Implementation to motivate physician response to opioid dependence in HIVsetting

描述(申请人提供)：我国正处于阿片类药物过量死亡的流行之中。艾滋病毒携带者(PLWH)中阿片类药物的普遍使用，以及苯二氮卓类药物的普遍使用，导致了PLW中阿片类药物过量的高比率。3理想情况下，艾滋病毒医生将提供有效的基于办公室的阿片类药物治疗(OBOT)，以减少药物使用和过量死亡率，4-6但艾滋病毒医生一直不愿采用丁丙诺啡/纳洛酮(Bup/NX)。7目前的研究表明，多年来一直与艾滋病相关死亡作斗争的艾滋病毒医生将发现，通过纳洛酮处方(NXP)预防过量死亡更有说服力，更容易培训，更简单。8从恩智浦开始，目前的项目将利用学术细节和动机访谈(MI)来鼓励艾滋病毒医生接受在办公室BUP/NX治疗原发病(阿片成瘾)方面发挥更大作用。在阶梯式楔形设计中，拟议的研究将在20个艾滋病毒实践环境中实施恩智浦和OBOT，这些环境接受瑞安·怀特的资助；治疗成年人；拥有4名或更多处方医生；拥有电子医疗记录(EMR)；以及来自全国阿片类药物过量死亡排名前一半的州。这项实施将在三个9个月的阶段中，在随机挑选的符合条件的做法中按顺序推出。实施战略将包括(1)1.5小时的现场点对点培训，提供继续医学教育学分，重点是通过恩智浦拯救生命，并介绍办公室可用药物在其办公室治疗原发病(阿片成瘾)的想法；(2)为医生和实践提供专家指导和技术支持；(3)在最初培训后1、3、5和7个月由接受MI培训的临床医生进行学术详细说明； 以及(4)药剂师与当地药房进行对等接触，以确保药物可用。实施科学得出的主要结果将是从调查9、18和27个月后的积极实施阶段以及在9个月的随访中开出纳洛酮和Bup/NX的可行性、可接受性、就绪性和意向；临床医生开纳洛酮和Bup/NX(即摄取)的数量；以及EMR数据中开出纳洛酮或Bup/NX(即渗透率)的患者数量。形成性评价将在定性访谈中审查执行促进者和障碍。HIV门诊实践很有希望实施纳洛酮减少过量和Bup/NX治疗阿片类药物使用障碍。利用点对点的医生培训、积极的专家支持、激励访谈的学术细节和药房推广，这项创新的建议将利用“拯救生命”的主要价值，在艾滋病毒医生中实施纳洛酮处方，并增加他们采用基于办公室的Bup/NX治疗的动力。

DESCRIPTION (provided by applicant): Our nation is in the midst of an epidemic of opioid overdose deaths. The common use of opioids among persons living with HIV (PLWH), along with their common use of benzodiazepines, has resulted in high rates of opioid overdose among PLWH.3 Ideally, HIV physicians would provide effective office-based opioid treatment (OBOT) to reduce drug use and overdose mortality,4-6 but HIV physicians have been reluctant to adopt buprenorphine/naloxone (Bup/Nx).7 The current study posits that HIV physicians, who have been battling AIDS-related mortality for years, will find prevention of overdose death through naloxone prescription (NxP) more compelling, more trainable and less complex.8 Beginning with NxP, the current project will utilize academic detailing with motivational interviewing (MI) to encourage HIV physicians to accept a larger role in treating the primary disease (opioid addiction) with office-based Bup/Nx. In a stepped wedge design, the proposed study will implement NxP and OBOT in 20 HIV practice settings that receive Ryan White Funding; treat adults; have 4 or more prescribers; have an electronic medical record (EMR); and come from states in the top half nationally for opioid overdose deaths. The implementation will roll-out sequentially among randomly-selected eligible practices in three 9-month phases. The implementation strategy will include (1) a 1.5-hour, onsite peer-to-peer training with continuing medical education credits provided that will focus on saving lives through NxP and introduce the idea that office-based medication is available to treat the primary disease (opioid addiction) in their office; (2) expert mentoring and technical support for the physicians and practice; (3) academic detailing by a clinician trained in MI at 1, 3, 5 and 7 months after the initial training; and (4) pharmacist peer-to-peer outreach to local pharmacies to ensure that the medications are available. Primary outcomes drawn from implementation science will be feasibility, acceptability, readiness and intent to prescribe naloxone and Bup/Nx from surveys 9, 18, and 27 months into the active implementation phase, and at nine month follow-up; number of clinicians prescribing naloxone and Bup/Nx (i.e. uptake); and number of patients prescribed naloxone or Bup/Nx (i.e. penetration) from EMR data. Formative evaluation will examine implementation facilitators and barriers in qualitative interviews. HIV outpatient practices are promising settins in which to implement naloxone to reduce overdose and Bup/Nx to treat opioid use disorders. Using peer-to-peer physician training, proactive expert support, academic detailing with motivational interviewing, and pharmacy outreach, this innovative proposal will leverage the primary value of "saving lives" to implement naloxone prescription among HIV physicians and increase their motivation to adopt office-based Bup/Nx treatment.