An intervention that teaches patients in addiction treatment how to better connect with their primary care medical team on both mental and physical health concerns resulted in long-term benefits over 5 years, including more primary care use and fewer substance-related emergency department visits, Kaiser Permanente researchers have found.

The study, published in JAMA Network Open on November 10, was a 5-year follow-up of the LINKAGE trial, which studied 503 patients of a Kaiser Permanente outpatient addiction clinic in San Francisco between 2011 and 2013. The LINKAGE trial compared outcomes for patients who received the patient activation training with others who did not.

Patients with substance use disorder tend to have more physical and mental health problems than people without the disorder, said study lead author Esti Iturralde, Ph.D., a research scientist with the Kaiser Permanente Division of Research.

"These patients have relatively high rates of early mortality and chronic illnesses and tend to use emergency care rather than preventive services," Iturralde said. "This intervention was designed to help them better connect with primary care, to give them the skills and confidence to advocate for themselves in the health care system."

The intervention is provided in 6 group sessions led by a behavioral health professional. Participants learn strategies for communicating with clinicians, how to use the electronic patient portal, and how to set recovery- and health-related goals. LINKAGE participants also have a facilitated phone call or email exchange with their primary care provider to strengthen their partnership.

The results of the original LINKAGE trial were published in a 2016 JAMA Psychiatry study that reported positive short-term benefits to patients, such as greater use of the online patient portal, more abstinence from substance use, and greater likelihood of talking with a primary care provider about substance use.

This 5-year follow-up, using patient data through 2018, found patients who received the intervention were more likely to use primary care and less likely to go to the emergency department with a substance-related problem.

Kaiser Permanente has recently begun offering the intervention to patients in its addiction medicine and recovery service programs in Northern California, said Asma Asyyed, MD, chair of addiction medicine and recovery services in Northern California. "I have lost patients not from their drug addiction, but from health conditions that they neglected, perhaps because of their drug addiction," she said.

"If we can educate and encourage patients to maintain a relationship with their primary care physician and team, they are more likely to access preventive care and manage health issues before they become life-threatening. We now have evidence that this intervention program helps patients manage their health holistically."

Overcoming stigma

The patient activation curriculum was developed by a team led by Division of Research investigators Stacy Sterling, DrPH, MSW, and Constance Weisner, DrPH, MSW. It has also been adapted for virtual use as part of patients' outpatient addiction treatment.

One important skill taught during the intervention is how to get past the real or perceived stigma of being in addiction treatment, said Sarah F. Cunningham, PsyD, who manages the LINKAGE intervention program.

"Many of our patients have told us they feel it's hard to engage in medical care or preventive care because of the stigma that's often associated with substance use disorders," she said. "Some have said it's been life-changing to have a supportive place where they can share experiences they have had in the medical system and create a plan to move forward and address medical or mental health symptoms that have been affecting them for a long time."

Better managing overall health can also reduce the chance of a substance use relapse, Cunningham said.

Iturralde said it was gratifying that the study found long-term benefits from helping patients learn to manage their health and engage with the healthcare system. "I was happy to see lasting effects from a relatively brief intervention that takes place over six weeks," Iturralde said. "It really makes a difference to activate patients, to give them tools they can use for the rest of their lives."