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

影响：拟议的研究解决了关键的VHA和HSR&D优先事项，以改善阿片类药物的可及性 通过开发和试点测试一种新的远程保健治疗提供干预措施，对使用障碍（OUD）进行治疗。 背景：随着全国阿片类药物的流行，退伍军人的OUD患病率增加，许多 患有OUD的退伍军人经历严重和可预防的伤害，包括过量和自杀。增加 获得治疗，特别是使用丁丙诺啡药物，可以帮助预防这些伤害。然而，在这方面， 只有三分之一的退伍军人接受循证治疗。最大的障碍是缺乏 在VHA设施中现场培训丁丙诺啡提供者，导致治疗率特别低， 退伍军人在社区门诊诊所（CBOCs）接受护理。远程保健干预措施已成为 在VA开发，允许VA医疗中心的专家为CBOC的退伍军人提供治疗，但 对药物使用障碍的远程保健进行的研究极少。一些VA设施，包括 VA安阿伯医疗保健系统已经开始使用远程医疗来提供OUD治疗，但研究还不够。 需要告知一个可以跨设施扩展的远程医疗模式，检查对治疗使用的影响， 并确定远程保健应针对哪些领域以最大限度地发挥影响。方法和顺序具有 旨在通过以下三个目标解决这些紧迫问题： 目标1：将对四个机构的患者和临床医生进行半结构化访谈，包括 弗吉尼亚州安阿伯医疗保健系统，已开始使用远程医疗提供的OUD治疗的退伍军人， CBOC，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 使用.根据这些定性研究结果，包括一线供应商在内的德尔菲OUD专家小组将 帮助完善远程保健干预措施，使其在各设施之间都可行，并将在目标2中进行试点测试。 目标2：在一项试点试验中，患有OUD的CBOC退伍军人将被随机分配到远程医疗OUD干预中 目标1（n=20）或常规OUD治疗（n=20）。该研究将审查可行性， 可接受性，包括调查数据和对参与者和研究临床医生的定性访谈， 描述3个月随访期间的治疗参与、保留和药物使用结局。 目标3：使用患有OUD的CBOC退伍军人的国家VHA数据，分析将检查与 OUD治疗中患者和机构水平变化，以了解需要治疗的区域。分析将 还审查了丁丙诺啡提供者能力和远程保健使用方面的设施水平差异。这些发现将 确定与治疗需求相关的关键患者和设施因素，并指出哪些患者和 远程保健应优先考虑社区组织中心。 候选人：PI的长期目标是建立在她的成瘾临床和研究背景，成为一个 领先的VA卫生服务研究人员开发和评估干预措施，以改善治疗和 OUD和其他物质使用障碍的退伍军人的结果。PI将获得以下方面的培训：1）混合 方法，2）随机干预试验，3）实施科学和4）多层次建模。与 优秀的导师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 开展长期研究，制定和评估有效和可获得的干预措施， 改善患有OUD和其他物质使用障碍的退伍军人的预后。

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.