Integrating Treatment for Mental Disorders in Methadone Clinics in Ukraine

项目总结 乌克兰是一个深受阿片类药物使用障碍影响的中等收入国家。尽管阿片类激动剂疗法(OAT) 丁丙诺啡和美沙酮自2004年开始提供，但治疗结果受到一些患者、临床和结构层面障碍的破坏。目前，燕麦片是在精神病学的成瘾专科Narcology Center开的。尽管麻醉学家和精神病学家进行了类似的培训，但孤立和支离破碎的塞马什科苏联式医疗体系遗产导致OAT患者无法接受共生精神障碍(COD)的治疗，除非他们被转送到异地精神病中心。抑郁症严重到需要用一线选择性5-羟色胺再摄取抑制剂(SSRI)进行药物治疗，现在超过50%的燕麦患者，但只有11%的患者被诊断出来，1.2%的人开了SSRI处方。这在管理化学需氧量方面留下了相当大的改进空间。本申请寻求使用实施科学和PARIHS框架，通过引入改进的筛查、短暂干预和转诊到治疗(MSBIRT)，这是一种改善精神健康结果的循证实践(EBP)，以克服COD连续护理(服务水平结果)的障碍。在这个框架中，mSBIRT是我们假设将导致SSRI处方治疗抑郁症的EBP。用化学需氧量治疗燕麦片患者的抑郁症 它与许多患者层面的结果有关，如减少燕麦片辍学和药物使用，改善心理生活质量，减少犯罪活动和艾滋病毒风险行为。目前的护理标准(SOC)是麻醉师转介OAT患者进行异地精神评估，尽管他们有能力开SSRIs。SOC诊所和他们的患者将与OAT诊所/患者进行比较，这些患者将mSBIRT实践与使用Project ECHO的持续指导相结合。我们的ECHO-COD是基于证据的促进实践，将为麻醉师提供技能和持续支持，为抑郁症提供现场和综合精神治疗。实施mSBIRT的诊所将使用按绩效支付(P4P)激励措施进一步分层，我们在乌克兰研究过 确定他们实现预先规定的质量指标的动机(化学需氧量连续护理的要素)。集成 通过医疗一体化和P4P经济激励来管理COD的治疗方法被优先考虑，并与乌克兰新的医疗改革计划保持一致，这一提议得到了卫生部的支持。具体目标是：1)采用随机分组对照设计，比较来自4个地区(组)和12个临床环境的1350名阿片类药物使用障碍患者的服务水平(mSBIRT要素)和患者水平(SSRI启动、OAT退出和精神生活质量)的结果。在站点随机化之前，每个参与站点的所有OAT客户将进行基线评估，然后站点随机化，以接受标准护理(N=450)与使用ECHO-COD促进的综合护理(N=450)和有(N=450)或不(N=450)P4P激励的综合护理；2)使用多层次实施科学框架，检查患者、临床医生和组织因素对服务水平和患者水平结果的贡献；以及3)使用来自AIMS 1和2的数据以及国家数据，进行将COD服务整合到OAT诊所的成本效益分析，无论是否有P4P SOC OAT站点。这项建议汇集了乌克兰内容方面的专家，他们在实施科学、医疗保健整合、mSBIRT、P4P、项目ECHO、临床成瘾和精神病学、临床试验和成本效益方面拥有长期的合作研究经验。

Project summary Ukraine is a middle-income country profoundly impacted by opioid use disorders. Despite opioid agonist therapies (OAT) like buprenorphine and methadone being available since 2004, treatment outcomes have been undermined by a number of patient-, clinic- and structural-level barriers. Currently, OAT is prescribed in Narcology Centers, an addiction subspecialty of Psychiatry. Despite similar training by Narcologists and Psychiatrists, the siloed and fragmented Semashko Soviet-style healthcare system legacy has resulted in OAT patients not receiving treatment for co-occurring psychiatric disorders (COD) unless they are referred offsite to Psychiatric Centers. Depression severe enough to warrant pharmacotherapy with first-line selective serotonin reuptake inhibitors (SSRI) now exceeds 50% of OAT patients, yet only 11% have been diagnosed and 1.2% are prescribed SSRIs. This leaves considerable room for improvement in managing COD. This application seeks to use implementation science and the PARIHS framework to overcome obstacles to the COD continuum of care (service-level outcomes) by introducing a modified Screening, Brief Intervention and Referral to Treatment (mSBIRT), an evidence-based practice (EBP) that improves mental health outcomes. In this framework, mSBIRT is the EBP that we hypothesize will result in SSRI prescription to treat depression. Effectively treating depression in OAT clients with COD is associated with a number of patient-level outcomes like reduced OAT dropout and drug use, improved psychological quality of life, and lower criminal activities and HIV risk behaviors. Current standard of care (SOC) is for Narcologists to refer OAT patients offsite for psychiatric assessment, despite their ability to prescribe SSRIs. SOC clinics and their patients will be compared OAT clinics/patients integrating mSBIRT practices with ongoing coaching using Project ECHO. Our ECHO-COD is evidence-based facilitation practice that will provide skills and ongoing support for Narcologists to provide onsite and integrated psychiatric treatment for depression. Clinics implementing mSBIRT will be further stratified using pay-for-performance (P4P) incentives, which we have studied in Ukraine to determine their motivation for achieving pre-specified quality indicators (elements of the COD continuum of care). Integrating treatments for managing COD through healthcare integration and P4P economic incentives are prioritized and aligned with Ukraine’s new healthcare reform plan and this proposal is supportive by the Ministry of Health. The specific aims are: 1) To compare both service-level (mSBIRT elements) and patient-level (SSRI initiation, OAT drop-out and psychiatric quality of life) outcomes in 1,350 patients with opioid use disorders receiving OAT from 4 regions (clusters) and 12 clinical settings using a randomized, cluster-controlled design over 24 months. Before site randomization, all OAT clients at each participating site will have baseline assessments followed by site randomization to receive standard of care (N=450) versus integrated care using ECHO-COD facilitation with (N=450) or without (N=450) P4P incentives; 2) Using a multi-level implementation science framework, to examine the contribution of patient, clinician and organizational factors that contribute to the service-level and patient-level outcomes; and 3) To use data from aims 1 and 2 alongside national data to conduct a cost-effectiveness analysis of integrating COD services into OAT clinics, with or without P4P, compared to SOC OAT sites. This proposal brings together experts in the Ukrainian content with a longstanding collaborative research experience with implementation science, healthcare integration, mSBIRT, P4P, Project ECHO, clinical addiction and psychiatry, clinical trials and cost-effectiveness.