Using telehealth to expand treatment access for Veterans with opioid use disorder

影响：拟议的研究涉及关键的VHA和HSR&D优先事项，以改善阿片类药物的获得 通过开发和试点测试一种新的远程保健治疗交付干预，使用障碍(OUD)治疗。 背景：随着阿片类药物在全国的流行，退伍军人中的OUD流行率增加，许多 患有过敏症的退伍军人会受到严重的、可预防的伤害，包括服药过量和自杀。渐增 获得治疗，特别是丁丙诺啡药物，可以帮助防止这些伤害。然而， 只有三分之一患有抑郁症的退伍军人接受循证治疗。最大的准入障碍是缺乏 VHA设施中训练有素的丁丙诺啡提供者，有助于特别低的治疗 退伍军人在社区门诊接受治疗。远程医疗干预一直是 在退伍军人管理局开发，允许退伍军人医疗中心的专家为CBOCs的退伍军人提供治疗，但 关于远程保健治疗物质使用障碍的研究很少。几个退伍军人管理局设施，包括 VA Ann Arbor Healthcare System已经开始使用远程医疗来提供OUD治疗，但研究表明 需要告知可跨设施扩展的远程医疗模式，检查对治疗使用的影响， 并确定远程医疗的目标位置，以最大限度地发挥影响。所述方法和序列具有 旨在通过以下3个目标解决这些紧迫问题： 目标1：将在四个机构与患者和临床医生进行半结构化访谈，包括 VA Ann Arbor Healthcare System，已经开始使用远程医疗向#年的退伍军人提供治疗 CBOCs，以了解其干预措施的组成部分、对治疗的看法以及障碍和促进者 来使用。受这些定性调查结果的启发，德尔福的一个专家小组，包括一线供应商，将 帮助改进远程医疗干预措施，该干预措施可以在所有设施中可行，并将在AIM 2中进行试点测试。 目的2：在一项试点试验中，患有OUD的CBOC退伍军人将随机接受远程健康OUD干预 目标1组(n=20)或面对面治疗组(n=20)。这项研究将探讨可行性和 可接受性结合了调查数据和对参与者和研究临床医生的定性访谈 在3个月的随访中描述治疗参与度、保留率和药物使用结果。 目标3：使用具有OUD的CBOC退伍军人的全国VHA数据，分析将检查与以下因素相关的因素 OUD治疗中患者和设施水平的变化，以了解需要治疗的区域。分析将 还要检查丁丙诺啡提供者能力和远程保健使用方面的设施水平变化。这些发现将 确定与治疗需求相关的关键患者和设施级别因素，并指明哪些患者和 应优先考虑CBOC的远程医疗。 候选人：PI的长期目标是以她的成瘾临床和研究背景为基础，成为 领导退伍军人健康服务研究人员开发和评估干预措施，以改善治疗和 患有OUD和其他物质使用障碍的退伍军人的结果。PI将在以下方面获得培训：1)混合 方法，2)随机干预试验，3)实施科学和4)多水平建模。使用一个 优秀的指导团队和关键的运营合作伙伴，在这个CDA的研究和培训将使她能够 启动一系列研究，开发和评估有效和可获得的干预措施，以 改善患有OUD和其他物质使用障碍的退伍军人的结局。

Impacts: The proposed research addresses a critical VHA and HSR&D priority to improve access to opioid use disorder (OUD) treatment by developing and pilot testing a novel telehealth treatment delivery intervention. Background: With the national opioid epidemic, OUD prevalence in Veterans has increased and many Veterans with OUD experience serious and preventable harms including overdose and suicide. Increasing access to treatment, especially with the medication buprenorphine, can help prevent these harms. However, only a third of Veterans with OUD receive evidence-based treatment. The biggest access barrier is lack of trained buprenorphine providers on-site across VHA facilities, contributing to particularly low treatment for Veterans receiving care in Community-Based Outpatient Clinics (CBOCs). Telehealth interventions have been developed in the VA to allow specialists in VA Medical Centers to deliver treatment to Veterans in CBOCs, but minimal research has been done on telehealth for substance use disorders. A few VA facilities, including the VA Ann Arbor Healthcare System have begun to use telehealth to deliver OUD treatment, but research is needed to inform a telehealth model that can be scalable across facilities, examine impact on treatment use, and determine where telehealth should be targeted to maximize impact. The methods and sequence have been designed to address these pressing questions in the following 3 aims: Aim 1: Semi-structured interviews will be conducted with patients and clinicians in four facilities, including the VA Ann Arbor Healthcare System, that have begun to use telehealth delivery of OUD treatment to Veterans in CBOCs, to understand components of their interventions, perceptions of treatment and barriers and facilitators to use. Informed by these qualitative findings, a Delphi panel of OUD experts, including frontline providers, will help refine a telehealth intervention that can be feasible across facilities and will be pilot tested in Aim 2. Aim 2: In a pilot trial, CBOC Veterans with OUD will be randomized to the telehealth OUD intervention refined in Aim 1 (n=20) or in-person OUD treatment as usual (n=20). The study will examine feasibility and acceptability incorporating survey data and qualitative interviews with participants and study clinicians and characterize treatment engagement, retention and substance-use outcomes over 3 month followup. Aim 3: Using national VHA data of CBOC Veterans with OUD, analyses will examine factors associated with patient and facility-level variation in OUD treatment to understand areas where treatment is need. Analyses will also examine facility level variation in buprenorphine provider capacity and telehealth use. These findings will identify key patient and facility-level factors associated with treatment need and indicate which patients and CBOCs should be prioritized for telehealth. Candidate: The PI's long-term goal is to build on her addiction clinical and research background to become a leading VA health services researcher developing and evaluating interventions to improve treatment and outcomes for Veterans with OUD and other substance use disorders. The PI will gain training in: 1) mixed methods, 2) randomized intervention trials, 3) implementation science and 4) multi-level modeling. With a stellar mentorship team and key operational partners, the research and training in this CDA will allow her to launch a long trajectory of research developing and evaluating effective and accessible interventions to improve outcomes for Veterans with OUD and other substance use disorders.