Peer-Delivered, Behavioral Activation Intervention to Improve Polysubstance Use and Retention in Mobile Telemedicine OUD Treatment in an Underserved, Rural Area

同伴提供的行为激活干预可改善服务不足的农村地区移动远程医疗 OUD 治疗中多物质的使用和保留

• 批准号: 10578063
• 负责人: Sarah M. Kattakuzhy
• 金额: $ 235.79万
• 依托单位: UNIV OF MARYLAND, COLLEGE PARK
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-09-30 至 2025-09-29
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10578063
• 关键词: Abstinence; Address; Adherence; Adoption; Appointment; Area; Behavior Therapy; Behavioral; Buprenorphine; Caring; Communities; Effectiveness; Environment; Evidence based intervention; Health; Health Care Sector; Health Personnel; Individual; Intake; Intervention; Lead; Left; Maryland; Medical; Medically Underserved Area; Methods; Modeling; Nurses; Outcome; Patients; Persons; Pharmaceutical Preparations; Pharmacy facility; Population; Positive Reinforcements; Proctor framework; Professional counselor; Provider; Psychological reinforcement; Randomized; Reach Effectiveness Adoption Implementation and Maintenance; Recovery; Recovery Support; Resources; Rewards; Rural; Rural Community; Rural Population; Services; Site; Specialist; Substance Use Disorder; Telemedicine; Training; Urinalysis; Work; acceptability and feasibility; addiction; base; community setting; contingency management; cost; cost effectiveness; design; economic value; effectiveness evaluation; effectiveness implementation study; effectiveness implementation trial; effectiveness outcome; experience; free behavior; implementation cost; implementation evaluation; implementation outcomes; improved; non-opioid analgesic; opioid overdose; opioid use; opioid use disorder; peer; peer support; polysubstance use; primary outcome; provider-level barriers; rural America; rural area; rural counties; rural underserved; stimulant use; stimulant use disorder; substance use; treatment as usual; treatment services; underserved area; underserved rural area; urban area; virtual; waiver

Background. More than 50% of rural counties in the US do not have a single buprenorphine-waived provider, and approximately 10% of people in the US live more than 10 miles away from their nearest prescriber. Compounding the devastating effects of the opioid use disorder (OUD) crisis in underserved, rural areas is increasing polysubstance use, notably stimulant use disorder co-occurring with OUD. Since 2019, our team has filled a void of rural addiction treatment practitioners in underserved rural Maryland areas by providing buprenorphine for OUD treatment with the use of telemedicine (TM) aboard a mobile treatment unit (MTU). Our team has demonstrated the effectiveness of the TM-MTU model in reducing opioid use by 32.8% at three- months. Yet, 92% of patients in the past year presented with polysubstance use at intake, approximately half with OUD and stimulant use. Further, treatment retention is a challenge, amplified by polysubstance use; less than 60% of patients were retained at three-months. Reinforcement-based approaches, such as contingency management, have empirical support for improving treatment retention and stimulant use, yet have low adoption in community settings due to organizational and provider barriers, including cost. A behavioral reinforcement-based approach, such as behavioral activation (BA), which aims to increase positive reinforcement through rewarding, substance-free behaviors, may be a promising effective and sustainable strategy to improve both OUD treatment retention and polysubstance use, particularly stimulant use. Further, our team has demonstrated that it is feasible to train peer recovery specialists (PRSs) in BA. Preliminary Studies. This proposal builds upon our team’s prior studies demonstrating the feasibility, acceptability, and effectiveness of: 1) the TM-MTU model reaching rural communities hard hit by the OUD crisis and polysubstance use; 2) integrating PRS support on the TM-MTU; and 3) a PRS-delivered BA intervention (“Peer Activate”) for improving treatment retention and reducing polysubstance use, including OUD and stimulant use. Approach. Building upon this work, we propose a randomized Type 1 hybrid effectiveness-implementation trial (n=180) to evaluate the PRS-delivered BA intervention on the MTU (Peer Activate-MTU) compared to enhanced treatment as usual (ETAU; facilitated referrals and general peer support) on the following over 12- months: (1) effectiveness outcomes: a) OUD treatment retention (primary: chart review of appointment attendance); b) polysubstance use (co-primary: urinalysis of co-occurring use of ≥2 substances); and c) buprenorphine adherence (secondary: urinalysis and pharmacy refill); (2) implementation outcomes, including feasibility, acceptability, fidelity, and adoption guided by RE-AIM; (3) cost of implementing and sustaining Peer Activate-MTU and its economic value relative to ETAU. Implications. This proposal is designed to lead to a potentially scalable model for improving OUD treatment retention and polysubstance use, particularly co- occurring OUD and stimulant use, and increasing the reach of addiction treatment in underserved, rural areas.

背景 美国超过 50% 的农村县没有一家免除丁丙诺啡的提供者， 大约 10% 的美国人居住地距离最近的处方医生超过 10 英里。 阿片类药物使用障碍 (OUD) 危机对服务不足的农村地区造成的破坏性影响更加严重 自 2019 年以来，我们的团队发现，多物质使用不断增加，值得注意的是，兴奋剂使用障碍与 OUD 并存。 通过提供服务，填补了马里兰州服务不足的农村地区农村成瘾治疗治疗师的空白 丁丙诺啡通过我们的移动治疗装置 (MTU) 上的远程医疗 (TM) 进行 OUD 治疗。 团队证明了 TM-MTU 模型在三小时内将阿片类药物使用量减少 32.8% 的有效性 然而，去年有 92% 的患者在摄入药物时出现过使用多种物质的情况。 一半是使用 OUD 和兴奋剂。此外，治疗保留是一个挑战，而多物质的使用则加剧了这一挑战； 不到 60% 的患者坚持使用基于强化的方法，例如。 应急管理，有改善治疗保留和兴奋剂使用的经验支持，但 由于组织和提供商的障碍（包括成本），社区环境中的采用率较低。 基于行为强化的方法，例如行为激活（BA），旨在增加积极性 通过奖励性的、无物质的行为进行强化，可能是一种有前景、有效且可持续的方法。 改善 OUD 治疗保留和多物质使用（特别是兴奋剂使用）的策略。 我们的团队已经证明在 BA 中培训同伴恢复专家 (PRS) 是可行的。 研究。该提案建立在我们团队之前的研究基础上，证明了可行性、可接受性和有效性。 有效性：1) TM-MTU 模式覆盖受 OUD 危机重创的农村社区，以及 多物质使用；2) 在 TM-MTU 上集成 PRS 支持；以及 3) PRS 提供的 BA 干预（“Peer”） 激活”）以改善治疗保留并减少多物质使用，包括 OUD 和兴奋剂的使用。 在此工作的基础上，我们提出了一项随机 1 类混合有效性实施试验。 (n=180) 评估 PRS 提供的 BA 对 MTU (Peer Activate-MTU) 的干预，与 对以下超过 12 种情况照常加强治疗（ETAU；便利转诊和一般同伴支持） 月数：(1) 有效性结果：a) OUD 治疗保留（主要：预约图表审查 b) 多种物质使用（共同主要：同时使用 ≥2 种物质的尿液分析）； 丁丙诺啡依从性（次要：尿液分析和药房补充）；（2）实施结果，包括 RE-AIM 指导下的可行性、可接受性、忠诚度和采用率 (3) 实施和维持 Peer 的成本； Activate-MTU 及其对 ETAU 的相对经济价值。 用于改善 OUD 处理保留和多物质使用的潜在可扩展模型，特别是共同 发生 OUD 和兴奋剂使用，并扩大服务不足的农村地区的成瘾治疗范围。