Transforming the recovery process for opioid use disorder

History of the opioid epidemic

The opioid epidemic emerged in the United States in the mid-1990s, having a significant impact on the population’s public health, economic, and social outcomes.¹ The crisis accelerated during the COVID-19 pandemic, leading to the highest number of drug-related overdoses on record, with nearly 70,000 fatal drug-related overdoses having involved an opioid in 2020.² As a result, the crisis has reached a tipping point, calling for more effective methods in which individuals struggling with opioid use disorder (OUD) can access treatment and recovery.

Innovative advances in opioid use disorder (OUD) treatments

Medications for opioid use disorder (MOUD) are a highly effective treatment for OUD. Studies show that after six months, individuals who utilize MOUD treatment experience decreased substance use, improved physical and mental health, and reduced symptoms.³

MOUD can also significantly reduce the risk of overdose and death. A recent study indicated that people with OUD were 82% less likely to die of an overdose when receiving MOUD, compared with those who were not receiving the treatment.⁴

The data on MOUD is so promising that it has inspired wide-sweeping changes now gaining momentum. The 2023 Consolidated Appropriations Act, signed into law by President Joe Biden on December 29, 2022, bypasses the requirement that qualified healthcare providers need to obtain a special waiver to prescribe MOUD.⁵  

Carelon Behavioral Health, in conjunction with the Connecticut Behavioral Health Partnership (CTBHP), is at the forefront of this response to the opioid epidemic. The CTBHP is an integrated behavioral health alliance between the Department of Children and Families (DCF), the Department of Social Services (DSS) and the Department of Mental Health and Addiction Services (DMHAS). Working together, they initiated the Changing Pathways model to promote MOUD utilization throughout the state for individuals struggling with OUD.

What is Changing Pathways?

Changing Pathways promotes the use of MOUD instead of the traditional withdrawal management known as detox. In-patient facilities and emergency departments (EDs) educate patients experiencing OUD on various treatment options. Patients can choose to begin MOUD immediately, rather than going through the traditional withdrawal management protocol.

Upon discharge, patients transfer to a community provider who continues the patients’ MOUD treatment. Changing Pathways’ goals are to increase adherence to treatment and connection to care, and to reduce readmissions and ED visits. Ultimately, the program strives to increase patients’ chances of recovery and to reduce their risk of overdose.

The Connecticut-based program began in 2018 with two initial withdrawal management pilot providers, expanding to in-patient psychiatry. The program originated with OUD, eventually expanding to other substance use disorders (SUDs).

Fast forward to 2023, Changing Pathways has expanded its model to EDs, and is in the process of implementing its model in residential facilities in Massachusetts and New York.

Changing Pathways in Massachusetts

Massachusetts American Society of Addiction Medicine (ASAM) 3.7 providers, in partnership with Carelon Behavioral Health, have embraced the Changing Pathways framework for several years. The state has also established a network of Community Behavioral Health Centers (CBHCs) and a 24/7 Behavioral Health Help Line (BHHL), both of which are overseen by Carelon teams, to connect people with mental health and substance use services in their communities.

The program also established MOUD and medications for addiction treatment (MAT) bridge clinics to link the treatment gap between EDs and continuing services. The clinics provide on-demand care to members at all stages of addiction who have a need for immediate access. In 2023, the state will include claims codes allowing EDs to submit claims for inducting members in the ED. This will be a significant step toward the Changing Pathways program expanding its framework and success.

The Massachusetts program also focuses on creating strong provider connections, including Memorandums of Understanding (MOUs) with EDs, hospitals, ASAM 3.7s and opioid treatment programs (OTPs).

Changing Pathways in New York

Changing Pathways in New York aims to increase providers’ and members’ awareness of MAT options, promote members’ MAT use during inpatient stays for OUD and alcohol use disorder (AUD) diagnoses, and enhance members’ MAT adherence. The program achieves these goals by utilizing peer specialists and case managers who provide members with warm handoffs to MAT providers at discharge.

The program also strives to improve members’ overall health and SUD outcomes by facilitating medical and psychiatric outpatient appointments after discharge. The goal is to reduce members’ emergency room utilization and inpatient admissions for mental and physical health needs.

How the program is transforming recovery

Changing Pathways increases patients’ access to the three medications that the Food and Drug Administration (FDA) has approved for OUD treatment: naltrexone, methadone, and buprenorphine.⁶ The program also promotes patient use of FDA-approved medications for AUD: naltrexone, acamprosate, and disulfiram.⁶

Since its inception in Connecticut, the program has seen a 32% increase in the number of members discharged from withdrawal management who successfully connected to a MOUD provider in the community. Individuals engaged in Changing Pathways also experienced a 2.5-times higher adherence rate when utilizing MOUD treatment than those not in the program.⁷

Peer counseling as a support piece

A peer is typically involved in the individual’s treatment process, which is a benefit the provider includes in the service. “Members are more likely to listen to peers than to doctors and nurses,” says Daniel Langless, Assistant Vice President, Network Management, Carelon Behavioral Health.

Peer engagement occurs after the patient goes through triage, when peers visit the individual in the in-patient facility and begin working together.

“The peer will stay engaged with the member, providing a warm handoff to the next level of care, which is typically after three days. However, the peer will continue to engage the member up until 90 days post discharge,” explains Langless.

Making a genuine connection

“We have a short window in which we can connect with a member,” emphasizes Mary Jo Capitani, Wellness and Recovery Specialist, Carelon Behavioral Health. “That first 48 hours is a critical window for the individual. The way we hand them off to the next level of care is one of the most important parts of the process.”

Building a relationship with the member on a sincere level is an important part of creating trust, and ultimately, the path to recovery. “We ask the member how we can best support their recovery, letting them decide what that will feel like. We learn about their living environment, their faith, their family, and their job. Their relationship to self is important. Our goal is to have them focus on what they need to maintain hope for treatment and recovery, while expressing empathy and enthusiasm,” Capitani adds.

Being an advocate

She explains how the peer provides crucial support for the member to return to the community and to have an aftercare plan. “We teach the member how to advocate for themselves. We connect them to community resources and groups, whether it’s special interest, faith based, or 12 step. Sometimes we can go with the member to the first few group meetings, if they need us to.”

Connecting with the provider side is another critical piece of the puzzle. “Peers need us to reach out to someone on the provider side, so that we can advocate for the member,” notes Capitani.

Data indicating promising results

Data indicates that individuals with OUD who engage in Changing Pathways tend to experience better outcomes. In a recent Carelon Behavioral Health study, within a 30-day period, 12.2% individuals in the Changing Pathways program experienced readmittance to an inpatient facility, compared with 24.2% individuals engaged in traditional withdrawal management.⁸

Furthermore, individuals were less likely to discharge against medical advice, more likely to connect to care, and more likely to continue taking their medications in the 90 days after discharge. Patients who continued taking their MOUD experienced fewer behavioral-health-related visits to EDs, with a 95% post-discharge MOUD adherence rate. They also experienced fewer inpatient days, withdrawal management episodes, and opioid overdoses, compared with the 90-day preadmission period.⁹

“This is promising data,” observes Dr. Kris Noam, PhD, MSc, Health Research Scientist, Carelon Behavioral Health. “We can eventually use it to build out predictive models. Over time, we will be able to include data from inpatient sites, EDs, and hospital systems for an even larger sample size.”

The data will help to create even better success rates from the program. “The data helps regional network managers when they go out into the field and share results. They can demonstrate outcome measures, help other providers see MOUD’s long-term benefits, and how individuals fare long term after having participated in treatment. Many providers do not have access to that kind of data,” Noam explains.

How do people find out about the program?

“People find out about Changing Pathways by word of mouth or through providers. Oftentimes providers will ask patients, ‘Are you familiar with this program?’” notes Langless.

Changing Pathways also has an educational component in which the Carelon Behavioral Health team reaches out to providers, presenting to the provider’s whole team, to get organizational buy-in.

How the program can be replicated

“Partnering with EDs, whenever possible, is a highly effective way of replicating the program,” explains Langless.

“We can help our partners expand the program without their having to duplicate efforts. Our data is convincing as opposed to anecdotal, in the way that we calculate adherence and initiation. We have evidence,” explains Noam.

How Changing Pathways makes a difference

“By effectively collaborating with our members, we play an important role in community,” emphasizes Capitani. “We leverage resources and connect with individuals on leveraging these resources. Staying involved as our members go through the recovery process is an opportunity to make a vital difference. This is the heart of what we do.”