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

摘要 美国退伍军人是受当前气候变化影响最大的人群之一 阿片类药物危机。由于伤害率和使用阿片类止痛药治疗慢性疼痛的历史最高水平，退伍军人 流行初期广泛使用的阿片类药物(通常与苯二氮卓类药物联合使用)， 自那以后，与阿片类药物相关的过量服药和艾滋病毒/丙型肝炎病毒感染的风险一直在上升。此外，当前数据 关于影响退伍军人的阿片类药物相关伤害，可能会低估情况的严重性，因为大多数研究 的退伍军人集中在使用退伍军人保健设施的不到50%的退伍军人身上。使用阿片类药物的退伍军人 没有连接到退伍军人管理局医疗系统的人无家可归率高，体验到的情况也更多 共病物质使用障碍和精神健康诊断的患病率高于与服务有关的疾病 对口单位。由于这些脆弱性，以及在退伍军人中观察到的检测和治疗障碍- 尤其是与物质和精神健康有关的污名、毒品幼稚和有限的支持网络--退伍军人 使用阿片类药物的世卫组织是旨在减少过量用药和艾滋病毒/丙型肝炎病毒风险的干预措施的关键目标 行为。对于社会孤立的退伍军人和获得医疗保健机会有限的退伍军人，有效的计划 正规医疗保健以外的机构和机构是迫切需要的。此应用程序建议 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 退伍军人通过实现以下目标：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危险行为；2)检查 中介因素(如知识、自我效能感、自我羞辱)和中等因素(如心理健康、痛苦/抑郁 严重性、年龄)干预效果；以及3)探索干预参与者和同伴外展工作人员 关于实施的观点，以及干预实效的障碍和促进者。这个 建议的干预将由三名经验丰富的同伴外展工作者提供-一名专门负责 三个主要干预组件(教育、导航和支持)。这项研究将招募300名退伍军人 有阿片类药物使用障碍的患者参加随机对照试验。CENS的干预将有150人参与 持续教育课程、医疗保健和治疗导航以及社会支持的参与者 (涉及一对一和团体社会融合协议)旨在提高自我效能，减少 自我羞辱，提高服务和医疗保健利用率，并增强知识。这项研究将对 一项及时的、文化上量身定做的创新，以应对吸毒过量和预防艾滋病毒/丙型肝炎病毒/丙型肝炎病毒的正常情况，由 三元影响力理论直接面对阿片类药物的社会、个人和结构层面的障碍- 减少退伍军人的相关风险。研究结果将对以社区为基础的社区和公民非常感兴趣 提供过量用药和减少艾滋病毒/丙型肝炎病毒风险外展的医疗保健组织以及机构 致力于提高退伍军人的医疗参与度。

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.