enhanced at discharge by, for instance, the provision of flexible aftercare or follow-up services until the client is established with a new provider.
Among the many practice-based methods that address or otherwise influence retention, some are specific to OUD treatment, including being able to offer multiple OUD medications at the same site, timing the dispensing of methadone to improve access, and doing whatever it takes to get clients stabilized on an optimum dose of methadone or buprenorphine as quickly as it is safe to do. Reducing the threshold for medication receipt is critical, and flexibility throughout the process of treatment is very helpful in promoting retention. Approaches to treatment that recognize that people leave treatment for different reasons, such as incarceration or scheduling, also may help with care continuity. Aftercare or bridge services can promote continued medication adherence, as can providing a therapeutic environment and connection until the person can receive treatment elsewhere. Even if such services are not accepted, keeping the door open means that individuals who leave may return. Additionally, because a substantial number of discharges involve clients entering the CJS, approaches that avoid discharge, facilitate communication between the CJS and the treatment provider, and facilitate ongoing treatment while the person is incarcerated are very important.
Clinical guidelines recommend concurrent medication and psychosocial treatment or supports for those with OUD (e.g., American Society of Addiction Medicine, 2015). There is ongoing debate about the necessity of psychosocial treatment for everyone (Carroll & Weiss, 2017; Martin et al., 2018). However, our review of the recent literature did identify studies associating retention with receipt of such services (Manhapra et al., 2018) and highlighted psychosocial treatments that seem promising, including trauma-focused treatment (Meshberg-Cohen et al., 2018).
The programs interviewed represented a cross-section of treatment approaches, all committed to supporting treatment that includes medication. Psychosocial supports identified included individual and group therapy (e.g., motivational interviewing, cognitive approaches, and trauma-informed treatments), strong case management, and other services such as financial counseling, acupuncture, and patient advocacy. Each program approaches psychosocial supports somewhat differently. At a broad level, they range from programs that identify as "strongly therapeutic-focused" to ones that have embraced a low-threshold approach to treatment. A low-threshold approach to treatment can include flexibility regarding the types and amount of psychosocial treatment required of clients. Some programs require individual and group counseling as a condition of receiving medication; others encourage counseling but do not consistently mandate it.
Many of the programs struggle with providing or connecting mental health treatment to everyone who needs it, and many also said that the number of people they serve with a serious mental illness is increasing. At least two of the large providers indicated that about 70 percent of their clients have a serious mental illness. The common inability to access sufficient mental health treatment may variously reflect a growing population with great need, a shortage of mental health providers in the community, and constraints in the number of mental health treatment providers, including specialty psychiatric hospitals, that treat individuals with SUDs. Some of the programs studied provide limited psychiatric care in house, whereas others rely on referrals, and some offer full mental health treatment internally.
The issue of the role that psychosocial services should play is contentious. Some providers feel very strongly that psychosocial treatment is a key component of MAT, whereas others feel that the most important thing is to get clients stabilized on medication, hoping that they will be receptive to psychosocial treatment as they move further into medication-supported recovery. The latter camp also often sees mandated psychosocial treatment as impeding retention for many people. However, every provider interviewed stressed the need to "meet people where they are at." This means using client-specific approaches beginning at intake and providing what a person needs when the person needs it. Yet to know what clients need, providers must be able to establish some meaningful relationship with them. Whether that occurs via individual counseling, group therapy, intensive case management, high-quality medication management meetings, or participation in an OTP-supported choir, it involves some sort of psychosocial support and connection.
Reimbursement approaches such as contractual incentives have shown mixed results in the recent literature (Acevedo et al., 2018; Acquavita et al., 2013; Lee et al., 2018; Stewart et al., 2013). In the programs studied, reimbursement approaches vary by treatment provider and state. Populations served by the sites visited are predominantly Medicaid beneficiaries. Medicaid payment approaches encountered include fee for service (FFS), bundled rates, per service under an ambulatory patient group (a patient classification system for payment of facility costs of care that originally was created for the Medicare program), and case rates. Some programs receive value-based payments, which may include monetary awards only or both monetary awards and penalties for performance, depending on the state. Vermont Medicaid uses a health home managed care model for payment. The Vermont hub interviewed has a bundled rate and also can refer out to other providers who are paid FFS, as necessary.
The general consensus is that FFS reimbursement can encourage overuse of certain services and impede the ability to provide collaborative, integrated, and holistic care that supports retention. On the other hand, reimbursement by case rates alone may incentivize shortened and less complex responses to a population that is quite complicated. What seems to be key is a thoughtfully bundled reimbursement system that encompasses necessary services, including case management and care coordination, yet recognizes the need for some flexibility regarding providers. Such a system could be stratified or risk adjusted to account for complex cases (e.g., dually diagnosed with serious mental illness, multiple SUDs) and recognize that there are times when extra support is required, such as when clients are newly initiated into treatment. Reimbursement should encourage and reward continuity of care as well as retention in treatment. Pharmaceutical coverage of SUD treatment medications also should be consistently treated just like coverage of medications for other chronic conditions, including with regard to prior authorization and quantity limits.
Factors that promote or impede retention and continuity of care are complex. Additional research may help us determine how to further shift the culture of substance use treatment away from a lingering abstinence-only approach and how to bridge the silos between methadone, buprenorphine, and naltrexone treatment for OUD. We need to understand how best to integrate mental health and substance use treatment and best practices for treating non-MAT-responsive SUDs. Those are two of the biggest hurdles to retention that the programs we interviewed face, along with loss of clients to the CJS, where treatment often is unavailable. Providers need practical guides for moving clients to an optimum dose of medication as rapidly as is safe, including guides to structural practices that support early engagement. Many practices identified in this report can facilitate retention, but adequate reimbursement for services such as outreach, tracking, case management, and care coordination is needed to enable implementation of best practices. Reimbursement that is risk adjusted to address complexity would help support delivery system reforms that enhance retention in treatment.
Treatment providers, policymakers, and others are diligently seeking ways to reverse the tide of mortality and morbidity that has accompanied the opioid epidemic. Research shows that retention in medication-assisted treatment (MAT) treatment for opioid use disorder (OUD) results in better outcomes, including reduced rates of all-cause and overdose mortality (Ma et al., 2018; Stone et al., 2018). Further, studies have shown that mortality rates increase following discharge from treatment, and multiple transitions in and out of treatment expose people to repeated periods of high mortality risk (Ma et al., 2018). Treatment retention also has been associated with greater likelihood of abstinence from opioid use (Bhatraju et al., 2017; Jarvis et al., 2018; Monico et al., 2015; Stone et al., 2018; Weintraub, 2018) and reduced utilization of high-intensity treatment such as inpatient and emergency department services (Lo-Ciganic et al., 2016; Shcherbakova et al., 2018). Other studies have shown decreased rates of HIV transmission and criminal activity and improved social functioning (see, e.g., studies referenced in Manhapra et al., 2018) associated with retention.
In light of the known relationship between retention in MAT for OUD, this study sought to identify best practices for retaining individuals in treatment and, given the reality of movement in and out of treatment and between treatment settings, best practices for achieving continuity of care between settings. The research questions that this study answers are as follows:
Question 1: What variables affect retention in substance use disorder (SUD) treatment across disorders? How have these variables changed with the evolution of drug use patterns?
Question 2: What are evidence-based methods to address treatment retention in SUD treatment, and how do these apply to treatment of OUD?
Question 3: Are there promising models of psychosocial support that assist in maintaining an individual in MAT for OUD? Do longer, more continuous durations of treatment result in better outcomes?
Question 4: How have changes in reimbursement policy affected the provision of services? Have reimbursement policy changes expanded retention in treatment?
Question 5: What types of settings have seen success in implementation of SUD treatment retention methods, and how do they structure their programs? Have these methods been specifically applied to MAT for OUD, and are these programs structured differently?
Retention and Continuity of Care Defined
Retention and continuity of care are two different concepts. Retention is continuous or near-continuous treatment for some period of time. It has been operationalized in ranges from 3 months to 7 years, with or without gaps. Allowed gaps range from 7 days to 18 weeks in recent publications (Bhatraju et al., 2017; National Quality Forum [NQF], 2018). Studies looking at retention often define it on the basis of the duration of data available, if the study is claims-based, or on a reasonable time frame within which data can be collected. Recent systematic studies that have addressed retention in MAT show widely disparate retention rates (Jarvis et al., 2018; Lagisetty et al., 2017; Timko et al., 2016; Wilder et al., 2015).
Observations From Key Informants
Gaps in treatment for buprenorphine MAT are difficult to categorize because need for treatment changes over time and by individual. There may be apparent gaps based on buprenorphine fills that actually represent reduced dosing by the individual, that may be increased subsequently when needed, or breaks from treatment that may end when treatment is needed again.
The term continuity of care is commonly used in one of three ways: (1) as synonymous with retention in treatment; (2) as continuous possession of MAT medication, with assorted gaps (e.g., Saloner et al., 2017); or (3) as continuity from one setting to another (e.g., Acevedo et al., 2018). The NQF uses the second approach in its measure of continuity of care, defining it as 180 days with no more than a 7-day gap in medication possession (NQF, 2018).
As indicated above, no standard definition of retention or of continuity of care exists, and although a standard definition would provide better context to study factors associated with retention, there are possible pitfalls to seeking that uniformity. One pitfall raised by the American Society of Addiction Medicine (ASAM) (2014) is that a potential consequence of defining sufficient retention or continuity of care, such as in a performance measure, is that payers may decline to make a payment after the defined time period. Other pitfalls of embracing a single definition of retention too intensely are reflected in some of the gaps in the literature on retention. For example, studies of retention seldom look at treatment re-entry after disengagement. However, those that do find repeated episodes to be relatively common (Shcherbakova et al., 2018; Weinstein et al., 2017). Reifying retention as a single episode of care ignores the reality of a chronic relapsing disorder. Additionally, studies of retention typically do not address the nature or extent of treatment participation or the quality of the treatment being offered. Measuring retention without attention to those factors does not capture an adequate picture of treatment.
Influences on Retention
Multiple factors can affect retention, including patient characteristics, treatment-related variables, reimbursement policies, and other factors.
Recovery--Thoughts From Key Informants
Patients may be abstinent and still have poor quality of life. Treatment should go beyond abstinence and consider how patients are functioning in society and in their lives. Social functioning and quality of life metrics are needed. Sustained recovery can span many different domains, including overdose, infectious disease, likelihood of being employed, and quality relationships with family.
Patient characteristics can affect retention. Multiple studies show that retaining younger adults is more difficult than retaining older adults (Saloner et al., 2017; Samples et al., 2018; Schuman-Olivier et al., 2014). However, timely treatment of young adults newly diagnosed with OUD has been associated with improved retention (Hadland et al., 2018). Results regarding differential retention by sex vary, with studies finding variously that men (Samples et al., 2018) or women (Saloner et al., 2017) may be more difficult to retain. Nuanced analyses indicate that multiple factors may play an interactive role with sex, including ones discussed further below. Co-occurring mental health conditions can influence retention, some more negatively than others (Choi et al., 2015; Cui et al., 2016; Kumar et al., 2016). Co-occurring substance use also can negatively affect treatment, including cocaine, alcohol, and cannabis use, although evidence for the latter two substances varies (Choi et al., 2015; Franklyn et al., 2017; Samples et al., 2018; Schuman-Olivier et al., 2014; Socias et al., 2018; Springer et al., 2015). Patient acuity, as evidenced by inpatient service use in the period before buprenorphine induction, has been associated with decreased retention in treatment (Samples et al., 2018). Other patient characteristics found to influence retention include pregnancy status, whereby a longer prenatal connection may lower risk of postnatal discontinuation (Wilder et al., 2015); higher levels of education, which can be associated with better retention (Cui et al., 2016); less severe employment issues, which may support retention (Choi et al., 2015); and unstable housing status, which is associated with poorer retention (Cui et al., 2016). Patient geography also may affect retention. For example, studies suggest that patients who must travel significant distances, such as crossing county lines, may have lower rates of retention (Saloner et al., 2017).
Medication treatment is an evidence-based practice for OUD, including treatment with buprenorphine, methadone, or naltrexone (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018). However, considerable evidence suggests that the dose of methadone or buprenorphine prescribed affects treatment outcomes, including treatment retention. A 2014 summary of the evidence on dose by the Institute for Clinical and Economic Review (ICER) indicates that doses that are too low can adversely affect retention. ICER's summary of the evidence references three case studies concluding that methadone doses of more than 60 mg/day, precisely 96 mg/day, or up to but not exceeding 100 mg/day of methadone enhance retention. The evidence on buprenorphine dosing referenced by ICER includes randomized controlled trials (RCTs) indicating that less than daily dosing can be as effective as daily dosing. In more recent analysis using Medicaid claims data, Samples et al. (2018) examined factors associated with discontinuation of buprenorphine treatment. Results indicated that discontinuation of buprenorphine treatment before 180 days was significantly associated with having an initial dose of buprenorphine less than or equal to 4 mg/day.
Psychosocial Support Models
Clinical guidelines recommend concurrent medication and psychosocial treatment or supports for those with OUD (e.g., ASAM, 2015; British Columbia Centre on Substance Use, 2017). The psychosocial treatment is intended to help patients control urges to use drugs and to assist patients in coping with the emotional strife that often accompanies addiction (Dutra, et al. 2018). However, some argue that the psychosocial supports are not a necessity for everyone (Martin et al., 2018), and Carroll and Weiss (2017) suggest that a stepped-care model might be preferable, whereby the level of treatment is matched to the patient. Yet we do know that the therapeutic alliance and patient motivation to participate in treatment both have been associated with improved treatment retention (Choi et al., 2015; Joe et al., 1998; Meier et al., 2005). This tension is a defining one at this point in the field of OUD treatment, as we seek ways to get and keep people in treatment to save lives.
One major reason for this debate is that, over the past decade and a half, studies do not consistently find that concurrent treatment results in improved retention in treatment or other outcomes (see, e.g., Carroll & Weiss, 2017; studies referenced in Meshberg-Cohen et al., 2018). A 2016 systematic review on the use of psychosocial interventions with medication for treatment of OUD examined three literature reviews and 27 more recent publications; contingency management (CM) and cognitive behavioral therapy (CBT) were the most widely studied, and the medication most often studied was methadone (Dugosh et al., 2016). Dugosh et al. agreed that results were inconsistent but concluded that there were benefits and that the evidence was strongest in the studies with methadone treatment. Studies examining methadone maintenance found significant effects of psychosocial treatment (i.e., CM and general supportive therapy) on treatment attendance and drop out, whereas a smaller number of studies showed significant effects on attendance and retention in buprenorphine treatment (i.e., Intensive Role Induction). Positive effects on retention and attendance also were found with oral naltrexone (i.e., behavioral therapy and CM) and extended-release naltrexone (XR-NTX) (i.e., CM).
It has been noted that many of the studies not finding benefits from concurrent psychosocial treatment were conducted in primary care settings; excluded patients with varieties of clinical severity such as alcohol or other drug disorders, trauma, mental illness, or poor physical health; and may not have addressed fidelity to treatment protocols. Klein (2017) suggests that studies focusing on patients with less clinical acuity may rule out those who might benefit most from psychosocial supports. Dugosh et al. (2016) noted that a RCT of treatment as usual that comprises receipt of medication with medication management may actually provide a level of medication management that goes beyond the clinical norm, perhaps obviating relative results of the comparison arm with psychosocial treatment. This also suggests, of course, that more intensive medication management services may be an effective counterpart to formal psychosocial services.
To provide an updated review of the literature on psychosocial treatment, we examined more recent studies and found several that find some support for those services. Thus, although claims analyses cannot identify types of psychotherapy received, a recent large-scale claims analysis indicated that receipt of psychotherapy in conjunction with buprenorphine among the privately insured was associated with increased retention in MAT (Manhapra et al., 2018). Other recent studies that focus on specific treatments identify promising models of psychosocial support. These include outpatient treatment involving individual CBT, relapse prevention groups, and medication education groups, with buprenorphine treatment, focused on patients with OUD and early childhood trauma (Kumar et al., 2016); trauma-specific treatments such as Prolonged Exposure or Cognitive Processing Therapy (CPT), with buprenorphine treatment, for veterans with post-traumatic stress disorder (PTSD) (Meshberg-Cohen et al., 2018); and combined use of buprenorphine or naltrexone with CBT, motivational interviewing, and 12-step approaches (Klein, 2017). Another recent study did not find markedly improved retention from the use of Cognitive Rehabilitation Treatment (CRT) in a court-mandated methadone maintenance residential program in Tehran (Rezapour et al., 2017). Despite not showing improvement in retention, this study highlights a problem with chronic opioid use, specifically that it can lead to neurocognitive impairment, which can impede treatment. CRT as a potential treatment approach may merit more attention, perhaps in different settings.
Treatment System Structure or Approach
A number of studies have examined office-based opioid treatment (OBOT) with buprenorphine, including a study based on the Massachusetts-originated Collaborative Care or nurse care manager model. The model includes: (1) screening and assessment of appropriateness for office-based treatment; (2) medication induction under a nurse care manager's supervision; (3) stabilization; and (4) maintenance. This model has been the subject of at least two studies that indicate it can be associated with successful retention in treatment (LaBelle et al., 2016; Weinstein et al., 2017).
Initiatives that aim to streamline receipt of care also show some promise to increase retention. A Network for the Improvement of Addiction Treatment (NIATx) open-access model of rapid enrollment in methadone treatment was implemented at a community-based organization in New Haven, Connecticut. The model was associated with modest improvement in retention (Madden et al., 2018). Similarly, methadone delivery in clinics with onsite pharmacies had better rates of retention than did those with offsite pharmacies (Gauthier et al., 2018). These are two examples of efforts to make engagement and retention less burdensome.
In addition to standard office-based or specialty outpatient settings such as an opioid treatment program (OTP), other settings for medication treatment also are being studied to determine effects on retention. Some examples that have shown promise include induction into buprenorphine treatment in an inpatient setting (Bhatraju et al., 2017; Liebschutz et al., 2014); buprenorphine induction in the emergency department (D'Onofrio et al., 2017); home-delivery of XR-NTX combined with medication management services, assertive outreach, and case management, provided with decreased emphasis on psychosocial treatment or abstinence from non-opioid substances (Vo et al., 2018); buprenorphine treatment with comprehensive medical and social services integrated into HIV clinics (Fiellin et al., 2011; Weiss et al., 2011); and buprenorphine treatment in a suburban health department that involved physician-pharmacist collaboration (DiPaula & Menachery, 2015). Recent studies in some other settings have shown fewer positive effects on retention (e.g., induction into treatment with XR-NTX in a county correctional center (Lincoln et al., 2018).
Electronic approaches to treatment also show promise for retention. Weintraub et al. (2018) studied the use of telehealth for prescribing buprenorphine in a drug treatment center for adults in rural Maryland and found positive effects of telehealth on retention, as have other studies (Eibl et al., 2017; Franklyn et al., 2017). Although not telehealth, the use of electronic reminders significantly enhanced continuity of care for residential agencies that already were performing at a moderate or high level at baseline but were lower-performing agencies (Acevedo et al., 2018).
Reimbursement or Payer Policy
Reimbursement policy levers such as incentives or payment withholds for providers typically are implemented using a metric established or adopted for that purpose. The metrics and associated reimbursement policies are designed to encourage changes in provider behavior, with the ultimate intention of influencing outcomes such as retention in treatment. They may be regarded as the provider counterpart to the use of CM for patients.
The published literature on effects of reimbursement policy on retention in SUD treatment is limited. To improve quality of care in SUD treatment (not specific to MAT), Delaware implemented contract requirements for outpatient SUD treatment facilities, including monthly incentive payments and penalties (reduced base payments). Two of the measures used were active participation in treatment and program completion. The first measure resulted in an increase in active participation across all four phases of care (1-30, 31-90, 91-180, and 180+ days), particularly the last two phases (McLellan et al., 2008). Delaware subsequently added a quality improvement (QI) component to this initiative, with facilities participating in QI through NIATx and Advancing Recovery. Data from the QI component of the initiative showed that length of stay increased after the introduction of the contracting component and increased further with the QI intervention (Stewart et al., 2013).
In an initiative in Washington State that was designed to enhance care continuity, randomized residential and detoxification agencies received public funding into one of four trial arms: (1) weekly electronic reminders on recently discharged patients not receiving follow-up; (2) financial awards based on patient continuity of care relative to either a benchmark or improvement; (3) both of the continuity interventions; or (4) no intervention. Adjusted difference-in-difference results revealed that clients at residential agencies already performing at either a moderate or high level at baseline had improved continuity of care, although those at lower-performing agencies did not (Acevedo et al., 2018). A similar intervention in Washington State, involving performance-based contracting and reminders for specialty outpatient services, targeted engagement in treatment within 14 days of treatment initiation (Garnick et al., 2017). Most results were not significant, but analysis of the residential, detoxification, and outpatient data comparing clients with an SUD only to those with co-occurring psychiatric disorders found that the interventions had a positive effect on continuity of care from residential treatment for those with co-occurring disorders (Lee et al., 2018).
Although the Delaware and Washington State initiatives focused on agencies, a smaller scale initiative looked at rewards to individual staff. The "contracting with staff incentives" (CSI) model is a reimbursement-focused approach to improving continuity of care. A staff incentive to encourage client intake and attendance led to significantly higher rates of admission to outpatient care after residential treatment, with outpatient intake highest when it was at a clinic onsite with the residential facility (Acquavita et al., 2013).This indicates that at least two factors, staff incentives and reduced burden, combined to facilitate continuity.
This three-part study included a literature review, key informant interviews, and five case studies of sites or models that show promise for improving retention in treatment.
We performed a literature review (Appendix 1) that addressed retention in SUD treatment with a primary focus on treatment for OUD. The literature review included both peer-reviewed and gray literature.
Peer-reviewed literature. The peer-reviewed literature included English-language publications from the years 2014-2018, supplemented with seminal literature prior to 2014, where appropriate. Our searches of the peer-reviewed literature used the PubMed and Google Scholar databases. We culled the recent literature to determine what is known about the components of SUD treatment that support retention and sustained recovery, including psychosocial supports, reimbursement structures or payment models that support retention and sustained recovery, and other factors that may support retention and sustained recovery and that may interact with or influence the development or application of treatment models. We first reviewed identified abstracts to determine whether they were relevant to the research questions. Next, for abstracts identified as relevant, we retrieved the full-text articles to determine whether they provided material related to retention in SUD treatment. We then abstracted those articles for further use in the literature review. Keywords were used to track pertinence to research questions, allowing sorting and filtering of literature as part of our synthesis. On the basis of the findings in the articles identified, we included additional literature referenced in the initial publications.
Gray literature review. The gray literature review included searches of websites of federal and state government agencies (e.g., state health department and Medicaid programs, SAMHSA, the Centers for Medicare & Medicaid Services [CMS], the Agency for Healthcare Research and Quality [AHRQ], the U.S. Department of Veterans Affairs [VA]), private payers and health systems, non-profit stakeholders, and research organizations. We searched for information on ongoing treatment models, programs, program evaluations, and reimbursement initiatives with an eye toward their influence on retention in treatment. We also reviewed reports and information supplied by key informants being interviewed as part of the larger study.
Approach to synthesis. The resources identified in the peer-reviewed and gray literature were reviewed with the objectives of: (1) describing the meaning of "retention" and "continuity" as used in the literature; (2) synthesizing the information collected to address each of the research questions for this study; (3) identifying gaps in the literature; and (4) beginning the process of developing criteria for selecting case study sites and starting to identify a subset of sites for further consideration. Our findings also informed the development of a case study protocol in advance of site visits.
Key Informant Interviews
We conducted six key informant interviews with subject matter experts who filled in gaps in the literature regarding our research questions and guided us as we considered sites for case studies. The key informant interviews were designed to:
Identify program features that are essential to retention and sustained recovery.
Identify reimbursement structures or payment models that support retention and sustained recovery.
Develop a list of models or sites for potential inclusion in the case studies.
Facilitate connections with sites selected for interview.
From an initial list of seven potential interviewees, we worked with the Office of the Assistant Secretary for Planning and Evaluation (ASPE) to determine which candidates to approach for interview. We developed a semistructured interview guide that could be modified to the key informants' areas of expertise. Interviews were approximately 45 minutes and were conducted via telephone. One IBM® Watson Health™ participant conducted the interview, and the other recorded (with participant permission) and took notes.
The six individuals ultimately interviewed, and the five organizations with which they are affiliated, are as follows:
Colette Croze, MSW, Principal, Croze Consulting
Rick Harwood, Deputy Executive Director, National Association of State Alcohol and Drug Abuse Directors
Brendan Saloner, PhD, Assistant Professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health
Peter Thomas, Quality Assurance Officer, National Association of Addiction Treatment Providers
Melanie Whitter, Director of Research and Program Applications, National Association of State Alcohol and Drug Abuse Directors
Arthur (Robin) Williams, MD, Assistant Professor/Addiction Psychiatrist at Columbia University
Scattered throughout this report are "Key Informant Thoughts" on different subjects. These are not attributed because they are paraphrases and, often, compiled from interviews with more than one key informant.
The objectives of conducting case studies were: (1) to obtain an in-depth understanding of different models of specialty SUD treatment that are thought to be successful in retaining individuals in treatment; and (2) to determine the programmatic and financial structures required to support retention in treatment and sustained recovery.
Site selection. In collaboration with ASPE, we established criteria for selecting sites that were designed to address the research questions and provide variety in the sites to be selected (see site selection criteria in Appendix 2). On the basis of those criteria, Watson Health recommended multiple sites with higher retention rates or practices that showed promise of improving retention and, in conjunction with ASPE, selected five organizations and three alternates to approach for site visits.
Case study protocol. We developed a case study protocol for use during the site visits. The protocol took the form of a semistructured interview guide, designed to attain ASPE's overarching goal of understanding different models of specialty SUD treatment, particularly OUD treatment. We also focused on the models' success in the provision of care to patients, patient retention, and patient outcomes. The components of the protocol were further influenced by our understanding of factors that may affect retention and outcomes, gleaned from the literature review and expert interviews. The protocols were configured to reflect different potential stakeholders being interviewed at each setting and were subject to adjustment as we moved through the site visits (see basic protocol in Appendix 3). Types of personnel identified for interview varied but often included administrators and executive personnel, the medical director, other clinical staff, case managers/care coordinators, QI experts, personnel familiar with payment and reimbursement issues, and peer support specialists/navigators. We also worked with the site to, as needed, arrange interviews with individuals outside the program, such as local or state government officials and other members of the SUD and mental health treatment system.
Recruitment. We recruited five organizations or treatment models for site visits. We used formal methods of program recruitment, along with contacts that the team has developed through other projects and input from key informants. Recruitment materials--including an introductory letter, project description, and site visit fact sheet--were developed and sent via email to identified contacts at the potential sites. As necessary, we followed up with additional emails and subsequent telephone calls to further explain the study and answer questions. Upon site agreement to participate, we worked with the program to develop the agenda, acceptable dates, working schedules, and locations for the interviews. Administrators helped identify appropriate personnel from their organizations and helped to link us to appropriate government or treatment systems interviews as appropriate.
Site visits. We conducted site visits at the locations shown in Table 1.
|TABLE 1. Site Visit Dates and Locations|
|May 13, 2019||
|June 18, 2019
Follow-up call: July 8, 2019
|June 20, 2019||
|July 9, 2019||
|August 14, 2019||
The Watson Health Project Director used the interview protocol to conduct the discussion with individual or small groups of respondents while a second staff member took notes. The two members of the interview team debriefed after the interviews, and interview notes were reviewed for quality purposes. In addition to the data from interviews, we collected relevant contextual information such as demographic characteristics, substance use patterns in the area, and other local and state context. We conducted follow-up calls as needed to clarify information from the site visit or to fill in crucial details. We conducted a phone interview with one key individual who was scheduled for an interview but was not available during the site visit.
Summary memos. We prepared a brief memo to summarize key findings for each site visit. The memos are attached as Appendix 4. All sites reviewed the memos and any needed clarifications were made to the final memos. In the next regularly scheduled meeting with ASPE following each visit, we provided a telephone debriefing to summarize key findings and describe any challenges encountered. We used feedback from ASPE and lessons learned from each visit to inform and improve subsequent site visits.
It is tempting to divide factors influencing treatment retention into simple categories, such as client, provider, and larger systems and influences. Yet the truth is that each of these categories has subcategories and, more important, that there is considerable overlap and interaction among categories. Treatment is an interaction between the client and the provider and between each of them and external influences. However, for the sake of simplicity, our identification of factors affecting treatment retention are categorized, but with relevant interconnections noted.
Settings and Retention in Treatment
The settings for our five diverse case studies include the following:
Multiple providers in central Vermont that are part of the statewide hub-and-spoke system, including a pilot inducting buprenorphine in the emergency department.
A multifaceted service provider in Portland, Oregon, with a clientele that is 90 percent homeless or exiting homelessness, which offers a variety of services and supports that address physical and behavioral health treatment needs as well as housing and employment services that help address social determinants of health.
A large, well-resourced health system in New York City that includes the oldest methadone clinic in the country.
An SUD treatment provider in Baltimore, Maryland, that, among other things, as part of academic research has piloted home-delivery of XR-NTX for young adults and is about to pilot the same for XR-buprenorphine.
An SUD treatment system in Washington State that includes a mobile methadone clinic to serve specific neighborhoods without a fixed clinic and that has used telehealth to facilitate buprenorphine prescribing.
We describe components of these sites throughout this report. In this section, we identify some of the unique aspects of the settings that either are not addressed elsewhere or that provide context for other findings.
Vermont Hub-and-Spoke System, Rapid Access to MAT Pilot
Vermont has a mature statewide hub-and-spoke treatment system, organized into six service regions. The original design of the system called for patients to be inducted into MAT at a hub clinic (typically an OTP) and stepped down to a spoke clinic (often an outpatient general or specialty practitioner) after stabilization and for continued treatment. The hub remains available if restabilization is needed. The model in practice has evolved into a more fluid system. The case study included interviews with personnel from the Vermont Department of Health, Division of Alcohol and Drug Abuse Programs; the emergency department at the Central Vermont Medical Center (CVMC) in Berlin, Vermont; Central Vermont Addiction Medicine (CVAM), a hub-and-spoke located in Berlin; and Treatment Associates in Montpelier, Vermont, a specialty spoke. We also observed a Washington County Substance Abuse Regional Partnership (WCSARP) Community Meeting. WCSARP is a partnership of providers, state and local agencies, local law enforcement, and others that meets regularly to coordinate services and solve access problems. In addition to the original hub-and-spoke model, Vermont is implementing rapid access to MAT (RAM) with the pilot at CVMC, although the model is spreading across the state. Depending on the setting, medications used for OUD may include buprenorphine or methadone. Some key aspects of this system, as they relate to retention, include the following:
The RAM program has many intricacies (see Vermont Site Visit Memo, Appendix 4), but the model allows induction in an emergency department, by a waivered prescriber, where the person can be observed with guaranteed follow-up within 72 hours at a hub or a spoke. A recovery coach bridges the transition. The emergency department may discharge a patient with one dose of buprenorphine, a buprenorphine pack, a prescription, some combination, or just a referral. They still are working to determine which approach best supports retention, but anecdotally it appears that the patients who receive more medication from the emergency department tend to move into further treatment better.
Preliminary data from the RAM program show follow-up rates over the first 9 months (Table 2).
The 90-day retention rate at CVAM for December 2018 was 74 percent.
In 2017, the statewide initiation in OUD treatment rate was 60-65 percent (75-80 percent for Washington County) and the statewide engagement rate was 40-45 percent (55-60 percent for Washington County).
The Vermont system is diligent about integrating lessons learned, one part of which has been the need for communication of critical information between the emergency department and receiving providers and preparation of the client for treatment by both settings.
Two-way communication between the hubs and spokes is critical, including when a spoke needs to refer a client back to the hub for restabilization.
The WCSARP community meeting clearly illustrated that the hub-and-spoke treatment system is a local community system that is deeply embedded in the community with strong cross-system relationships.
|TABLE 2. RAM Preliminary Follow-up Data|
|Outcome||3 Months||6 Months||9 Months|
|Follow-up within 72 hours||13||24||49|
|Follow-up exceeded 72 hours||1||4||3|
Central City Concern, Portland, Oregon
Central City Concern (CCC) is a multifaceted service provider in Portland, Oregon, with a clientele that is 90 percent homeless or exiting homelessness. It offers a variety of services and supports that address physical treatment needs (two Federally Qualified Health Centers [FQHCs]), SUD treatment (including withdrawal management and stabilization, intensive outpatient (IOP) and outpatient treatment, buprenorphine, and some naltrexone), mental health treatment, housing and employment services that help address social determinants of health, and an assortment of other services. The objective of this holistic system is to create a recovery environment (see CCC Site Visit Memo, Appendix 4). Several key factors are particularly relevant to retention in treatment:
The varied services allow CCC to support a vulnerable population in multiple ways and, unique to the providers interviewed, include housing, which is critical to maintaining people in treatment.
The CCC Hooper Detoxification Stabilization Center includes a bridge clinic designed to bridge needed medication or other services for individuals completing treatment at Hooper when some portion of follow-on services are not immediately available. People can stay in the bridge program until needed services are available, subject to insurance limitations. In addition, Hooper has moved from using buprenorphine for withdrawal, followed by taper and discharge. Instead, they now initiate the maintenance phase followed by a transition to outpatient treatment or bridge clinic services.
Between January 2019 and July 2019, Hooper served 561 clients with a primary diagnosis of OUD. A total of 361 patients (64 percent) completed admission, and 188 (34 percent) had at least one completed bridge clinic visit. For a subset (179 patients) who discharged on buprenorphine maintenance with a scheduled follow-up appointment, 68 percent were engaged in treatment at 7 days and 56 percent at 30 days after discharge from Hooper. Of the subset, 93 percent were discharged to supportive housing and 7 percent were homeless.
In mid-2019, CCC opened its new Blackburn Center, which incorporates all services in one location while still maintaining the original separate facilities elsewhere in the metropolitan area. It is anticipated that lessons learned there will inform services and retention throughout the system.
As part of the Old Town Clinic (OTC), which is the original FQHC at CCC, SUD treatment providers are embedded in the clinic, maintain an open-door policy, and provide a mechanism for warm hand-offs from physical or mental health treatment providers.
CCC maintains data related to medication possession ratio (MPR) as an indicator of MAT retention. For the period between February 2018 and January 2019, approximately two-thirds of clients in the OTC had an MPR greater than 0.75 with engagement longer than 30 days. For the same time period, in the Community Engagement Program (CEP), MAT initiation rates were 91 percent, while 55 percent had an MPR greater than 0.75 with engagement longer than 30 days. Also, in the CEP cohort, another 25 percent had engagement longer than 30 days with a moderate MPR of 0.5 to 0.74.
Mount Sinai Beth Israel Gouverneur Clinic, New York City
The Gouverneur Clinic is an OTP situated in Manhattan and is part of the larger Mount Sinai Beth Israel (MSBI) health system, which includes ten OTPs (the Gouverneur Clinic is referred to hereafter as MSBI). As an OTP, the clinic primarily uses methadone for OUD treatment medication, with much lighter use of buprenorphine. The following are factors particularly pertinent to retention:
The resources and linkages of the larger health system provide supports that would not be accessible otherwise, including onsite financial counseling and participation in a study using telemedicine for Hepatitis C treatment in an SUD setting.
MSBI has linkage with certain long-term residential programs, where the clinic provides methadone to the residents and the residential program pharmacy takes custody of the medication through a special exemption arrangement with the Center for Substance Abuse Treatment.
The MSBI clinic works with the Key Extended Entry Program (KEEP) at Rikers Island to keep incarcerated individuals on MAT. When a patient is discharged from Rikers, the patient has 30 days to come back to the clinic for MAT. Individuals at Rikers are retained on the clinic rolls.
MSBI is a program of long duration, and some patients have been in the clinic for decades. The treatment for longer-term patients is different than for more recent patients. They often are on a low dose of methadone, with reduced pick-up schedules. Some people taper; others may switch to buprenorphine. This reflects recognition that long-term retention requires flexibility.
Annual retention rates for MSBI are shown in Table 3.
|TABLE 3. MSBI Gouverneur Clinic Retention Rates (%) at 30, 90, 180, and 365 Days by Year|
Maryland Treatment Centers, Baltimore, Maryland
Maryland Treatment Centers (MTC) is a Baltimore-based provider of SUD treatment that includes a research division. MTC uses buprenorphine drugs and XR-naltrexone for OUD medication treatment. MTC has completed a pilot study of a home-delivery program for XR-NTX for young adults and will be expanding the study to incorporate XR-buprenorphine (see MTC Site Visit Memo, Appendix 4). Key factors related to retention include the following:
The home-delivery program makes it much more convenient for clients to receive medication treatment and removes the obstacle of travel to obtain treatment. The low-threshold approach that does not mandate attending counseling at a treatment facility further relieves client burden.
Monetary incentives that increase over time help induce continued receipt of naltrexone.
Having family locators identified helps ensure that clients can be more easily located.
Home-delivery is loosely defined and has included a partner's hospital bedroom while visiting, fast food restaurants, and abandoned buildings (Fishman, 2019).
Preliminary data presented at the April 2019 ASAM conference indicate that, in the MTC RCT, the mean number of outpatient XR-NTX doses received in the home-delivery program at 6 months was greater than four, and the mean number of such doses in treatment as usual was less than one. At 6 months, nearly 60 percent in the home-delivery program had received all scheduled doses, compared with less than 5 percent in the treatment as usual arm (Fishman, 2019).
Evergreen Treatment Services, Seattle, Washington
Mobile Vans--Thoughts From Key Informants
Evergreen Treatment Services (ETS) is a Seattle-based SUD treatment provider with several clinics (see ETS Site Visit Memo, Appendix 4). The clinic visited was a Seattle area OTP, which relies primarily on methadone for medication treatment but also prescribes buprenorphine. The following are some retention-related factors:
ETS has revised intake procedures to maximize engagement in the first 90 days. It considers this approach critical to getting clients to an optimal dose of methadone as quickly and safely as possible, to encourage retention in treatment. Among the steps that they have taken are: (1) allowing broad dosing times rather than requiring appointments; (2) providing treatment on demand to the extent possible and head-of-the-line privileges the next day if treatment is not available upon walk-in; (3) using an engagement tracker for the first 90 days of treatment; (4) relying strongly on their peer engagement specialist to connect with clients at intake and to remain in close touch throughout the first 90 days; and (5) reaching out after two consecutive missed doses.
ETS has a mobile methadone clinic to serve specific neighborhoods that lack a fixed clinic. This mobile clinic expands capacity and client access.
The Grays Harbor clinic used telehealth as part of buprenorphine treatment, first using a prescriber in Portland and then in Seattle. As of early 2017, it was estimated that about 200 patients in rural coastal Washington State, who previously had no access to MAT for OUD, received buprenorphine (SAMHSA, 2018). However, that clinic closed in mid-2019.
Client-Related Factors Influencing Retention in Treatment
The providers we interviewed primarily treat adults, and several identified age as a prime indicator of retention, with younger adults less easily retained. MTC, which has a naltrexone home-delivery pilot focused on young adults but which also treats older adults, identified several possible reasons for poorer engagement in the younger group. These include less self-recognition of impairment, fewer social barriers and more positive reinforcement for drug use, a shorter history of suffering the consequences, available safety-nets, and greater tolerance within society for experimentation and deviant behavior in younger adults than is allowed for those who are older. Coupled with this are certain social determinants that may especially affect young adults, including sex trafficking and being a young parent.
Most providers interviewed indicated that a large segment of their clients have mental health issues and that the extent of serious mental illness in their clientele is growing. CCC identified these clients as the most difficult to retain in treatment. Although some substance use providers are equipped to treat many mental health issues in house, many cannot provide the time and resources that are required. It is at this point where client need intersects with the larger system, including instances where some psychiatric treatment providers, including psychiatric hospitals, will not treat individuals with SUDs. The inability to provide both types of care diminishes the ability to stabilize and maintain dually diagnosed individuals in SUD treatment.
Polysubstance use makes retention more difficult. Our interviews uncovered at least four contributors: (1) The clients are more complex and therefore require more resources and expertise. For example, the CCC detoxification facility noted that withdrawal management for opioids with benzodiazepines requires simultaneous use of two protocols. (2) For SUDs that are not treated with MAT, Treatment Associates noted that the medication "hook" does not exist and that those treated with medication are more likely to continue in treatment in order to obtain their medication. (3) Related to this is the fact that medication increases stability, making it easier for individuals to engage and remain in treatment, something not at play when treating anything other than OUD or alcohol use disorder (AUD). (4) Some treatment facilities will not accept individuals who are dependent on benzodiazepines, limiting the ability of those individuals to enter into or remain in treatment.
Other diagnostic complexity can complicate the ability to enter and remain in treatment. Examples include clients with pain, pregnancy, or serious physical conditions, including infectious disease. Each of these requires that a facility will accept individuals with these conditions, that they have the expertise to manage the patients' care, and that they can effectively coordinate care across providers.
Clients' ability to understand the treatment process is critical to retention. Many have mild to moderate cognitive impairment, some of which precedes substance use and some of which can be substance-induced. This factor has two implications for treatment retention. First, the treatment facility needs the expertise to work effectively with individuals with cognitive disabilities. Second, the processes of intake, transitions, and ongoing treatment need to be designed for simplicity, for all clients. Even without a cognitive disability, trying to navigate a complicated treatment process can be daunting for someone with an SUD.
Stigma and shame can be powerful treatment inhibitors. Self-stigmatization and shame, along with stigma and shame fed by others, can induce withdrawal from treatment. Support and acceptance of the client as they are was identified across the board as important to helping them feel comfortable in treatment. Clinicians consistently stressed the importance of "meeting clients where they are at." The use of peer providers, particularly during the early stages of treatment, can help alleviate shame. ETS has introduced a peer engagement specialist who meets intakes on their first day and who approaches them as an equal. This work is ongoing, but the focus is on engaging with patients in the first 90 days of treatment to help remove some of the shame that new patients may feel. Many clients have been in treatment where relapse is met with ejection from treatment. Therefore, the feeling of shame associated with relapse can be pronounced, even if a provider does not discharge upon relapse. Meeting episodes of relapse in a way that does not exacerbate shame is important. Some providers also have begun relying less on observed urine screens, perhaps only requiring observation when child welfare agencies require it or relying on the possibility of random observation. The thinking behind this is that it can be demeaning to be observed and that a large segment of clientele have trauma histories.
Employment can be a barrier to treatment in at least two ways. First, it can interfere with someone's ability to attend regular treatment, particularly if daily dosing of methadone is required. Many OTPs begin dosing very early to assist people before they must go to work. Second, if someone who was reliant on Medicaid obtains employment with insurance in the midst of treatment, depending on the private insurance policy, the medication they are taking may not be covered.
Social supports can be critical to keeping people in treatment. This includes a support system that does not stigmatize treatment or induce shame. Social supports also can be a valuable means of remaining in contact with clients who may, for instance, have unreliable phone service. To improve retention, MTC identifies "locators" at the first touch of treatment. Locators are people who can be contacted to help MTC get back in touch with a patient if needed.
Just as clients may not have phones, they also may lack transportation or childcare. Although state Medicaid programs can facilitate transportation for many who do not have it, this does not always solve the problem. CVMC noted that, because so much of Vermont is rural and mountainous and can have treacherous weather, even people with cars may find it extremely difficult to get to treatment. This is most often a problem when someone is attending treatment at one of the hubs, of which there are fewer than there are spokes. Additionally, individuals who rely on Medicaid-funded treatment may not be allowed to bring their children using that transportation and, absent childcare, may not be able to attend treatment consistently (O'Brien et al., 2019). Only one of the providers interviewed include any childcare as part of their outpatient services, and most reported that clients often are forced to bring their child with them to treatment. MSBI noted that parents who are doing well and maintain abstinence and sobriety can have reduced visits and counseling schedules. Because the MSBI OTP is part of a large health system, it also can transfer doses to the system's "late-day clinic," facilitating access for people with complicated schedules.
Housing is a social determinant of health. Lack of housing is a major impediment to treatment retention and was a consistent refrain across interviews. MSBI noted that they can link people to housing support services but that there is very little housing available. CCC is a social service agency with a clientele that is approximately 90 percent homeless or exiting homelessness. It explicitly addresses this issue with the housing and housing supports that it provides and integrates with the rest of its treatment system, including substance use treatment. Unfortunately, even with the housing resources that CCC can provide, lack of housing stock remains a substantial problem. Additionally, the traditional approach to housing for those with SUDs often ejects people from housing if they relapse, does not use a Housing First approach, and may even not accept people who are receiving MAT. MTC noted that it is considering opening its own recovery housing to overcome certain barriers, including a lack of housing supportive of MAT and that often is not developmentally specific or able to meet patients' age-appropriate needs (for example, recovery housing may not be supportive of young adults' romantic relationships).
One other factor that affects retention, that is client-specific but closely linked to the larger treatment system and environment, is criminal justice system (CJS) involvement. Interviewees noted that their clients often may be stable on medication but forced to go through painful withdrawal upon entry into jail or prison. Treatment Associates indicated that much of its non-retention has historically involved incarceration. Steps have been taken in recent years by certain jurisdictions to improve this situation. The State of Vermont is working to ensure that MAT is maintained in jail and that there is a plan in place when the person is released, with the Department of Corrections and the CJS working to improve care coordination with providers. Similarly, MSBI noted that it receives many referrals from Rikers Island, which has its own methadone program. The OTP and Rikers maintain communication to facilitate smooth transitions in each direction.
Evidence or Practice-Based Approaches to Addressing Retention
Our case studies revealed a wealth of information on evidence or practice-based approaches that facilitate retention (i.e., approaches supported either by research or by experience in settings with higher rates of retention).
One of our interviewees at MTC noted that retention itself may be one of the best facilitators of continued retention. Engagement and therapeutic alliance tend to be reinforcing of help-seeking. The more symptom relief patients experience, the more they are retained. Thus, getting someone into evidence-based treatment and onto an effective maintenance dose of medication, be it methadone, buprenorphine, or naltrexone, may be key to keeping them in treatment. Interviewees noted that clients who are being treated only for non-MAT-responsive SUDs are much harder to retain. This raises issues regarding clinical and pharmacological approaches, philosophical approaches, and innovative approaches to patient engagement and monitoring.
Clinical and Pharmacological Approaches
Clinical and pharmacological approaches to treatment play an important role in treatment retention. We discuss psychosocial approaches separately, yet there is some thought that even relationship-building as part of a medication management encounter may be as effective as specific psychosocial approaches to treatment. Every provider interviewed emphasized the need for a solid, trusting therapeutic relationship. However, this extends beyond having clinicians and counselors who can build an effective relationship. It also is affected by workforce shortages and inability to retain clinicians. Treatment Associates indicated that clients find it challenging to continually retell their story to new clinicians, and when a clinician leaves, the clients lose their connection and may disengage from treatment. With the exception of MSBI, which provides strong benefits and has a unionized workforce, every provider interviewed cited workforce turnover as an impediment to retaining clients in treatment.
Observations From Key Informants
The relationship between the counselor and patient is important and not easily measured.
Team-based approaches also are used to better retain clients in treatment. In addition to team meetings, such as those that CCC uses in its bridge and housing programs, providers may take extra steps when a client is having difficulty. For example, at CVAM, the management team meets to discuss difficult cases. The MSBI OTP uses a multidisciplinary approach and, when patients are having difficulty, they are asked to participate in a multidisciplinary team (MDT) meeting. This meeting brings multiple disciplines to the table and helps clients feel connected and better understood.
The primary evidence-based treatment for OUD is MAT. Methadone and buprenorphine are most commonly used but are seldom prescribed or administered at the same sites. Methadone may be administered only at an OTP, removing methadone treatment as a possibility absent appropriate licensure. Buprenorphine may be prescribed or administered by a waivered prescriber at an OTP and elsewhere, but many OTPs use it infrequently. Only CVAM, which is a hub and a spoke, was both an OTP and a major prescriber of buprenorphine. It noted that this ability to use either medication allows flexibility in being able to medicate most appropriately. Research is starting to suggest that having access to and a choice between both methadone and buprenorphine or all three medications may enhance adherence and outcomes (Yarborough et al., 2016). The frequent splitting of the possible treatments into different settings may undermine possibilities for retention in treatment.
Another medication-related factor affecting retention is dose. The research literature is clear that inadequate dosing of either methadone or buprenorphine can reduce treatment retention. This finding was confirmed by our qualitative research. ETS indicated that individuals who miss 11 consecutive doses are its largest source of discharges. If clients miss appointments early in treatment where dose evaluation takes place, they tend to linger at 30 mg of methadone a day and their dose cannot be increased beyond the initial limit. The suboptimal dose results in greater likelihood of missed doses and discharge. To address this issue, ETS is focused on getting patients on a stabilized dose early and safely. Adequate dosing also has implications for continuity of care across settings. For example, CCC has found that the introduction of buprenorphine maintenance into its withdrawal management facility decreased the rate of those leaving against medical advice from 70 percent to 30 percent and greatly increased the rate of those leaving stabilized, including stabilized into housing.
Philosophical Approaches to OUD Treatment
A second group of practice-related factors affecting retention might be categorized as philosophical approaches that translate into treatment strategies. These include not discharging people simply because of relapse and treating individuals who also use benzodiazepines.
A traditional approach to OUD treatment is to discharge someone who relapses. This approach has been closely linked to the use of urine drug screens (UDSs) to identify relapse. However, because OUD is a chronic relapsing disease, providers increasingly understand that simple relapse should not automatically force someone out of treatment. None of the providers we interviewed eject a client from treatment simply because of relapse. They may discharge someone who comes to the clinic intoxicated, who is dealing or acting unsafely, who is showing no effort to engage in treatment, or who misses so many doses that there is concern about monitoring and tolerance. To these providers, relapse is considered a sign of the client's illness and addressing that with treatment, rather than discharging them, is seen as the appropriate step. If a client does continuously relapse, it is more likely that the provider will get them into a higher level of care. As an example, Treatment Associates will move people in steps, starting with a transfer to IOP treatment. If that is not sufficient, Treatment Associates moves them to the hub and then, if necessary, to inpatient treatment.
Clients may be abstinent from opioids but using another substance. This is most frequently a problem for a prescriber of methadone or buprenorphine when someone is using benzodiazepines. At the MSBI OTP, the clinic's concern is that the patient may appear fine but be sedated after dosing. In addition to counseling about polysubstance use, its approach to this issue is to check the prescription drug monitoring program (PDMP) and to ask the patient to show a prescription for the medication. However, even if the patient is using illicit benzodiazepines, the clinic will not restrict methadone unless the patient is sedated. Watching the patient after dosing is critical, and oversedation may result in a call to emergency medical services. At least one provider interviewed does not dispense methadone to clients taking Xanax because of its higher mortality rate when combined with opioids and preferred use as an illicit drug, but that provider will allow dispensing to clients taking other benzodiazepines.
Patient Engagement and Monitoring Approaches
We discovered a wide range of innovative approaches to facilitate patient engagement and monitoring, most of which involve flexibility in many aspects of treatment.
Service flexibility is an important consideration for improving retention and can be introduced at any point in the treatment process. Intake is often the first time that someone experiences a provider, and it frequently is a period of transition from one provider to another, whether from a hospital to outpatient treatment or, in Vermont, perhaps between a hub and a spoke. One of the biggest problems is ensuring that there is an opening when someone seeks treatment. One of the Vermont spokes, Treatment Associates, is working to smooth this process as part of the RAM program. Treatment Associates has hired additional staff for intake to facilitate movement between emergency department induction and spoke maintenance. Other providers, such as CCC, have walk-in physical or behavioral health appointments allowing prompt induction of buprenorphine, with a plan for follow-up within 48-72 hours. ETS also has implemented same-day treatment if there is an open medical slot. If clients have to come back because ETS does not have an opening, they are given head-of-the-line privileges on the day they return.
An important part of intake and of promoting effective continuity of care between settings involves helping patients understand the treatment process by setting the stage so that they know what to expect. One approach is to have an orientation group, such as the one MSBI requires. CVAM also has introduced spoke informational groups to assist in the transition. Similarly, as part of the RAM program in Vermont, the emergency department and recipient hubs or spokes are working together so that patients leaving the emergency department know what will be expected of them when they go to outpatient treatment. This was a lesson learned as part of the RAM pilot.
Practice-Based Approaches to Retention--Thoughts From Key Informants
Flexibility also is important during ongoing treatment. CCC continues the idea of accessibility, for instance, with its SUD providers who are embedded in its FQHC and who maintain an open-door policy. Several providers also spoke of the inability of some clients to accept high-intensity treatment. MTC is emphasizing flexibility as a way to improve retention. Rather than trying to fit people into a preprescribed model of group therapy, MTC has made its counseling more flexible in order to "meet patients where they are at." Another provider described a flexible approach as necessary for clients who cannot accept rigidity or structure.
Flexibility in methadone dosing also can be helpful. Many methadone clinics dose early in the day, with hours often beginning at 5:30 or 6:00 a.m., to allow people to receive their daily dose before work or school begins. ETS also has moved away from scheduled appointments for dosing to allowing clients to receive dosing at any point in the clinic's dosing hours. Late visits also may be needed and often not available. Because the MSBI OTP is part of a very large health system, it can transfer doses to the system's "late-day clinic," facilitating access for people with complicated schedules.
Client tracking and outreach are approaches that providers take to improve retention and continuity in care. ETS routinely reaches out if a client misses two consecutive doses. It also uses an engagement tracker to closely monitor clients during the first 90 days of treatment. The engagement tracker is color coded and addresses risk factors for avoidable discharges, such as being homeless, being under 30 years old, being new to treatment, or having a co-occurring diagnosis. This lets ETS keep better track of the risk factors and allows the peer recovery specialist to step in before the patient leaves treatment. ETS can flag a patient's dose so that peer recovery specialist is alerted if they need to check in with someone who is at higher risk. MSBI also has an outreach process when clients miss doses. At 7 days, they receive an outreach call, and at 14 days, they are sent a letter. MSBI and others noted that individuals who do not appear often are transient, with no fixed address and no reliable phone. MTC relies on patient locators, who are often family members. Tracking also can be helpful to facilitate continuity of care. The CCC bridge clinic does client tracking through regular meetings, care coordination, and case management, which has allowed them to triple the rate of placements from the bridge program.
Peer providers also are increasingly seen as key to retention. Some programs use peer volunteers, and others employ peers as staff. Peer providers are used by most of the programs interviewed. CCC relies on both peers and certified recovery mentors with lived experience in the treatment and housing programs. Becoming a peer employed by CCC requires 2 years of abstinence, and many are former clients. Becoming a mentor requires 2 years of relevant experience or certification. CCC conducts internal training and funds part of the activities needed for certification. As part of its culturally specific programming at the Imani Center, CCC also offers Afrocentric approaches to peer support and case management. ETS hired a peer engagement specialist who works with clients on an ongoing basis but focuses on the first 90 days. The emergency department that piloted the RAM program in Vermont uses a recovery coach who works with patients in the emergency department, using a Recovery Coach Checklist, and then follows up with the patient by phone or text. The peer also may have a later physical meeting with the patient. MTC has a family advocacy group that focuses on peer supports for client family members.
As part of its naltrexone home-delivery pilot, MTC uses a "contract" with the patient and, with consent, the patient's family. It is introduced at the first meeting and is a tool to sustain relationship-building and is an attempt to make everyone feel included and supported. It is flexible and tries to be responsive to the individual's treatment needs. MTC also offers monetary motivational incentives for medication adherence specific to the naltrexone initiative, with increased amounts tied to longer retention.
Toxicology Screens--Thoughts From Key Informants
Urine toxicology has been over-reimbursed and, therefore, overused. It has a role for objective monitoring, but there are other services that can be more valuable.
Even though none of these providers discharge clients because of a positive toxicology screen, a UDS is still important as an indicator of treatment success and appropriate dosage and to ensure that clients are actually taking their medication. Some providers interviewed do still rely on observed UDSs, and some may do so only if it is a condition of parole or may maintain the possibility of an observed UDS to confirm that clients are taking their medication. The general rationale for this change is that pressure to produce a sample when observed is a barrier and that observed collection is demeaning. The MSBI OTP is one of the providers that never uses observed UDS. Instead, if there is a concern about adulteration, if an observed test is required by parole or child welfare services, or if it is needed for a reduction in schedule, MSBI uses an oral swab.
Providers also are increasingly using telehealth in different ways to improve access to care for prescribing, counseling, and other needs. ETS used telehealth to facilitate buprenorphine prescribing at its rural Grays Harbor Clinic in the township of Hoquiam, Washington, until the clinic closed in mid-2019. Treatment Associates is using telehealth to provide counseling services when that is necessary to allow client access. MSBI is participating in a study using telehealth to provide Hepatitis C services in its very urban OTP. These three different approaches to integrating telehealth into SUD treatment suggest that other uses of telehealth also might be viable ways to provide integrated treatment within a single location.
Structural flexibility also can be helpful if treatment is ending. ETS has found that some people, such as construction workers, simply have conflicting schedules that cannot accommodate its dosing times, which are from 5:30 a.m. to 1:00 p.m. Some elect to taper off MAT but wish to stay in treatment. If someone voluntarily tapers, ETS offers aftercare services during which the patient can see his or her counselor. Others such as CCC can provide buprenorphine continuity for up to 30 days if someone leaves for another provider. Additionally, if a client does not have a place to receive treatment upon discharge from withdrawal management and stabilization, CCC also can maintain continuity of medication via prescription or dispensing, including through its bridge clinic.
The programs interviewed represented a cross-section of treatment approaches, all committed to supporting treatment that includes medication. CCC changed a few years ago from a traditional 12-step approach to one that embraces MAT as fundamental to evidence-based treatment, while still offering 12-step options to those who wish to use them. The remainder have a longer history of focus on medication. All programs approach psychosocial supports somewhat differently. At a broad level, they range from programs that identify as "strongly therapeutic-focused" to ones that have embraced a low-threshold approach to treatment with pronounced flexibility.
Psychosocial Services--Thoughts From Key Informants
Some programs require individual and/or group counseling as a condition of receiving medication; others do not. Some, such as ETS, an OTP, are required by the state (Washington) to mandate counseling. Even then, the state has recently removed strict requirements related to frequency, leaving that to the individual treatment plan. The MSBI OTP in New York indicated that state requirements have now changed to "as needed." Despite this, MSBI feels strongly that counseling is important and requires it at least once a week for the first 90 days in treatment. Vermont requires at least 60 minutes of counseling a month, but because it receives a bundled payment, CVAM can be flexible, requiring shorter, more frequent visits until a patient becomes more stable, with the frequency then reduced. Also in Vermont, Treatment Associates expects counseling but is flexible on the basis of individual need, no longer requiring it to obtain medication. The general expectation at Treatment Associates is between two sessions a month to five per week (group and/or individual). At CCC's new Blackburn Center, it is encouraging but not mandating psychosocial treatment, while still requiring it at the Hooper withdrawal management site. As part of its home-delivery of naltrexone program for young adults, MTC expects those receiving home-delivery to attend an outpatient group, but if they do not, they still receive the injection every 3-4 weeks, along with a counseling session in the home.
Every program emphasized the importance of meeting clients "where they are at." In Vermont, Treatment Associates lets clients choose an approach to treatment that is the right fit for them rather than mandating a specific approach. This is tied to the need for relationship-building. MTC finds that helping the patient with something else in their life (e.g., a personal crisis, family issue) helps MTC build a connection. CVAM works hard to match patients to a good counselor for that patient during the intake interview. It noted that "engagement is both the impediment to successful treatment and the answer to successful treatment."
Modalities of Treatment
Several of the programs noted that they routinely use the ASAM criteria for evaluating patient treatment needs. Based upon such assessments, treatment plans are developed. Psychosocial services then delivered may include individual or group therapy, case management, peer supports (discussed above), and other services.
Individual and Group Treatment
Treatment programs differ with regard to how heavily they rely on individual or group therapy as their primary modality of treatment, and many seem to have a well-defined identity that attaches strong preferences to one or the other. This may be a legacy of historical program structure, current program philosophy, or resource constraints that limit the workforce of trained individual or group counselors. One program spoke of having to limit patients to one group per day to ensure access for all patients.
The two most commonly mentioned therapeutic approaches were motivational interviewing and cognitive approaches. Motivational interviewing was used by all programs, most on an ongoing basis. This was seen as a method to motivate and reinforce change and to retain and encourage participation in treatment. In Vermont, Treatment Associates noted that it has incorporated motivational interviewing into all levels of treatment, including case management, individual counseling, and group counseling. Cognitive approaches were widely used, both individually and in groups. Related to that is Dialectical Behavior Therapy (DBT), which at least two of the programs have implemented with DBT-trained counselors. Several mentioned providing trauma-informed care. Psychoeducation, often in groups, also is widely used.
The variety of groups that are offered is quite diverse. MSBI begins treatment with an orientation group, which orients clients to everything about the program, including loitering and toxicology policies. Among the groups offered through different programs were ones that are more clinical and ones that focus more on life skills. Group topics mentioned included CBT, DBT, seeking safety, co-occurring or dual diagnosis, pharmaceutical treatment education, harm reduction, overdose prevention, tobacco cessation, life skills, job training, and budgeting. Groups for women, men, older clients, and lesbian, gay, bisexual, and transgender (LGBT) clients also are offered.
Case management is a critical component of all programs interviewed. This may include onsite case managers, case managers in the community, and special programs for those requiring additional support. Special case management programs often include or are part of MDTs. The ETS REACH program includes case managers, along with other providers, to work with clients who are homeless. The CCC CEP uses a MDT that includes case managers to work with clients who have both mental disorders and SUDs. Case management is also a strength of CCC's housing programs; case managers help people find and sustain housing and help them engage and remain in treatment. MTC's naltrexone home-delivery program relies strongly on high-touch case management to sustain the connection to treatment. As part of the Vermont health home managed care model, to provide enhanced case management, treatment spokes have supplemental access to one licensed clinician case manager for every 100 patients across multiple providers and their offices. The CVMC emergency department that piloted the RAM program includes a robust obstetric case management system that is used to get pregnant people into medication treatment quickly. Many of the programs spoke of instituting tracking systems as part of case management to help identify where additional outreach or support is needed.
Mental Health Treatment
Many of the programs struggle with providing or connecting mental health treatment to everyone who needs it, and many also said that the numbers of those they serve with serious mental illness is increasing. At least two of the large providers indicated that approximately 70 percent of their clients have a serious mental illness. The common inability to access sufficient mental health treatment may reflect various issues, such as a growing population with great need, a shortage of mental health providers in the community, and mental health treatment providers, including specialty psychiatric hospitals, that do not treat individuals with SUDs or, in some cases, specifically anyone on benzodiazepines. Some programs such as ETS provide limited psychiatric care in house if a client cannot obtain it in the community. ETS also is exploring obtaining a community mental health license to offer services regularly. Vermont's Treatment Associates offers full mental health and substance use treatment in house. CCC has the embedded CEP, a multidisciplinary recovery model for the population of chronically homeless people with co-occurring mental disorders, SUDs, and/or physical concerns. The MSBI OTP routinely screens intakes for mental disorders to determine whether a referral is needed, and if so, a referral is made either to the hospital or to another specialty mental health program.
The programs interviewed offer a wide array of other services that enhance SUD treatment. Some examples include the following:
The MSBI OTP includes vocational rehabilitation counselors, financial counselors, a coordinator for child and family services (CFS), and a patient advocate. It also offers activities that are designed to provide recreational opportunities in a non-drug setting, including a client choir.
MTC's low-threshold naloxone home-delivery pilot for young adults uses patient-family-provider contracts to leverage the family and also emails, group texts, calls, and Facebook messages.
CCC takes a holistic approach to its largely homeless urban population and includes an array of services beyond SUD treatment. It encompasses mental health treatment, physical health treatment, acupuncture, housing, and employment services. It also offers culturally specific programming at the Puentes program for the Portland Latinx community and the Afrocentric Imani Center.
ETS also provides acupuncture and, until recently, used telehealth to help bring sufficient buprenorphine treatment to rural Grays Harbor County, Washington.
Current reimbursement approaches vary by treatment provider and state. Populations served by the sites visited are predominantly Medicaid beneficiaries, although commercial insurance and self-payment, usually on a sliding scale, also applies for small segments of the population.
Reimbursement--Thoughts From Key Informants
Medicaid payment approaches encountered include fee for service (FFS) (MTC); a bundled rate as an OTP (ETS); a bundled rate as a hub, with FFS paid to outside providers (CVAM); per service under an ambulatory patient group (APG) as an OTP (MSBI); and a case rate (CCC). Vermont Medicaid uses a health home managed care model for payment. This allows flexibility in terms of services provided, avoids quantity-based FFS payments, and allows for enhanced staffing.
Some providers, including the MSBI OTP and a spoke in Vermont, noted that they are not part of value-based purchasing in their states. However, as part of King County's HealthierHere initiative, ETS reports measures that are part of a value-based payment model that includes a retention measure.
In addition to insurance reimbursement, providers may rely on other sources for funding certain things. For example, the MSBI clinic received deficit funding from the state, and MTC relies on grant funding for supports not covered by insurance for its naltrexone pilot. For outreach and engagement, CCC uses overhead.
Observations from Key Informants
Insurer quantity limits are not a real barrier to accessing treatment, but for those in treatment there is no reason to have quantity limits. There are not similar quantity limits for comparable medications, such as insulin.
Several providers noted areas where changes to reimbursement might enhance treatment and retention. The following are some of the ideas:
Moving away from FFS payment, where that still is used, to more flexible approaches that support services such as high-touch case management, treatment supervision, and outcomes monitoring.
Including case management within an OTP bundled rate, which some states do and others do not.
A value-based payment model that pays for outcomes and quality.
Reimbursement that recognizes periods or instances when more intensive services are needed, such as during the first month of treatment or for complex cases (e.g., polysubstance, dual diagnosis).
Statewide removal of prior authorization for buprenorphine treatment so that Medicaid managed care organizations within the state do not apply different requirements.
At least one perverse incentive of the case rate was noted by CCC. As CCC has moved from detoxifying people with buprenorphine and tapering them off for release to maintaining them, its withdrawal management stays have increased in length. In addition, since buprenorphine maintenance was added, discharges against medical advice have decreased from 70 percent to 30 percent. These are positive signs for stabilization and recovery. Yet, the detoxification facility is paid a case rate if there is an intake and the person remains past midnight, with no additional payment regardless of the duration of the stay. For those who still opt not to use maintenance medication, the case rate could have the perverse incentive of encouraging rapid tapering and discharge, which may undermine recovery. For those who opt not to taper, the case rate could incentivize more rapid discharge that does not allow time for the process of connecting, for example, a homeless person who has OUD and psychosis to all needed supports. CCC was clear that it does not succumb to these incentives to reduce care but acknowledged that the longer stays affect its bottom line.
What variables affect retention in SUD treatment across disorders? How have these changed with the evolution of drug use patterns?
As our examination of the literature and our study findings indicate, many variables affect retention in SUD treatment, including treatment for OUD. The interaction of those variables is critical--whether client characteristics, provider or service delivery characteristics, setting-based factors, or external variables such as cross-system collaboration or payment policies. Influences on retention cannot easily be reduced to simple, quantifiable measures. Treatment is an interaction between the client and the provider and between each of them and external influences. Retention depends on those interactions and the ability of domains such as providers, payers, or clients to adjust.
Systemic adjustment helps answer part of the question of how variables influencing retention have changed with the evolution of drug use patterns. Traditionally, SUD treatment was abstinence-based, as were other systems on which people relied, such as housing and mental health treatment. These systems traditionally required abstinence to partake in services, and non-abstinence could be a reason for loss of SUD treatment, mental health treatment, and housing. This approach has not disappeared from the landscape, but there have been changes.
Among SUDs, only tobacco disorder, AUD, and OUDs are treated with medication that has been approved for that purpose. Despite its effectiveness in treating OUD, medication such as methadone or buprenorphine often has not been accepted in SUD treatment or in housing. As an interviewee at CCC noted, "MAT was not considered abstinence." The major force propelling changes that support retention is the fact that so many people in so many places are dying in the opioid epidemic. Two of our interviewees brought this basic fact to the fore. An MTC provider stated, "OUD is different from some other SUD treatment in the sense that it is more urgent. With OUD treatment, the provider doesn't have the luxury of learning from their mistakes and the patient doesn't hit rock bottom before they start getting better. If you let them hit rock bottom, they will die." Similarly, a person in the CCC housing division attributed their culture change from abstinence-based to a flexible mix of recovery and Housing First approaches, with MAT heavily involved for both, to the fact that "people were dying and it had to change."
To some extent, the question of change is moot because polysubstance use, both intended and unintended, is the reality for a large portion of those who should be served by the treatment system. The introduction of fentanyl into heroin, cocaine, and methamphetamine (National Institute on Drug Abuse, 2019), for instance, as well as the fact that most people using opioids illicitly also intentionally use other substances (Winkleman et al., 2018), means that the treatment system must address all substances in whatever way is best in terms of providing access to treatment, getting people into effective treatment, and keeping them there.
Certain factors influence retention. Below we discuss evidence or practice-based, psychosocial, reimbursement, and setting factors and, to the extent that there are factors specific to OUD (e.g., medication dosing), we highlight that fact. Client factors, however, clearly also play a role. Potential client factors are numerous but certain characteristics seemed most significant in the eyes of those we interviewed. Serious and untreated mental health conditions, polysubstance use, non-robust supports for social determinants of health such as housing and social supports, CJS involvement, and age are all important influences on retention. Each of these, in turn, interact with providers, settings, and other external factors.
What are evidence-based methods to address treatment retention in SUD treatment, and how do these apply to treatment of OUD?
In addition to psychosocial supports or setting-specific practices, which we discuss below, this study uncovered many practice or evidence-based methods to address or otherwise influence retention. Practices related to delivery of medication are the ones most specific to treatment of OUD. These include: (1) offering 2-3 medications rather than just one; (2) for methadone, timing availability to maximize ability to receive the medication (e.g., late-day clinic); and (3) doing whatever it takes to get clients stabilized on an optimum dose of methadone or buprenorphine as quickly as it is safe to do so.
However, these medication-specific practices interact with other practices that seem applicable regardless of substance, and many relate to treatment flexibility. Preintake communication across settings is paramount, as is preparing the client for the next stage of treatment. When an individual is ready for treatment, it needs to be available, induction needs to be same-day, and follow-up must be guaranteed. Embedding substance use and mental health treatment into physical health settings, where warm hand-offs can be effectuated, provides greater ease in moving a person who is already physically present into an office where substance use treatment can be initiated. Increasingly low-threshold or no-threshold treatment is becoming accepted as necessary for initiation, engagement, and retention. This may mean many things, but at a minimum, it means reducing the burden of intake and increasing the availability of treatment when someone is ready to receive it. However, it also may mean, providing treatment that is client centered and not rigidly the same for everyone. Use of telehealth sometimes may be helpful to facilitate part of this process.
Individuals in SUD treatment often do not have reliable homes or telephones. Tracking systems and outreach are imperative, and payment that supports these activities is critical. Use of peer providers or others to connect with and provide persistent outreach can be a tool in this regard. Use of "locators," such as the locators that MTC uses with young adults, may not always be feasible, but other creative approaches to outreach may be possible. Motivational incentives and "contracts" also can support retention.
Traditional SUD treatment involved discharge if a person relapsed, frequent observed UDSs, and, in OUD treatment, not allowing individuals taking benzodiazepines to receive MAT. None of the providers interviewed discharge individuals simply because of relapse, and observed UDSs are becoming increasingly less common. Although caution in treating individuals codependent on opioids and benzodiazepines is important, as is not prescribing benzodiazepines to individuals taking opioids, careful treatment of both is possible. Indeed, the Food and Drug Administration (FDA) has issued guidance that providers should not refuse OUD treatment to those taking benzodiazepines (FDA, 2016). Reimbursement for complexity might mitigate some of the concerns providers have about treating this population, which requires extra screening, assessment, treatment, and monitoring.
Approaches to treatment that recognize that people leave treatment for different reasons also may help with care continuity. Aftercare or bridge services, such as those offered by the CCC Hooper bridge program, can promote continued medication adherence, as can providing a therapeutic environment and connection until the person can receive treatment elsewhere. Even if such services are not accepted, keeping the door open means that individuals who leave may return. Additionally, because many discharges involve clients entering the CJS, approaches that avoid discharge, facilitate communication between the CJS and treatment provider, and facilitate ongoing treatment while the person is incarcerated are very important. Vermont and New York City are making strides in dealing with this reality.
Are there promising models of psychosocial support that assist in maintaining an individual in MAT for OUD? Do longer, more continuous durations of treatment result in better outcomes?
We are at a point where the value of requiring psychosocial treatment for everyone receiving MAT is being debated, and steps slowly are being taken away from rigid requirements. Some providers feel very strongly that psychosocial treatment is a key component of MAT, and others feel that the most important thing is to get clients stabilized on medication, hoping that they will be receptive to psychosocial treatment as they move further into medication-supported recovery. The latter camp also often sees mandated psychosocial treatment as impeding retention for many people who are uncomfortable with structure and with being forced to participate in group or individual therapy in order to obtain needed medication for their illness.
This debate raises questions more than it answers. For instance, could high-quality, consistent medication management meetings and intensive case management suffice for some people? Is better preparation for and orientation into treatment necessary to help clients understand why counseling can be helpful and to accept it? Are a substantial portion of those with SUD who also have extensive trauma histories being treated in a trauma-informed fashion, and might they not benefit from some of the trauma-informed treatments being used at, for instance, VA facilities? Would consistent integration of high-quality mental health and substance use treatment for the dually diagnosed not better support those individuals than siloed and often unavailable separate treatment? Would conscious and intentional and well-trained use of motivational interviewing throughout treatment better maintain readiness for change and retention than would treatment that foregoes or provides motivational interviewing only at the inception of treatment?
Every provider interviewed stressed the need to "meet people where they are at." This means using client-specific approaches beginning at intake and providing what the person needs when they need it. However, to know what clients need, providers must be able to establish a meaningful therapeutic relationship. Whether that means individual counseling, group therapy, intensive case management, high-quality medication management meetings, or supporting a choir, it involves some sort of psychosocial support and connection.
How have changes in reimbursement policy affected the provision of services? Have reimbursement policy changes expanded retention in treatment?
The general consensus is that FFS reimbursement can encourage overuse of certain services (e.g., UDS) and impede the ability to provide collaborative, integrated, and holistic care that supports retention. On the other hand, as one of our interviewees noted, case rates alone may incentivize shortened and less complex responses to a population that is quite complicated. What seems to be best received are thoughtfully bundled payments that address necessary services, including case management and care coordination. As a hub in the Vermont health home managed care reimbursement system, CVAM receives bundled payments. Yet, if a client prefers or needs to see an outside provider, CVAM can refer them out. That provider is paid via FFS, and CVAM still is paid the bundled rate for the services it provides, as long as it meets the requirements for its bundle.
What seems to be key is a thoughtfully bundled reimbursement system that encompasses necessary services, including case management and care coordination, yet recognizes the need for flexibility regarding providers. Such a system could be stratified or risk adjusted to account for complex cases (e.g., dually diagnosed with serious mental illness, multiple SUDs) and recognize that there are times when extra support is required, such as when clients are newly initiated into treatment. Reimbursement should encourage and reward continuity of care as well as retention in treatment. To this end, additional research is needed to determine, for instance, why low-performing agencies in Washington State did not respond to contract incentives in the same way that moderate to high-performing agencies did (Acevedo et al., 2018) and whether and how low-performing providers can improve retention, continuity of care, and high-quality treatment. This may mean a strengthened workforce, mandatory QI initiatives, or other steps that revise the status quo.
Finally, several interviewees and key informants commented on the way that medication used to treat OUD is not consistently treated like medications for other chronic diseases. Not all commercial insurers reimburse for methadone, buprenorphine, and naltrexone, nor do all state Medicaid programs. Of those states that do reimburse for some or all of those medications as part of their Medicaid benefits, some still impose prior authorization requirements or quantity limits, often with substantial disparities between how different Medicaid managed care plans within a state reimburse (SAMHSA, 2018). The opioid crisis has pushed many states away from this approach, but some persist in limiting access to life-saving medications.
What types of settings have seen success in implementation of SUD treatment retention methods, and how do they structure their programs? Have these methods been specifically applied to MAT for OUD, and are these programs structured differently?
The settings visited included two programs that are first and foremost OTPs, largely reliant on methadone for treatment with more limited use of buprenorphine. They differ in their relative focus on individual versus group therapy, but both have undertaken substantial steps to facilitate access to care and to improve retention, as well as to address polysubstance use and integrate care. Both programs have clients who have been in treatment for many years. MSBI is part of a large health system that can provide access to mental and physical health treatment and other services, can provide access to a late-day methadone clinic, has a strong base of long-time staff with deep connections to the clientele, and works closely with the CJS to facilitate ongoing treatment. ETS has worked very hard to maximize client engagement in the first 90 days of treatment, including by providing broader opportunities for methadone dosing, providing treatment on demand to the extent possible, and hiring and relying on a peer engagement specialist to connect with new clients as a person with lived experience, tracking their attendance and risk factors and following up promptly when signs appear of disconnection. The mobile methadone clinic expands ETS services to neighborhoods without a clinic, making client access easier. Until mid-2019, ETS also had an effective buprenorphine telehealth program at a rural location, providing access to MAT to people who often otherwise had to drive for hours to receive treatment.
In contrast to MSBI and ETS, MTC is not an OTP and uses buprenorphine and naltrexone for OUD medication treatment. Unlike an OTP, its mission is not so extensively focused on clients with OUD. MTC is fortunate to have a research division and grants that have supported its ability to implement and evaluate a RCT comparing treatment as usual for young adults to treatment in the form of home-delivery of XR-NTX. This program is supported by intensive case management, use of social media and electronic connections to retain contact with participants, client "contracts" and monetary incentives to remain in treatment, and, with client consent, family involvement as "locators" and other supports. The preliminary data show positive effects on retention in treatment, and MTC is expanding the trial to compare the relative benefits of using XR-NTX and XR-buprenorphine via home-delivery. The low-threshold approach does not mandate that individuals attend counseling at a treatment facility but brings individual case management and counseling to them with delivery of medication that must be injected only once monthly.
Like MTC, CCC is not an OTP and relies primarily on buprenorphine and, to a lesser extent, naltrexone for medication treatment. As a non-OTP, it also is not exclusively focused on serving the OUD population. It can provide services and supports that include two Health Care for the Homeless FQHCs, mental health treatment, housing and employment services, and embedded substance use treatment that includes withdrawal management and stabilization, IOP, and outpatient treatment, as well as other services. These services let CCC serve and support a vulnerable population holistically. In addition to the wide range of services, CCC recently implemented an integrated version of much of its spectrum of care in a single location and, separately, created a bridge clinic at its detoxification facility that permits continued treatment of those stabilized on buprenorphine until other services are available.
Lastly, the State of Vermont's hub-and-spoke system, including its RAM pilot of buprenorphine induction in the emergency department, includes a mixture of OTPs and non-OTPs, permitting some portions of its system to provide both methadone and buprenorphine and allowing the six service regions to consistently provide both at some place within that subsystem. The central Vermont sites that we interviewed are part of a fluid and responsive meta-system that is deeply embedded in the community served. Data from the pilot RAM program is being evaluated as the program evolves and it is being replicated in other parts of the state. Critically, the impetus for the RAM program was an earlier alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) triage program at the same hospital. Key factors supporting retention and continuity of care within the Vermont State system include the ability to use different medications; the ability to provide different levels of support (hub or spoke) as needed with two-way communication across sites; organized efforts to build and improve the buprenorphine emergency department induction program, with guaranteed follow-up at hubs and spokes upon discharge from the emergency department; the state's efforts to continue medication treatment within the jail system; and a health home managed care reimbursement model that is flexible enough to support the settings that are hubs and spokes but also to allow other treatment when needed.
Factors that promote or impede retention and continuity of care are complex. That complexity provides us with opportunities to better understand many things. Additional research and thought may help us determine how to further shift the culture of substance use treatment away from a lingering abstinence-only approach and how to bridge the silos between methadone, buprenorphine, and naltrexone treatment for OUD so that everyone has access to whichever treatment is best for them. We need to think hard about how best to integrate mental health and substance use treatment and best practices for treating non-MAT-responsive SUDs. Those are two of the biggest hurdles to retention that our interviewees face, along with loss of clients to the CJS, where treatment often is unavailable. Providers need practical guides to moving clients to an optimum dose of medication as rapidly as is safe, including guides to structural practices that support early engagement. Many practices identified in this report can facilitate retention, but adequate reimbursement for necessary services such as outreach, tracking, case management, and care coordination is needed to enable implementation of best practices. Reimbursement that is risk adjusted to address complexity and periods when greater resources are needed would help support services and delivery system reforms that enhance retention in treatment. We also need to better understand how to move providers who are not using best practices further along the quality spectrum.
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An APG is a patient classification system for payment of facility costs of care that was originally created for the Medicare program.