Commentary on Cochran et al: Meeting people where they are in addictions research

Abstract

In addiction treatment, it’s important to ‘meet people where they are’. However, in research, we commonly ask participants to meet us where we are in the interventions we develop. Cochran et al. report on a patient navigation intervention for pregnant and postpartum people with opioid use disorder. Their study illustrates a delicate balance reached between the research need to maximize scientific rigor and the clinical need to ‘meet people where they are’.

If you work in a substance use disorder (SUD) treatment setting, you likely hear the phrase “it’s important to meet people where they are.” Most SUD professionals will attest that, after walking alongside the people they serve on their treatment and recovery journeys, the importance of prioritizing person-centered, compassionate care approaches quickly becomes clear. However, in addictions research, there remains a gap where the interventions we develop and study are commonly the reverse, where we ask participants to meet us where we are. Cochran et al. report on feasibility and preliminary effectiveness of a patient navigation intervention for pregnant and postpartum people with opioid use disorder (OUD) (1). Their study illustrates a delicate balance reached between the research need to maximize scientific rigor and the clinical need to ‘meet people where they are’. This commentary discusses how these investigators narrowed the gap between research priorities and person-centered care, offering pearls for SUD researchers desiring for their findings to be translatable into real-world clinical settings.

Adjunctive behavioral therapies and psychosocial services are common in medication for OUD (MOUD) treatment settings (2). However, existing findings are inconsistent that these additions improve clinical outcomes (3). A likely contributor to these inconsistencies is how adjunctive interventions to MOUD are commonly implemented without intentional tailoring to the patients’ biopsychosocial needs (4). This ‘one size fits all’ approach compromises our ability to translate new treatments into clinical care for high-risk subgroups. Focusing on pregnant and postpartum people with OUD, the patient navigation intervention tested by Cochran et al. was designed to prioritize adaptability to patients’ needs, in lieu of prioritizing an evaluation of outcomes among patients adapting themselves to an intervention’s design. For example, navigators were given resources to deliver a set number of intervention sessions in the prenatal and postnatal settings, yet they were allowed to also ‘meet people where they are’ between these sessions and individually tailor these contacts to participants’ preferences. This added adaptability is unique for a research protocol, as maintaining consistency and intervention fidelity are highly important. The navigation arm was compared to usual care which received case management services typical of an outpatient clinic setting. These services were likely delivered by well-trained, compassionate, high-quality individuals (i.e., social worker). However, these services still were rendered to participants within the constraints (and inherent biases) of the healthcare system, rather than within the sociocultural context of the individual patient. The overall positive findings should encourage SUD researchers to be creative in the design of their next study protocols – such as with the addition of individualization options and less of a ‘one size fits all’ approach.

Many adjunctive interventions to MOUD are also implemented with good intentions to improve patient outcomes, yet their prior design and development did not adequately incorporate the patient perspective. In this preliminary effectiveness trial, investigators recognized this potential pitfall for their patient population of pregnant and postpartum people (who have unique needs and preferences) and incorporated into their evaluation opportunities to capture the patient perspective. As an example, the authors did not a priori state what number of completed navigator sessions would be categorized as a positive outcome; instead, they designed their statistical analysis to explore utilization patterns to allow participants’ data to identify the acceptable number of sessions (to inform future trials’ outcome definitions). Further, participants were not required to complete a pre-set number of sessions, and participants were not removed from the study if they did not complete navigator sessions. Harm reduction (5) and ‘meeting people where they are’ approaches in SUD treatment (6) are effective strategies, including in the perinatal period; a kitchen sink approach where patients are required to engage in certain services does not achieve better outcomes than offering evidence-based treatments while allowing patients to have a voice in what they will utilize. This study’s high research assessment completion rates, especially their 87% follow-up at 6-months postnatal, are notable in this context. Their successful balance of scientific rigor with person-centeredness should be encouraging to investigators seeking to be better at ‘meeting people where they are’ in research.

MOUD are life-saving, with optimal treatment benefits gained with longer MOUD durations, including in the postpartum period (7). However, patient-level outcomes vary tremendously, especially for individuals facing social determinants (8). These poor outcomes leave individuals at persistent overdose risk, exacerbating disparities in OUD-related morbidity and mortality (9). As the authors point out, while efforts in the U.S. aimed at increasing MOUD access continue, we simultaneously need to prioritize the development and dissemination of evidence-based approaches to improve the quality of OUD treatments, especially for the priority population of pregnant and postpartum people. Findings from Cochran et al emphasize how we can achieve this goal by taking a step back and relying on our core strength as addiction clinicians and researchers to ‘meet people where they are’ while simultaneously generating high-quality data to advance clinical care in the ongoing overdose crisis.