Promoting Health Equity Among People With Opioid Use Disorder and Serious Mental Illness Through the Chronic Disease Self-Management Program

Abstract

People with opioid use disorder (OUD) experience higher prevalence of serious mental illness (e.g., schizophrenia and bipolar disorder) and chronic disease (e.g., diabetes) relative to the general population, less access to high quality health care, and limited access to evidence-based treatments that promote self-management of chronic health conditions. The Chronic Disease Self-Management Program is a widely used patient education intervention that imparts disease knowledge and self-management skills to people with a range of medical conditions. In this Perspective Column, a multidisciplinary team of community-based researchers representing the fields of social work and addiction medicine argue that implementing the Chronic Disease Self-Management Program in a primary care environment is a promising way to build the self-management skills of people with OUD and co-occurring mental illness and chronic disease.

Introduction

Opioid use disorder (OUD) is defined as the chronic use of opioids that causes clinically significant distress or impairment ¹ and is characterized by loss of control of opioid use, compulsive use, and continued use despite harms. ² If untreated, OUD is associated with significant morbidity and mortality. While opioid misuse and overdose are global challenges, ³ the U.S. has experienced a uniquely severe opioid crisis, with higher rates of opioid misuse, addiction, and overdose deaths compared to other countries. ⁴ In the U.S., more than 100 000 people have been dying annually from drug overdoses, and 75% of such deaths involve opioids, ⁴ which has made opioid addiction and overdose the focus of national initiatives such as the National Institutes of Health’s Helping End Addiction Long-Term (HEAL) initiative. ⁵ People living with OUD also experience higher prevalence of physical ⁶ (e.g., diabetes, hypertension) and mental health comorbidities relative to the general population, ⁷ yet have limited access to evidence-based treatments that promote self-management of chronic care conditions, which adds to the increased morbidity and mortality of this population. In this Perspective article, an interdisciplinary team of community-based researchers representing the fields of social work (ES and LJC) and addiction medicine (AJG) review the physical and mental health and health care inequities among people with OUD and argue that implementing the Chronic Disease Self-Management Program in a primary care environment is a promising way to build the skills of people with OUD to self-manage their physical and mental health care needs and promote health equity in this population.

Mental and Physical Health Inequities Among People With Opioid Use Disorder

People with OUD experience increased prevalence of serious mental illness (SMI; e.g., schizophrenia, bipolar disorder), ⁸ with national data estimating that roughly 27% of persons with OUD have SMI, compared to 4% the general population. ⁹ Persons with OUD and SMI are also known to have more severe psychiatric symptoms and higher rates of hospitalization.

OUD also increases risk for significant physical health conditions^8,9 and for worse self-rated health and health-related quality of life compared to the general population. ¹⁰ Chronic diseases, such as hypertension, hyperlipidemia, and diabetes are also prevalent among those with OUD ¹¹ ; Research also indicates that having an OUD and 1 or more co-morbid health conditions also increases risk for social vulnerabilities including homelessness, which can increase risk for opioid overdose fatality, ¹² unemployment, ¹⁰ and justice involvement. ¹³ While the high co-occurrence of substance use disorders, SMI, and chronic disease has also been established, these inequities in mental and physical health among persons with OUD are especially problematic because they increase risk for opioid fatality ¹⁴ and for early mortality. ⁶

Many social determinants contribute to the inequities described above. A recent analysis of the U.S. National Survey on Drug Use and Health ¹⁵ identified barriers to accessing clinical supports for managing OUD, which include lack of affordability across insurance statuses, lack of access to OUD treatment programs, lack of readiness, stigma, and individuals not prioritizing treatment. ¹⁵ Service fragmentation (ie, when health care is delivered by multiple providers with limited care coordination) also undermines access to care that can support the management of OUD and other health conditions. ¹⁶ Service fragmentation can increase the time it takes to access care and requires skills for navigating across care sectors, while exacerbating transportation and insurance challenges. Notably, these barriers exist against a background of stigma and mistrust of medical institutions, ¹⁷ and contribute to racial and ethnic disparities in use of OUD treatment. ¹⁸

Health care quality is another social determinant that impacts the health of people with OUD. Research has documented substantial shortcomings in quality of care for persons with OUD and co-occurring chronic disease, when compared with the general population. ⁹ A study of US commercial insurance and Medicare Advantage claims compared healthcare outcomes between persons with and without OUD, reporting that those with OUD received lower quality care coordination, including less follow up for mental health needs and for chronic diseases, and a greater number of potentially avoidable hospitalizations. ⁹

Supporting Self-Management of People With Opioid Use Disorder

The concept of self-management consists of tasks that individuals must undertake to live well with 1 or more chronic conditions. These tasks include knowing how to confidently deal with medical management (e.g., taking medication and attending health appointments) role management (e.g., modifying or maintaining professional or family routines), and emotional management (e.g., anxiety or frustration) of their conditions. ¹⁹ For people living with OUD, self-management is a critical component of recovery and is needed to change deeply entrenched behaviors that have led to recurrent drug use. ²⁰ Self-management tasks related to OUD might include attending behavioral therapy appointments in conjunction with medical appointments where they might receive medication treatment for OUD (MOUD; formulations of buprenorphine, naltrexone, and methadone) and developing new personal relationships. ²⁰ The concept of self-management is at the heart of many person-centered interventions that aim to promote behavioral change, ²¹ and Self-Efficacy, or the belief in one’s ability to successfully perform a behavior, is at its foundation. ²²

Self-management tasks can become more complex as the number and severity of chronic conditions increases. Someone with a co-occurring serious mental illness, such as schizophrenia, would also need to manage psychiatric symptoms, while a person with a co-occurring chronic disease, such as diabetes, would also need to manage chronic disease symptoms and delay its progression. Someone with OUD, SMI, and chronic disease would need to manage all 3 conditions’ symptoms and care. This is a complex and time-consuming undertaking, and the social determinants described above can severely undermine an individual’s capacity to do so. Given the limited access to health resources for this population, patient education and other self-management skill-building opportunities that empower individuals to independently manage their own health are needed. However, persons with OUD have less access to resources that support the management of chronic diseases. ⁹

The Chronic Disease Self-Management Program

Several clinician-delivered therapeutic interventions aim to reduce emotional distress and unhealthy behaviors among people in mental health and addiction recovery. Cognitive Behavioral Therapy (CBT), ²³ Motivational Interviewing (MI), ²⁴ and Family Therapy ²⁵ are popular interventions that have been applied to substance use in general^25,26 and OUD specifically. ²⁷ CBT is based on the idea that psychological distress is influenced and maintained by negative or unhelpful thought patterns, ²³ while MI explores individual ambivalence related to behavioral change, ²⁸ and Family Therapy focuses on improving relationships and behavioral patterns within families. Mutual aid ²⁹ or “self-help” groups also support recovery from substance use or mental illness through sharing of experiences and coping strategies in a group format. While evidence indicates that these interventions can change an individual’s cognitions, behaviors, and support systems related to substance use and mental health recovery, they do not specifically grow the skillsets for managing multiple conditions combined with chronic disease.

Self-management programs aim to develop the skills that an individual needs to manage multiple healthcare conditions. These programs have been developed for persons with OUD, ³⁰ with SMI, ³¹ for persons with chronic disease, ³² and for persons that have combinations of SMI and Chronic Disease. ³³ To our knowledge, there are no existing programs that support the development of skills that can support self-management of these 3 conditions simultaneously.

The Chronic Disease Self-Management Program (CDSMP)^{34 -36} is a widely used patient education intervention that imparts disease knowledge and self-management skills to people with a range of medical conditions.^19,36 As described by Lorig et al, ³⁴ three assumptions are foundational to the CDSMP. First, patients with various chronic conditions share common self-management challenges and tasks (e.g., self-monitoring, communicating with health care providers, taking medication as prescribed). Second, patients can learn skills that empower them to “own” the day-to-day management of their chronic diseases. Third, skilled and empowered patients will demonstrate improved health and consume fewer health care resources. The notion that peer health educators (e.g., individuals with similar backgrounds and chronic disease challenges) can effectively deliver the program and would be accepted by both patients and by providers is also at the program’s foundation. ³⁴ The CDSMP has been implemented worldwide, and a body of research has documented its effectiveness for improving self-management skills, behavioral activation, and clinical outcomes in general medical populations.^32,34,35

The CDSMP is based on self-efficacy theory ²² and incorporates elements of skills mastery, modeling, problem solving, and social persuasion into each session.^19,36 The program itself consists of 6 weekly group sessions, and can be delivered either in person or virtually. Each session focuses on different skills needed to manage any chronic condition. Example session topics include fatigue and getting a good night’s sleep, dealing with difficult emotions, making decisions, making an action plan, medication usage, communication skills, and working with your health care team. CDSMP sessions are highly interactive; during each session participants are invited to develop an “action plan.” An action plan is a self-management tool through which participants break down a larger health-related goal into small and achievable tasks. For example, if an individual has the goal of improving fitness, an action plan could be to start an exercise program by walking for 10 minutes 2 to 3 times per week, or to simply identify a place (such as a community center) that offers exercise classes. Group accountability is also a feature of the CDSMP; at the start of each session, CDSMP participants take turns sharing whether they completed their action plan since the last meeting. In instances when participants are unable to complete their plan, the group is invited to brainstorm ideas for ways to complete it during the following week or to modify their action plan to make it more achievable.

Tailoring the Chronic Disease Self-Management Program for Persons With Opioid Use Disorder and Co-occurring Serious Mental Illness and Chronic Disease

The CDSMP has been successfully implemented across a wide range of cultural and clinical populations,^37,38 including those with SMI. ³³ To address potential cognitive impairment and the potential for low health literacy among persons with SMI, one study adjusted the program manual to a sixth grade reading level. ³⁹ Instead of the standard 6 weekly 2.5 hour sessions, another delivered weekly 60 to 75-minute sessions for 13 weeks. ⁴⁰ Studies of the CDSMP that have been adapted for persons with SMI, including randomized controlled trials, have reported improvements in disease management skills, health-related quality of life, and mental health recovery.^33,41

While OUD and other substance use disorders are frequently identified and managed in psychiatric or community mental health clinics alongside mental health needs, mental health providers are often challenged to care for the physical health needs of this clientele.^{42 -44} A primary care environment is well-suited to care for patients with mild to moderate OUD and chronic disease through a longitudinal chronic care model of treatment that can provide self-management support. ⁴⁵ Consistent with the Stepped Care model and Clinical Practice Guidelines in the Department of Veterans Affairs, guidelines issued by the American Society of Addiction Medicine and the Cascade Care model endorsed by the National Institute on Drug Abuse indicate that primary care environments are optimal for treating this population^46,47 Several national initiatives have demonstrated the feasibility and effectiveness of implementing OUD care within primary care environments, particularly with MOUD.^{47 -49} While primary care settings are more accessible and less stigmatized than addiction specialty services, primary care providers have few tools for supporting patients with OUD and additional comorbidities (such as SMI) in managing their health and social care complexities. Increasing the availability of evidence-based interventions that strengthen patient skills to manage their own health is a logical way to promote health equity. An updated tool kit from Agency for Health Care Research and Quality includes several suggestions for primary care settings that wish to expand resources to support patients in recovery from OUD, and notes that providers need support in meeting the needs of this patient population. ⁵⁰

While the CDSMP has improved the self-management skills of persons with multiple conditions ³³ and has been implemented in primary care, ³⁶ it has not been adapted for a primary care patient population with OUD that also experiences long-term psychiatric conditions. Modifications are likely needed to ensure that people with OUD and mental health needs benefit maximally from this intervention. For instance, adaptations for a patient population with OUD and SMI might include the addition of content related to mental health and addiction recovery, whereas the standard CDSMP’s includes minimal content related to these topics. CDSMP group facilitators might consider incorporating examples into their sessions that involve communication with multiple providers (e.g., addiction, mental health, and primary care), while leaving space for group members to discuss the impacts of OUD on mental health and physical health and vice versa. People with OUD and SMI are often challenged by housing stability and transportation, and group facilitators and participants might wish to spend time brainstorming on these topics, though the precise social needs of a given group will vary.

At the same time, understanding barriers and facilitators to delivering a CDSMP in a specific clinical setting is critical. However, considerations for implementing the CDSMP in diverse clinical or organizational settings has not been a focus in CDSMP research. ⁵¹ Other implementation considerations include program length and intensity, ⁵¹ provider understanding of the CDSMP’s complexity (ie, the intervention’s number of “moving parts”) or its potential adaptability to specific populations or environments, or organizational context including its state policy environment, a health system’s financing considerations, or any number unique logistical factors that might affect program implementation. Attending to these considerations stand to improve the program’s adoption and reach in real-world settings.

Attention to the specific needs of the target population and clinical environment is particularly important for ensuring the CDSMP’s relevance to a primary care patient population with OUD and SMI. However, a recent search in the U.S. National Library of Medicine ⁵² using the terms “opioid use disorder” and “chronic disease self-management” revealed no studies of CDSMPs for this population. While the CDSMP could improve self-management skills, health activation, and quality of life for this population, barriers such as limited relevance and lack of primary care provider familiarity with the intervention could undermine implementation in a primary care setting. That the CDSMP has not been adapted for this population or setting constitutes an implementation research gap that, left unaddressed, limits the transportability of a promising intervention.

A community-based approach to program adaptation could ensure that the CDSMP meets the needs of both primary care patients in recovery and their providers. For example, the Collaborative Intervention Planning Framework (CIPF) ⁵³ is a community-based intervention planning approach that leverages stakeholder and researcher expertise to ensure fit between an intervention, its target clientele, and an implementation site. It follows the principles of community-based participatory research and first involves creating a Community Advisory Board (CAB) with expertise on the patient population and study sites. Intervention adaptations are then developed through an “Intervention Mapping” process, which involves an analytical review of the intervention’s theoretical foundation, objectives, and fidelity specifications and results in a revised intervention and implementation plan.

Conclusions and Future Directions

People with OUD experience significant inequities in mental health and chronic disease burden relative to the general population. Increasing access to self-management skill building opportunities through the CDSMP is a promising way to improve patient activation in this population. However, implementing a CDSMP in a primary care setting will require significant collaboration between multiple stakeholders and actors, including primary care providers, researchers, and people with lived experience that can offer a patient perspective. Future studies are needed to contribute to the field’s understanding of how to best adapt the CDSMP to hone its relevance to primary care patients with OUD and SMI.