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New $12.3 million NIMH grant explores MISSION recovery model for opioid addiction and mental illness

By Susan E.W. Spencer

UMass Chan Medical School Communications

October 18, 2021

A research team led by David Smelson, PsyD, professor of psychiatry and director of the Center of Excellence in Addiction, was awarded a $12.3 million, four-year grant from the National Institutes of Health to study components of a multidisciplinary team-based, wrap-around treatment program for adults with opioid use disorders and co-occurring mental illness.

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David Smelson, PsyD

The program model, Maintaining Independence and Sobriety through Systems Integration, Outreach and Networking, or MISSION, combines three evidence-based practices: dual recovery therapy, an integrated group therapy approach for co-occurring disorders; peer support, a recovery approach delivered by people with lived experience; and critical time intervention, a form of assertive community treatment that connects clients with housing, employment and other support resources to help them promote their own recovery. Clients will be offered six months of MISSION treatment, delivered by a case manager and peer specialist team, along with medications for opioid use disorder.

MISSION has been shown to be effective in individuals with addiction and mental illness, along with special populations that include veterans, people who are homeless and those in the criminal justice system, according to Dr. Smelson. But the model requires implementation support and specific financing mechanisms because of its complex cross-disciplinary structure.

The focus of the new grant, Supporting Treatment Access and Recovery for Opioid Use Disorders, is to assess whether it is possible to do effective and efficient, less-intensive community intervention combined with medication-assisted opioid use disorder treatment. The grant is funded by the National Institute of Mental Health through the Helping to End Addiction Long-term Initiative, or NIH HEAL Initiative.

“In many ways, this is the culmination of 25 years of work we have done on the MISSION model,” said Smelson.

Opioid use disorder afflicts more than 2 million people in the United States. Approximately 50 percent of these people have a co-occurring mental health disorder, and yet only half of those received treatment for their co-occurring disorders, Smelson explained. Individuals with co-occurring disorders are vulnerable to repeated substance use relapses, mental illness exacerbations, overdoses, homelessness and criminal justice involvement.

“We developed MISSION 25 years ago to bring services to people in the community, rather than for people to have to come to a hospital or community mental health center to receive services. And specifically for people who have a co-occurring mental health disorder and opioid addiction, they tend to have a hard time engaging in care, particularly at the beginning of care,” he said. “In our model, we link people, and we deliver treatment ourselves during a critical, vulnerable time, up to six months.”

The new study plans to enroll 1,000 patients from 11 sites across Massachusetts, with the first enrollees starting by Dec. 16.

Smelson said a critical piece to launching the study is to hire 23 new staff, including case managers and peer support specialists before Dec. 1. Job opportunities can be found at UMass Chan Medical School’s Center of Excellence in Addiction, or by emailing David.Smelson@umassmed.edu.

Participants will be randomly assigned to one of five arms: 1) medication-assisted treatment (buprenorphine) alone; 2) full MISSION (critical time intervention, dual-recovery therapy and peer support) plus medication-assisted treatment; 3) critical time intervention and dual-recovery therapy, plus medication-assisted treatment; 4) dual-recovery therapy and peer support, plus medication-assisted treatment; and 5) critical time intervention and peer support, plus medication-assisted treatment.

Researchers will assess the effectiveness of MISSION or its bundled parts with medication-assisted treatment versus medication alone, and the incremental benefits of its components. They will also examine how treatment participation and other measures are mediated by the various MISSION components and they will conduct a comprehensive economic evaluation of MISSION or its bundled components and medication-assisted treatment.

In addition, researchers hope to construct a predictive model that can match optimum combined use of MISSION parts with specific patients’ needs for greater improvements in health outcomes.

“We believe this will get us a step closer to personalized behavioral health care where we’ll know which clients, and which parts of the multicomponent intervention could be most effective; and then we’ll deploy that part of the intervention for those clients,” Smelson said.

Partners in the study include UMass Lowell, University of Texas at Austin, Harvard University and Yale University. The study also includes collaborations with the Massachusetts Department of Public Health and MassHealth, the state’s Medicaid program.

In addition to Smelson, co-principal investigators include Gerardo Gonzalez-Haddad, MD, associate professor of psychiatry; and Wenjun Li, PhD, professor of public health at UMass Lowell and adjunct professor of medicine at UMass Chan. Co-investigators are Kimberly Yonkers, MD, the Katz Family Chair in Psychiatry and chair and professor of psychiatry; Todd Olmstead, PhD, associate professor of public affairs at University of Texas at Austin; Paige Shaffer, MPH, instructor in psychiatry; Ayorkor Gaba, PsyD, assistant professor of psychiatry; Elizabeth Epstein, PhD, professor of psychiatry; and Dan Berlowitz, MD, MPH, chair and professor of public health at UMass Lowell.

The Helping to End Addiction Long-term Initiative, or NIH HEAL Initiative, is an aggressive NIH effort to speed scientific solutions to stem the national opioid public health crisis. Launched in 2018, the initiative is focused on improving prevention and treatment strategies for opioid misuse and addiction and enhancing pain management. For more information, visit https://heal.nih.gov.