Methadone Patient Access to Collaborative Treatment (MPACT)

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Methadone Patient Access to Collaborative Treatment (MPACT) is a staff-level trauma-informed practice change intervention for US opioid treatment programs (OTP). It is based on the theory that current OTP practice and culture likely contribute to the wide ranging methadone maintenance treatment (MMT) interruption (>30%) and relapse (>50%) rates known to increase opioid overdoses. OTP treatment culture has been described as “carceral,” and “not healthcare,” with patients reporting being bound to the clinic by required daily supervised medication dosing. Changes in OTP practices have been called for, but are recognized as ‘almost impossible.’ US federal regulatory flexibilities intended to facilitate OTP practice change during COVID did not result in wide-spread or sustained MMT delivery changes or service accommodations such as increased multi-day dosing for stable patients, less frequent urine analyses, or even telehealth. These accommodations would be highly beneficial to rural and home-bound patients. Evidence- based OTP practice change interventions are necessary if the US is going to effectively respond to the opioid overdose crisis. If this lifesaving treatment is available but not well used, we must look to the practice and culture of OTPs. Lack of practice change may be due to staff beliefs and experiences, including their own histories of substance use disorder treatment, traumatic experiences, and on-the-job exposure to vicarious trauma. When staff trauma is addressed, we expect OTP practice orientation will shift from punitive to harm-reduction/patient-centered. MPACT is designed to increase MMT retention and decrease in-treatment overdose and patient- and staff- reported posttraumatic stress symptoms (PTSS). MPACT has four evidence-based components: 1) a 4-module CME/CEU- accredited trauma-informed psychoeducation training program for OTP staff, 2) a trauma navigation model for patients and staff, 3) clinic trauma-informed care (TIC) self-assessment, and 4) separate reflective supervisory structures for counselors/case managers and medical providers. For this proposal, MPACT components will be adapted for OTP settings with patients and providers in a multilevel, trauma-informed planning process with guidance from the Arizona transdisciplinary Drug Policy Research and Advocacy Board comprised of methadone and buprenorphine providers, patients, people with lived/ing drug use experience, harm reduction NGOs, payers, trauma experts, and university researchers. MPACT will be finalized in year 1, pilot tested and refined in year 2, and tested in a cluster-randomized controlled intervention trial in OTP sites across the US in years 3-6. The primary means of gathering data are surveys pushed to staff and patients (baseline and monthly) and retrospective patient chart reviews. We enter a period of unprecedented regulatory change for MMT delivery. MPACT can facilitate and support MMT reform efforts that are planned or already in process. The future of OTPs and methadone treatment depend upon evidence-based OTP practice change interventions. The pivotal question is: Can OTPs adopt Trauma Informed Care (TIC) and, if so, does it improve patient outcomes? MPACT seeks to answer this question in a high risk/high reward proposal. If the answer is YES, then MPACT will be immediately implementable and scalable for any OTP in the US.