Collaboration Leading to Addiction Treatment and Recovery from Other Stresses (CLARO): process of adapting collaborative care for co-occurring opioid use and mental disorders

Abstract

Background: Opioid use disorders (OUD), co-occurring with either depression and/or PTSD, are prevalent, burdensome, and often receive little or low-quality care. Collaborative care is a service delivery intervention that uses a team-based model to improve treatment access, quality, and outcomes in primary care patients, but has not been evaluated for co-occurring OUD and mental health disorders. To address this treatment and quality gap, we adapted collaborative care for co-occurring OUD and mental health disorders.

Methods: Our adapted model is called Collaboration Leading to Addiction Treatment and Recovery from Other Stresses (CLARO). We used the five-step Map of Adaptation Process (McKleroy in AIDS Educ Prev 18:59-73, 2006) to develop the model. For each step, our stakeholder team of research and clinical experts, primary care partners, and patients provided input into adaptation processes (e.g., adaptation team meetings, clinic partner feedback, patient interviews and beta-testing). To document each adaptation and our decision-making process, we used the Framework for Reporting Adaptations and Modifications-Enhanced (Wiltsey Stirman in Implement Sci 14:1-10, 2019).

Results: We documented 12 planned fidelity-consistent adaptations to collaborative care, including a mix of content, context, and training/evaluation modifications intended to improve fit with the patient population (co-occurring disorders) or the New Mexico setting (low-resource clinics in health professional shortage areas). Examples of documented adaptations include use of community health workers as care coordinators; an expanded consultant team to support task-shifting to community health workers; modified training protocols for Problem-Solving Therapy and Written Exposure Therapy to incorporate examples of treating patients for depression or PTSD with co-occurring OUD; and having care coordinators screen for patients' social needs.

Conclusions: We completed the first three steps of the Map of Adaptation Process, resulting in a variety of adaptations that we believe will make collaborative care more acceptable and feasible in treating co-occurring OUD and mental health disorders. Future steps include evaluating the effectiveness of CLARO and documenting reactive and/or planned adaptations to the model that occur during its implementation and delivery. Trial registration NCT04559893, NCT04634279. Registered 08 September 2020, https://clinicaltrials.gov/ct2/show/NCT04559893.

Keywords: Adaptation; Collaborative care; Community health workers; Depression; Opioid use disorder; Post-traumatic stress disorder; Primary care behavioral health.

Fig. 1

Summary of Adaptation Processes for the CLARO Intervention. CLARO: Collaboration Leading to Addiction Treatment and Recovery from Other Stresses. The five steps shown are from the Map of Adaptation Process [1]. Recursive arrows indicate the potential to revisit earlier steps as adaptation proceeds

Fig. 2

Summary of Codes in the Framework for Reporting Adaptations and Modifications – Enhanced (FRAME) Coding System. This figure is adapted from Fig. 1 in Wiltsey-Stirman et al. [2]. The original article was distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided appropriate credit is given and any changes are noted. Our figure is a simplified version of the original, and our figure includes a new code we added for this project (Collaborative Care components)

Fig. 3

Overview of the Adapted CLARO Collaborative Care Model. CLARO: Collaboration Leading to Addiction Treatment and Recovery from Other Stresses; CC: Care Coordinator. Figure is adapted from the NIH Helping to End Addiction Long-Term (HEAL) Initiative^SM

Fig. 4

Summary of Goodness-of-Fit Considerations Identified in Map of Adaptation Process, Step 1: Assess Context. Based on the Map of Adaptation Process [1]. OUD: opioid use disorder; MDD: major depressive disorder; PTSD: post-traumatic stress disorder; FQHC: Federally Qualified Health Center; UNM: University of New Mexico