Reducing Overdose and Suicide Risk in Individuals with OUD and Co-occurring Disorders

项目摘要 自杀和过量死亡人数达到创纪录的水平，急诊室（艾德）处于最前沿， 为高危人群提供护理。阿片类药物使用障碍（OUD）和精神疾病是主要的 两者的贡献者。2017年，近一半的自杀和过量死亡与阿片类药物的使用有关， OUD和精神疾病患者的死亡率最高。OUD（MOUD）药物节省 大量的研究已经证明了MOUD中保留之间的剂量反应关系。 护理、全因死亡和自杀/过量。加州桥梁计划（CA Bridge）是最大的艾德- 在美国的成瘾治疗实施项目;主要目标是改善MOUD的访问， 与OUD患者的门诊治疗联系起来。然而，来自前52家医院的数据表明， 60%的患者在艾德访视后两周未填写门诊MOUD处方;国家数据 这表明，即使患者开始MOUD，许多人停止治疗，使他们的风险增加， 复吸过量死亡鉴于资源有限，艾德提供者需要循证指南， 管理患者的最佳方式，其中存在人与人之间的异质性（尽管 提供的服务，许多患者不访问它们）和人内异质性（即使当MOUD是 开始许多患者停止治疗），以及关于患者是否有既往病史的信息， 无论是吸毒过量还是同时发生的精神疾病，都应接受不同顺序的干预。这 人与人之间的异质性的组合，表明需要一种适应性干预 (AI)方法，根据患者的初始症状调整MOUD服务提供干预措施。 介绍和改变状态。我们提出了一个序贯多重分配随机试验， 开发一种人工智能，最有效地增加丁丙诺啡在成人中的使用， 发生OUD相关事件的艾德。我们的主要结果是丁丙诺啡处方的天数 在初次艾德访视后6个月内填写。我们预先规定的次要结局是一个复合结局， 测量从出现艾德到随后发生药物过量或自杀事件（包括死亡）之间的时间。到 进行这项研究，我们利用兰德，加州大学洛杉矶分校，斯坦福大学和两家医院之间的合作关系， 早期采用CA Bridge的人。艾德提供者通常为艾德中的急性问题提供有时间限制的护理， 在一个关键的过渡点上迫使一个不切实际的高风险的移交。测试不同的服务- 交付干预措施并积极主动地解决这一转变的关键性质是创新的，并使 提出了艾德护理的新愿景。我们的研究与NOT-NS-20-005中概述的NIDA优先事项一致， 将为多个关键问题提供明确的答案，这些问题对于构建一个具有 增加长期MOUD使用和挽救因过量、自杀和未经治疗的OUD而丧生的生命的潜力。

PROJECT ABSTRACT Suicide and overdose deaths are at record levels, and the Emergency Department (ED) is at the forefront of delivering care to those at the highest risk. Opioid use disorders (OUD) and mental illness are major contributors to both. In 2017 nearly half of suicide and overdose deaths were linked to opioid use, with the highest death rates seen in people with both OUD and mental illness. Medications for OUD (MOUD) saves lives, and substantial research has documented the dose-response relationship between retention in MOUD care, all-cause mortality, and suicide/overdose. The California Bridge Program (CA Bridge) is the largest ED- based addiction treatment implementation project in the US; the primary goal is to improve MOUD access and linkage to outpatient care for patients with OUD. However, data from the first 52 hospitals suggest that over 60% of patients had not filled an outpatient MOUD prescription two weeks after the ED visit; national data suggest that even when patients start MOUD, many discontinue treatment, putting them at increased risk of relapse, overdose, and death. Given finite resources, ED providers need evidence-based guidance about the optimal way to manage patients where there is both between-person heterogeneity (despite being offered services many patients do not access them) and within-person heterogeneity (even when MOUD is initiated many patients discontinue treatment), and information about whether patients with a prior history of either overdose or a co-occurring mental illness should receive a different sequence of interventions. This combination of between- and within-person heterogeneity, suggests the need for an adaptive intervention (AI) approach, whereby MOUD service-delivery interventions are adapted based on the patient’s initial presentation and changing status. We propose a Sequential Multiple Assignment Randomized Trial to inform the development of an AI that is optimally effective in increasing buprenorphine use for adults presenting to the ED with an OUD-related event. Our primary outcome is the number of days a prescription for buprenorphine was filled in the 6 months following the initial ED visit. Our pre-specified secondary outcome is a composite measure of the time between ED presentation and subsequent overdose or suicide events, including death. To conduct the study, we leverage a partnership between RAND, UCLA, Stanford and two hospitals that were early adopters of CA Bridge. ED providers typically provide time-limited care for acute problems in the ED, forcing an unrealistic and high-stakes hand off during a critical transition point. Testing different service- delivery interventions and proactively addressing the key nature of this transition, is innovative and puts forward a new vision of ED care. Our study is aligned with NIDA’s priorities as outlined in NOT-NS-20-005 and will provide definitive answers to multiple critical questions, necessary for building an optimal AI that has the potential to increase long-term MOUD use and save lives being lost to overdose, suicide, and untreated OUD.