Considering layering medication and psychosocial treatment for people with co-occurring opioid use and mental health disorders: What improves outcomes?


Editor’s note: This op-ed was written by Abigail Helm, PhD, Research Program Manager at the Division of Health Systems Science, Department of Medicine, University of Massachusetts Chan Medical School. Dr. Helm describes her team’s research on integrating medication for opioid use disorder treatment with a psychosocial behavioral intervention and its effectiveness in improving substance use and mental health outcomes.

Opioid use has increased dramatically over the past two decades. The prevalence rate for opioid use disorder is higher among people with co-occurring mental health disorders as compared to the general population. Integrated multi-component behavioral interventions for individuals with co-occurring substance use and mental health disorders (COD) are optimal for addressing the diverse needs of people with COD. However, engagement in treatment is a large issue for this population. Additionally, although medication for opioid use disorder (MOUD) is the gold standard of care for people with opioid use disorder, patients’ engagement in MOUD treatment also remains low among those with a COD.

In response to a special call for applications as part of the NIH Helping to End Addiction Long-termSM Initiative, our new 4-year grant entitled Supporting Treatment Access and Recovery for Co-occurring Opioid Use and Mental Health Disorders (STAR-COD) aims to target engagement issues by layering MOUD treatment with a multi-component psychosocial behavioral intervention and to examine the incremental therapeutic benefits of each component of treatment. The intervention is Maintaining Independence and Sobriety through Systems Integration, Outreach and Networking (MISSION), a 6-month team approach guided by the Heath Belief Model and harm reduction philosophies. MISSION integrates three evidence-based practices: (1) Critical Time Intervention (CTI), a form of time-limited assertive outreach which addresses situational and motivational barriers to care engagement; (2) Dual Recovery Therapy (DRT), a curriculum of 13 group sessions delivered by a case manager (integrating mental health and substance use); and (3) Peer Support (PS), a curriculum of 11 structured recovery group sessions delivered by a person with lived experience, who also links patients to community recovery services and activities.

STAR-LS includes a collaborative team with investigators from UMass Chan Medical School, Harvard Medical School, UMass Lowell, and University of Texas at Austin. The study will randomize 1,000 people with COD recruited from MOUD clinics across Massachusetts. Patients will receive six months of treatment, plus an additional six months of follow-up to examine study outcomes. During the study, participants with COD continue with their MOUD treatment as usual and get assigned to one of five conditions for additional care: (1) no MISSION (MOUD only); (2) full MISSION (CTI, DRT, PS); (3) CTI & DRT; (4) CTI & PS; or (5) DRT & PS. The study aims to evaluate the effectiveness of MISSION plus MOUD (condition 2), as well as the comparative effectiveness of MOUD only (condition 1), and MOUD plus combinations of the evidence-based components (conditions 3-5).

Over the year of study participation, we expect that reductions in substance use and improvements in mental health symptoms will be greatest among participants enrolled in the study conditions including MISSION components. We will also examine if some components of the intervention may be more cost-effective based on participants’ outcomes in this study and explore the outcomes associated with the different components of MISSION carefully to see if some components may be more beneficial for certain participants and their needs. Upon study completion, we hope to provide guidance to treatment providers about the ways in which MISSION, or other behavioral interventions, may be used in combination with MOUD to support patients with COD and their diverse needs.

In addition to the larger grant, we recently received an NIH supplemental funding to enhance equitable representation of Black/African American and Hispanic/Latino participants in the STAR-COD study (parent study described above). This funding will allow us to convene and gain insight from a Diversity, Equity, and Inclusion Community Advisory Board to improve participant diversity through guidance for the development of targeted recruitment strategies. While engagement and retention in treatment is already low for individuals with COD, rates of engagement are even lower among Black/African American and Hispanic/Latino patients with COD. Additionally, Black/African American, and Hispanic/Latino individuals are less likely to participate in clinical research trials due to prior damage done by disreputable researchers, institutions, and systems in the past (e.g., Tuskegee Syphilis study). This supplement will help us to better connect with community agencies, recovery support services, and other local resources to establish trusting and open relationships to engage Black/African American and Hispanic/Latino individuals with COD among the treatment communities across Massachusetts.

We intend to share our findings widely and hope that they will be of use to program developers beyond our own geographic area. In the meantime, we invite interested readers to learn more about our study, the STAR-COD grant, and the MISSION model.

— Abigail Helm, PhD, Research Program Manager, Division of Health Systems Science, Department of Medicine, University of Massachusetts Chan Medical School

Conflict of Interest Statement
Dr. Helm has no conflicts of interest to disclose of personal, financial, or other benefits that could be seen as influencing the content of this editorial.

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