Although effective interventions exist for preventing and treating substance use and SUDs, their reach has been limited. Only 11 percent of people with OUD receive one of the three medications approved by the FDA to treat it. To scale up research-based interventions in diverse settings, it is essential to understand and address the many individual, cultural, societal, and system-level factors that promote or impede prevention, treatment, and recovery. To this end, NIDA supports a portfolio of implementation research informed by stakeholder input to bridge the gaps among research, practice, and policy. Through this portfolio, NIDA is advancing scientific knowledge about how health information, effective interventions, and new clinical practices, guidelines, and policies can be optimally integrated and communicated across settings—including primary care, emergency departments, pharmacies, and community and justice settings—to ensure continuity of care.
- Goal 4.1: Study approaches to improve the integration of SUD care into medical practice
Despite the progress that has been made in recognizing addiction as a treatable medical disorder, addiction care remains isolated from other aspects of health care, ranging from primary care where comorbid somatic conditions like HIV/HCV are treated to specialty care for other mental illnesses. As a result, health care providers often fail to detect early treatable symptoms of SUDs or recognize individuals with SUDs and refer them to needed specialty care. This segregation of care can also result in difficulties paying for effective treatment.
NIDA’s portfolio in implementation science includes studies focused on increasing access to SUD care by better integrating it into medical practice. Through NIDA’s Clinical Trials Network, NIDA funds studies on strategies for incorporating SUD screening and management into settings such as emergency departments and primary care (see callout box below “Testing and Implementing Evidence-Based Strategies in Diverse Settings”). Given the complex nature of addiction, NIDA funds trials testing models of collaborative care. Collaborative care isa service delivery model that facilitates the provision of behavioral health treatment in primary and specialty care through a treatment team comprising the primary care or specialty care provider, a care manager, and a behavioral health specialty consultant. NIDA also supports studies that examine how best to integrate SUD care into the insurance and reimbursement process, including those that allow researchers to take advantage of opportunities arising from health care reforms, such as insurance reimbursement mandates and laws authorizing practitioners with a broader array of credentials to provide substance use treatment.
Key Focus Areas
- Evaluate the integration of substance use treatment with general medical care, including primary care, emergency services, and other specialty care.
- Develop and test innovative and pragmatic treatment models that have high potential for adoption and sustainability, including engagement of pharmacists, dentists, and nurses.
- Determine the effectiveness of adjuncts to clinical care to improve treatment engagement and outcomes.
- Evaluate optimal telehealth delivery and care models that ensure quality and equity.
- Evaluate the effectiveness of integrated prevention and collaborative care treatment interventions for individuals with SUDs and co-occurring health conditions.
- Study the effectiveness of interventions for managing subthreshold symptoms of SUDs.
- Leverage multiple data sources and artificial intelligence to predict risk and guide clinical decisions for substance use interventions across settings.
- Goal 4.2 Develop and test strategies for overcoming barriers to access and continuity of care
Barriers to health care services can take many forms, and NIDA is prioritizing research to understand and address these barriers. Some are logistical, such as difficulties accessing care for people who are experiencing homelessness, living in rural communities, or lack reliable access to transportation. Others may involve policy or regulatory impediments that limit or slow the deployment of an intervention. Legal systems pose particular challenges, as evidence-based treatments are often not the standard of practice in prisons and jails.
Stigma contributes to these barriers. Indeed, despite the well-established effectiveness of medications for treating OUD, only a fraction of people with OUD receives them, partly because they have long been stigmatized within health care and even within the addiction treatment world. Other barriers may be the result of discrimination or systemic racism and may require both a systemic intervention and a rebuilding of trust with the affected groups. For example, while the OUD medications buprenorphine and methadone are equally effective, Black and Hispanic/Latinx people are more likely to receive daily at-clinic methadone while white people are more likely to receive oral at-home buprenorphine, a racial inequity that contributes to significant health disparities in treatment and recovery. NIDA is supporting projects to study ways to help underserved populations by connecting individuals to care, with approaches ranging from utilizing telemedicine to leveraging partnerships with schools, legal systems, community organizations, and others.
In addition, even when services are available, they are often fractured. Research demonstrates that people who receive continuity of care (i.e., quality care over time), such as supportive services beyond initial treatment, have better outcomes. Yet, continuity of care is not standard practice, and barriers exist in terms of lack of standard models and insurance reimbursement. It is vital that we establish standards and models of care that meet the evidence needs of payors. This will require development of close partnerships with the Substance Abuse and Mental Health Services Administration, the Centers for Medicare and Medicaid Services, and insurance companies to ensure that measures of success can be tied to reimbursement practices.
Key Focus Areas
- Evaluate policies for enhancing access to SUD treatment that were implemented during the COVID-19 pandemic, such as increased telemedicine and take-home doses of medications to treat OUD.
- Test the implementation of telemedicine-based approaches and digital technologies for expanding the reach of effective SUD treatment.
- Develop strategies for overcoming barriers to delivering preventive care and treatment for individuals with SUDs and HIV and other infectious illnesses.
- Support research on the effects of racial inequity, cultural differences, and social structures on health disparities in SUD care, and develop tools for ameliorating these disparities.
- Develop interventions to reduce the stigma that impedes access to health care for people with SUDs and co-occurring conditions.
- Goal 4.3: Support research to scale up the application of evidence-based interventions for SUDs, including in justice settings
While effective interventions exist, they are underutilized, not implemented across settings, and not always implemented with fidelity. To reduce drug use and addiction and to address patients’ other health needs, it is crucial to scale up science-based interventions and extend their reach. NIDA’s implementation science portfolio includes studying ways to improve the effectiveness of SUD screening and the quality of treatment in real-life settings, as well as approaches to increase acceptance and adoption of systems-, structural-, and provider-level interventions. For example, NIDA’s Clinical Trials Network supports research on ways to optimize and expand access to current treatments for OUD; the Justice Community Opioid Innovation Network tests approaches to expand effective OUD treatment in justice settings; and the HEALing Communities Study is evaluating the implementation of community-based interventions for reducing opioid overdose deaths (see callout box below, “Testing and Implementing Evidence-Based Strategies in Diverse Settings”).
A critical component of implementing and sustaining effective interventions is sufficient reimbursement via health insurance or public payment. NIDA supports economic research to demonstrate the added value of novel interventions, research on the impact of insurance coverage and benefit design, and research on other aspects of financing on the quality, utilization, and outcomes of interventions. Continued scientific advancement in these areas will be needed to promote the efficient delivery of care, as new interventions are found efficacious and as novel financing mechanisms are developed. Another key issue affecting effective implementation is understanding which interventions work best for which patients, the intensity of services needed for each patient, and when it might be safe and appropriate to consider stepping down or discontinuing treatment. Such knowledge could enhance patient-centered care, prevent overdoses, and improve the efficiency of care delivery.
Testing and Implementing Evidence-Based Strategies in Diverse Settings
Effectively providing services across health care, legal, and community settings is key to addressing SUDs and is the most promising way to improve access to treatment. NIDA provides major infrastructure for research in these settings through our Clinical Trials Network (CTN), Justice Community Opioid Innovation Network (JCOIN), and HEALing Communities Study.
NIDA’s CTN allows medical and specialty treatment providers, treatment researchers, patients, and NIDA to cooperatively develop, validate, refine, and deliver new treatment options to patients. The CTN comprises 16 research nodes across the country in academic medical centers and large health care networks, and more than 240 community-anchored treatment programs. The CTN is conducting studies to evaluate strategies for integrating OUD screening and treatment into emergency departments, primary care clinics, infectious disease programs, and rural and American Indian/Alaska Native communities. It tests alternative models of care for SUDs, such as the use of pharmacies for delivering medication for OUD and the integration of digital tools to support and facilitate treatment. The CTN also leverages big health care data (e.g., electronic health record systems data) to create new clinical decision support tools.
NIDA’s JCOIN, funded through the NIH HEAL Initiative®, is testing strategies to expand effective OUD treatment and care for people in justice settings in partnership with local and state justice systems and community-based treatment providers. JCOIN includes a national survey of addiction treatment delivery services within justice systems; studies on the effectiveness and adoption of new medications, prevention and treatment interventions, and technologies; use of existing data sources in novel ways to understand SUD care in justice settings; and research on COVID-19 testing protocols in carceral settings where the risk of SARS-CoV-2 transmission is high. JCOIN is generating real-world data to inform policies and practices to reduce opioid use upon re-entry, a significant risk factor for overdose and a major predictor of reinvolvement with the legal system.
The HEALing Communities Study, also funded through the NIH HEAL Initiative®, is implementing coordinated approaches, tailored to the needs of local communities, to prevent and treat opioid misuse and OUD. Research sites are partnering with 67 communities highly affected by the opioid crisis in four states to measure the impact of these efforts and reduce opioid-related overdose. The HEALing Communities study includes a diverse communications campaign to increase awareness and demand for evidence-based practices and to reduce stigma against people with OUD and those taking medications for OUD.
Key Focus Areas
- Determine the effectiveness of evidence-based interventions for treating OUD and preventing opioid overdose implemented in medical, justice, and community settings.
- Build capacity to conduct addiction treatment research in legal- and community-based service settings.
- Develop approaches for scaling up effective harm reduction strategies.
- Encourage efforts to develop the addiction treatment and research workforce across practice settings.
- Develop and evaluate approaches to address barriers to SUD treatment uptake, access, and sustainability.
- Inform and assess the effects of novel coverage, benefit, and other financing strategies designed to improve care quality, access, and delivery.
- Conduct research to determine individual characteristics that predict outcomes associated with various OUD treatments.