Evaluation of a community-based education, navigation, and support (CENS) intervention to reduce opioid-related harms among military veterans

摘要 美国的退伍军人是受当前危机影响最严重的人群之一。 鸦片危机由于历史上受伤率和阿片类镇痛药用于治疗慢性疼痛的比例很高，退伍军人 在艾滋病流行的最初几年，广泛使用阿片类药物（通常与苯二氮卓类药物一起使用）， 从那以后，阿片类药物过量和HIV/HCV感染的风险增加。此外，目前的数据 关于影响退伍军人的阿片类药物相关危害的研究可能低估了情况的严重性，因为大多数研究 的退伍军人集中在不到50%的退伍军人谁使用VA医疗保健设施。使用阿片类药物的退伍军人 没有连接到VA医疗保健系统的人无家可归的比率很高， 共病物质使用障碍和心理健康诊断的患病率高于他们的“服务连接” 同行由于这些脆弱性和观察到的退伍军人检测和治疗障碍- 特别是物质和精神健康相关的耻辱，药物天真，和有限的支持网络-退伍军人 使用阿片类药物的人是旨在减轻过量和HIV/HCV风险的干预措施的关键目标 行为。对于在社会上孤立的退伍军人和获得医疗保健机会有限的退伍军人， 在正规医疗机构和机构之外，迫切需要。本申请建议 促进对预防阿片类药物相关危害的最有效和最有效方法的科学理解， 通过实现以下目标的退伍军人：1）评估同行交付的，以社区为基础的 教育，导航和支持（CENS）干预，以减少阿片类药物相关的风险行为; 2）检查 介导的因素（例如，知识，自我效能，自我耻辱）和中度（例如，心理健康，疼痛/OUD 严重程度，年龄）干预的有效性;和3）探索干预参与者和同伴外展工作人员 执行的观点以及干预措施有效性的障碍和促进因素。的 建议的干预措施将由三名经验丰富的同行外展工作者提供， 三个主要干预部分（教育、导航和支持）。这项研究将招募300名退伍军人 阿片类药物使用障碍参与随机对照试验。联合国安理会的干预将涉及150 参与正在进行的教育课程、医疗保健和治疗导航以及社会支持 （包括一对一和小组社会融合协议）旨在提高自我效能，减少 自我污名，增加服务和医疗保健利用率，并加强知识。这项研究有助于 一个及时的，文化上量身定制的创新，以过量和艾滋病毒/丙型肝炎病毒预防照常，由 三元影响理论，直接面对阿片类药物的社会，内在和结构层面的障碍， 降低退伍军人的相关风险。研究结果将引起社区和公民的极大兴趣， 提供过量和HIV/HCV风险降低外展的医疗保健组织，以及机构 致力于改善退伍军人的医疗保健参与。

Abstract Military veterans in the U.S. represent one of the populations most disproportionately impacted by the current opioid crisis. With historically high rates of injury and opioid analgesic use to treat chronic pain, veterans were widely prescribed opioids (often in conjunction with benzodiazepines) during the early years of the epidemic, and have been at elevated risk of opioid-related overdose and HIV/HCV infection since. Further, current data on opioid-related harms affecting veterans are likely to understate the severity of the situation, as most studies of veterans focus on the less than 50% of veterans who use VA healthcare facilities. Veterans who use opioids and are not connected to the VA healthcare system have high rates of homelessness and experience higher prevalence of comorbid substance use disorder and mental health diagnoses than their “service-connected” counterparts. Due to these vulnerabilities and the observed barriers to testing and treatment among veterans— especially substance- and mental health-related stigma, drug naiveté, and limited support networks—veterans who use opioids represent a critical target for interventions designed to mitigate overdose and HIV/HCV risk behaviors. For socially isolated veterans and veterans with limited access to healthcare, programs that work outside of formal healthcare institutions and agencies are desperately needed. This application proposes to advance scientific understanding of the most potent and efficient way to prevent opioid-related harms among veterans by achieving the following Aims: 1) Evaluate the effectiveness of a peer-delivered, community-based education, navigation and support (CENS) intervention to reduce opioid-related risk behaviors; 2) Examine factors that mediate (e.g., knowledge, self-efficacy, self-stigma) and moderate (e.g., mental health, pain/OUD severity, age) intervention effectiveness; and 3) Explore intervention participants’ and peer outreach staff perspectives on implementation as well as barriers to and facilitators of intervention effectiveness. The proposed intervention will be delivered by three veteran peer outreach workers—one dedicated to each of the three main intervention components (Education, Navigation, and Support). The study will recruit 300 veterans with opioid use disorder to participate in a randomized controlled trial. The CENS intervention will engage 150 participants in ongoing educational sessions, healthcare and treatment navigation, and social support (involving both one-on-one and group social integration protocols) designed to improve self-efficacy, reduce self-stigma, increase service and healthcare utilization, and bolster knowledge. This study stands to contribute a timely, culturally-tailored innovation to overdose and HIV/HCV prevention-as-usual that, informed by the theory of triadic influence, directly confronts the social, intrapersonal, and structural-level barriers to opioid- related risk reduction among veterans. Study findings will be of great interest to community-based and civic healthcare organizations that provide overdose and HIV/HCV risk reduction outreach, as well as to agencies committed to improving healthcare engagement among veterans.