Improving medication access within integrated treatment for individuals with co-occurring disorders in substance use treatment agencies

BACKGROUND: The best approach to provide comprehensive care for individuals with co-occurring disorders (CODs) related to substance use and mental health is to address both disorders through an integrated treatment approach. However, only 25% of behavioral health agencies offer integrated care and <7% of individuals who need integrated treatment receive it. A project used a cluster-randomized waitlist control group design to evaluate the effectiveness of network for the improvement of addiction treatment (NIATx) implementation strategies to improve access to addiction and psychotropic medications. METHODS: This study represents a secondary analysis of data from the NIATx project. Forty-nine agencies were randomized to Cohort1 (active implementation group, receiving the NIATx strategy [n = 25]) or Cohort2 (waitlist control group [n = 24]). Data were collected at three time points (Baseline, Year1, and Year2). A two-level (patient within an agency) multinomial logistic regression model investigated the effects of implementation strategy condition on one of four medication outcomes: both medication types, only psychotropic medication, only addiction medication, or neither medication type. A per-protocol analysis included time, NIATx fidelity, and agency focus as predictors. RESULTS: The intent-to-treat analysis found a statistically significant change in access to addiction versus neither medication, but Cohort1 compared to Cohort2 at Year 1 showed no differences. Changes were associated with the experimental intervention and occurred in the transition from Year1 to Year2, where greater increases were seen for agencies in Cohort2 versus Cohort1. The per-protocol analysis showed increased access to both medications and addiction medications from pre- to post-intervention for agencies in both cohorts; however, differences in change between high- and low-implementation agencies were not significant. CONCLUSIONS: Access to integrated services for people with CODs is a long-standing problem. NIATx implementation strategies had limited effectiveness in improving medication access for individuals with CODs. Implementation strategy adherence is associated with increased medication access. PLAIN LANGUAGE SUMMARY: Individuals with co-occurring substance use and psychiatric disorders face significant challenges in receiving care. With only 25% of behavioral health organizations offering integrated substance use and mental health services, it is not surprising that only 7% of individuals with a co-occurring disorder (COD) receive integrated care. The use of implementation strategies including feedback reports, external coaching, and in-person learning can provide staff with the necessary skills to implement changes in their organization. In this study, staff in addiction treatment agencies provided comprehensive assessments and treatment plans that targeted patients’ CODs, using proven implementation strategies. Results found that the application of these strategies increased patient access to addiction medications and their access to both addiction and psychotropic medications for their CODs. Higher implementation strategy adherence appears to be associated with improved access to addiction medications or both addiction and psychotropic medications but not psychotropic medications exclusively. Implementation researchers and addiction treatment agencies have evidence that implementation strategies can be utilized to improve access to medications as part of integrated treatment for individuals with CODs. However, additional research is needed to understand how adherence and fidelity to the implementation strategies are associated with more significant improvements. In addition, the results from this study raise questions as to whether efforts to improve access to psychotropic medications or addiction and psychotropic medications take longer to implement in addiction treatment agencies that do not typically provide integrated treatment for individuals with CODs.