Abstract
Objectives:
Patients with opioid use disorder (OUD) are increasingly being hospitalized for acute medical illnesses. Despite initiation of medications for OUD (MOUD), many discontinue treatment after discharge. To evaluate whether a psychosocial intervention can improve MOUD retention after hospitalization, we conducted a pilot randomized controlled trial of a peer recovery coach intervention.
Methods:
An existing peer recovery coach intervention was adapted for this trial. Hospitalized adults with OUD receiving MOUD treatment were randomized to receive either a recovery coach intervention or treatment-as-usual. For those in the intervention arm, the coach guided the participant to complete a relapse prevention plan, maintained contact throughout the 6-month follow-up period, encouraged MOUD continuation, and helped to identify community resources. Those receiving treatment-as-usual were discharged with a referral to outpatient treatment. Primary outcome was retention in MOUD treatment at 6 months. Secondary outcomes were the proportion of participants readmitted to the hospital, and the number of days until treatment discontinuation and to hospital re-admission.
Results:
Twenty-five individuals who provided consent and randomized to the recovery coach intervention (n=13) or treatment-as-usual (n=12) were included in the analysis. No significant differences were found in the proportion of participants retained in MOUD treatment at 6-months (38.5% vs 41.7%, p=0.87), proportion of participants readmitted at 6-months (46.2% vs 41.2%, p=0.82), or the time to treatment discontinuation (logrank p=0.92) or readmission (logrank p=0.85).
Conclusions:
This pilot trial failed to demonstrate that a recovery coach intervention improved MOUD treatment retention compared to treatment-as-usual among hospitalized individuals with OUD.
Keywords: opioid use disorder, peer recovery coach, buprenorphine, methadone
Introduction
Individuals with opioid use disorder (OUD) are increasingly hospitalized to treat acute medical illnesses, often complications of injecting drugs.1 While hospital teams can treat such complications, the underlying OUD often goes unaddressed. To address this need, some hospitals have implemented addiction consultation services staffed by addiction specialists to aid hospital teams, including to initiate MOUD.2,3 Unfortunately, a significant proportion of patients who initiate MOUD in the hospital will discontinue treatment within 6 months.4,5 Therefore, interventions to support patients during the transition from the hospital into the community are needed.
Peer recovery coaches are individuals in sustained recovery who help mentor and support individuals in recovery.6,7 The evidence-base in support of recovery coaches is growing, but research is limited on their impact on MOUD treatment retention.8 Therefore, we conducted a pilot randomized controlled trial of a peer recovery coach intervention in improving MOUD treatment retention following hospitalization.
Materials and Methods
The study was a 6-month, pilot randomized trial, approved by the Mass General Brigham (MGB) Institutional Review Board, registered (NCT03212794), and conducted between September 2018 and December 2021. Adults with OUD hospitalized for any admission diagnosis, either newly initiating MOUD or receiving MOUD for less than 6 months prior to admission, were considered for enrollment. Eligible participants were those who anticipated continuation of MOUD following discharge and possessed a telephone. Exclusion criteria was the inability to provide consent for any reason. After obtaining consent, participants were randomly assigned to either the peer recovery coach intervention or treatment-as-usual (Figure 1). Study follow-ups occurred remotely 1, 3, and 6 months after discharge.
The Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking (MISSION) model9 was adapted for this trial. MISSISON is an evidence-based intervention developed to specifically meet the needs of individuals with co-occurring mental health and substance use disorders. The coach for the trial was in sustained recovery, completed 40 hours of training sponsored by the State’s Bureau of Substance Abuse Services to be certified as a Certified Addictions Recovery Coach (CARC), and received training to deliver the intervention. The coach guided participants in completing a personalized relapse prevention plan. Following discharge, the coach facilitated discussions about recovery, encouraged MOUD continuation, and helped to identify recovery resources. Outreach to participants was expected to occur regularly, but the coach had great flexibility in changing the frequency of contact based on participant need. Outreach using telephone calls and text messaging were used due to the COVID-19 pandemic and if the location of the participant was too distant. The coach maintained a treatment fidelity log. As part of routine clinical care, all participants regardless of intervention assignment were referred for addiction consultation. Those in treatment-as-usual received no further support following discharge.
Primary outcome was retention in MOUD treatment at 6 months after discharge. Retention was confirmed in the electronic health records or via collateral contacts if available. If lost to follow-up, the participant was deemed to have discontinued MOUD treatment as of last known contact. Secondary outcomes were the proportion experiencing hospital readmission and ED visit at 6 months, and the number of days until MOUD treatment discontinuation and to hospital readmission or ED visit.
Analyses were conducted using STATA (College Station, TX: StataCorp LLC). An intention-to-treat analysis was employed such that all participants randomized were included in the analysis regardless of intervention fidelity. Chi-square compared the proportions retained in MOUD treatment and readmitted at 6-months. Logrank test compared the survival outcomes. A two-sided p-value of 0.05 or less was considered statistically significant. Proportion of participants completing the personalized relapse prevention plan, use of workbook, and the frequency of contact with the coach were summarized. Post-hoc, sensitivity analyses were conducted to control for statistically significant differences in participant characteristics using Cox proportional hazards regression, as well as assessing for association between treatment fidelity and the primary outcome.
Results
Participant characteristics are summarized in Table 1. Of the 27 individuals randomized, two were excluded (one individual never received the intervention due to an unanticipated prolonged inpatient stay and the other was discovered to be ineligible after enrollment). There were significantly more participants who were Hispanic (30.8% vs 0, p=0.036), had a history of depression (92.3% vs 58.3%, p=0.047) and had a tobacco use disorder (92.3% vs 58.3%, p=0.047) in the intervention arm. The coach successfully contacted participants on average 9.6 times (SD 9.0, range 1-26) during the trial. About half (45.5%) completed a personalized relapse prevention plan, and 21.4% utilized the workbook.
Table 1:
Summary of participant characteristics
| Variable | Total (n=25) |
Intervention
group (n=13) |
Treatment-as-
usual (n=12) |
p |
|---|---|---|---|---|
| Age, mean years (SD) | 42.8 (12.2) | 39.7 (10.1) | 46.1 (13.7) | 0.20 |
| Male sex, n (%) | 17 (68.0%) | 9 (69.2%) | 8 (66.7%) | 0.89 |
| Race, n (%) | ||||
| White | 18 (72.0%) | 8 (61.5%) | 10 (83.3%) | 0.21 |
| Black | 3 (12.0%) | 1 (7.7%) | 2 (16.7%) | |
| Native American | 1 (4.0%) | 1 (7.7%) | 0 (0.0%) | |
| Other | 3 (12.0%) | 3 (23.1%) | 0 (0.0%) | |
| Ethnicity, n (%) | ||||
| Hispanic | 4 (16.0%) | 4 (30.8%) | 0 (0.0%) | 0.036 |
| Non-Hispanic | 21 (84.0%) | 9 (69.2%) | 12 (100.0%) | |
| Education, highest level completed, n (%) | ||||
| Primary school | 6 (24.0%) | 2 (15.4%) | 4 (33.3%) | 0.29 |
| Secondary school | 19 (76.0%) | 11 (84.6%) | 8 (66.7%) | |
| Marital status | ||||
| Divorced/single/widowed | 18 (72.0%) | 9 (69.2%) | 9 (75.0%) | 0.75 |
| Married/living as a couple | 7 (28.0%) | 4 (30.8%) | 3 (25.0%) | |
| Work, unemployed, n (%) | 16 (64.0%) | 9 (69.2%) | 7 (58.3%) | 0.57 |
| Housing status, homeless, n (%) | 16 (64.0%) | 7 (53.4%) | 9 (75.0%) | 0.27 |
| Psychiatric history, n (%) | ||||
| Major depressive disorder | 19 (76.0%) | 12 (92.3%) | 7 (58.3%) | 0.047 |
| Bipolar disorder | 4 (16.0%) | 1 (7.7%) | 3 (25.0%) | 0.24 |
| ADHD | 7 (28.0%) | 4 (30.8%) | 3 (25.0%) | 0.75 |
| Anxiety disorder | 11 (44.0%) | 6 (46.2%) | 5 (41.7%) | 0.82 |
| PTSD | 12 (48.0%) | 7 (53.8%) | 5 (41.7%) | 0.54 |
| Substance history, n (%) | ||||
| Opioid use disorder | 25 (100.0%) | 13 (100.0%) | 12 (100.0%) | - |
| Tobacco use disorder | 19 (76.0%) | 12 (92.3%) | 7 (58.3%) | 0.047 |
| Cocaine use disorder | 17 (68.0%) | 9 (69.2%) | 8 (66.7%) | 0.89 |
| Amphetamine use disorder | 6 (24.0%) | 5 (38.5%) | 1 (8.3%) | 0.08 |
| Cannabis use disorder | 8 (32.0%) | 4 (30.8%) | 4 (33.3%) | 0.89 |
| Alcohol use disorder | 12 (48.0%) | 7 (53.8%) | 5 (41.7%) | 0.54 |
| Sedative/hypnotic use disorder | 6 (24.0%) | 4 (30.8%) | 2 (16.7%) | 0.41 |
| Linkage to care after hospitalization, n (%) | ||||
| Any community program | 20 (80.0%) | 11 (84.6%) | 9 (75.0%) | 0.55 |
| Our hospital’s Bridge Clinic | 15 (60%) | 7 (53.9%) | 8 (66.7%) | 0.51 |
| MOUD choice | ||||
| Buprenorphine | 13 (52.0%) | 8 (61.5%) | 5 (41.7%) | 0.32 |
| methadone | 12 (48.0%) | 5 (38.5%) | 7 (58.3%) |
ADHD=Attention deficit hyperactivity disorder; PTSD=Post-traumatic stress disorder
No significant difference was found in the proportion of participants who remained in MOUD treatment at 6 months (38.5% vs 41.7%, p=0.87). No significant differences were found in the proportion of participants readmitted (46.2% vs 41.2%, p=0.82) or visited the ED (53.9% vs 50.0%, p=0.85) at 6 months. No significant differences were found in the time to treatment discontinuation (logrank p=0.92), hospital readmission (logrank p=0.85), or ED visit (logrank p=0.71). Post-hoc, controlling for significant differences in baseline characteristics did not change the results for either primary or secondary outcomes. There were no associations between the primary outcome and the frequency of the contact, the proportion completing a relapse prevention plan, or the proportion utilizing the workbook.
Discussion
This pilot study failed to demonstrate greater MOUD treatment retention at 6 months following hospital discharge for those assigned to the recovery coach intervention. Although this study was designed to provide preliminary evidence for a larger study, there was not a suggestion that the intervention improved the target outcomes. These results add to the growing body of investigations demonstrating limited support for psychosocial interventions in improving MOUD-related outcomes.8,10 While evidence supports recovery coaches’ impact on increasing MOUD initiation, few studies have examined their impact on MOUD treatment retention.11-15 In an implementation study of an emergency department (ED)-based buprenorphine initiation program that included peer support, the majority (59%) of individuals with OUD who initiated buprenorphine in the ED remained in treatment at 30 days.11 In another implementation study that included peer recovery coaches in a multi-component intervention to increase MOUD initiation, 43% of those initiating buprenorphine remained in treatment at 30 days.13 However, neither of these studies evaluated the impact of the recovery coach intervention alone, nor did they include a control group.
There are several limitations to this study. This was a pilot study with a small sample size, and caution is warranted in interpreting these findings. All participants received an addiction consultation by specialists, making it difficult to generalize findings to hospitals without such a service. After 6 months of initiating the trial, the hospital launched a low-barrier, low-threshold “bridge” clinic that provided MOUD treatment and recovery coach support, potentially diluting the impact of the intervention. Additionally, in-person contact with the coach was more limited than initially planned due to the COVID-19 pandemic. While we made every effort to objectively ascertain MOUD treatment retention and illicit opioid use, we relied on self-report when medical records were not available.
This pilot trial failed to demonstrate that a recovery coach intervention improved MOUD treatment retention at 6 months compared to treatment-as-usual among hospitalized individuals with OUD. Future studies may need to include a more intensive intervention than what a recovery coach can provide alone, or conduct an adequately powered trial with a larger sample size.
Funding:
This work was supported by the National Institute on Drug Abuse [K23DA042326 (JS)]
Footnotes
Conflicts of interest: Dr. Weiss has consulted to Analgesic Solutions, Wayland, MA, ACI Clinical, Bala Cynwyd, PA, and Alkermes, Inc., Waltham, MA. All other authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.
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