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

降低 OUD 和并发疾病患者的服药过量和自杀风险

• 批准号: 10658129
• 负责人: Andrew Herring
• 金额: $ 64.86万
• 依托单位: RAND CORPORATION
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-06-15 至 2028-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10658129
• 关键词: Accident and Emergency department; Address; Adult; Ambulatory Care; Buprenorphine; California; Caring; Cessation of life; Data; Death Rate; Development; Disease; Dose; Emergency Care; Emergency department visit; Emergency treatment; Enrollment; Epidemic; Event; Goals; Heterogeneity; High Prevalence; Hospitals; Individual; Intervention; Link; Location; Measures; Mental Health; Mental disorders; Modeling; National Institute of Drug Abuse; Nature; Outpatients; Overdose; Overdose reduction; Patient Care; Patients; Persons; Population; Provider; Recording of previous events; Research; Resources; Risk; Self-Injurious Behavior; Sequential Multiple Assignment Randomized Trial; Services; Specific qualifier value; Suicide; Suicide attempt; Test Result; Testing; Time; Treatment outcome; Vision; acute care; adaptive intervention; addiction; behavioral health; bridge program; collaborative care; comorbidity; dual diagnosis; evidence base; high risk; improved; innovation; intervention delivery; medical complication; medication for opioid use disorder; mortality; mortality risk; opioid overdose; opioid use; opioid use disorder; overdose death; overdose risk; patient engagement; premature; prevent; primary outcome; relapse risk; response; secondary outcome; service delivery; substance use; suicidal morbidity; suicidal risk; suicide mortality; telehealth; treatment response

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.

项目摘要 自杀和吸毒过量死亡人数创历史新高，急诊科 (ED) 处于最前沿 为风险最高的人提供护理。阿片类药物使用障碍 (OUD) 和精神疾病是主要疾病 两者的贡献者。 2017 年，近一半的自杀和服药过量死亡与阿片类药物的使用有关，其中 患有 OUD 和精神疾病的人死亡率最高。 OUD (MOUD) 保存药物 生命，大量研究记录了 MOUD 保留之间的剂量反应关系 护理、全因死亡率和自杀/用药过量。加州桥梁计划 (CA Bridge) 是最大的 ED- 美国的成瘾治疗实施项目；主要目标是改善 MOUD 访问和 与 OUD 患者门诊护理的联系。然而，前 52 家医院的数据表明，超过 60% 的患者在急诊科就诊两周后没有填写门诊 MOUD 处方；国家数据 表明即使患者开始 MOUD，许多人也会停止治疗，这使他们面临更高的风险 复发、服药过量和死亡。鉴于资源有限，急诊科提供者需要基于证据的指导 在存在人与人之间异质性的情况下管理患者的最佳方法（尽管 所提供的服务（许多患者无法获得这些服务）和人内异质性（即使 MOUD 是 导致许多患者停止治疗），以及有关患者是否有既往病史的信息 服药过量或同时发生精神疾病应接受不同顺序的干预措施。这 人与人之间和人内部的异质性相结合，表明需要适应性干预 (AI) 方法，根据患者的初始情况调整 MOUD 服务提供干预措施 呈现和改变状态。我们提出了一项序贯多重分配随机试验来告知 开发一种人工智能，可以最有效地增加成人丁丙诺啡的使用 ED 与 OUD 相关事件。我们的主要结果是丁丙诺啡处方的天数 是在初次 ED 就诊后 6 个月内填写的。我们预先指定的次要结果是一个综合结果 测量出现 ED 与随后的服药过量或自杀事件（包括死亡）之间的时间。到 进行这项研究时，我们利用兰德公司、加州大学洛杉矶分校、斯坦福大学和两家医院之间的合作伙伴关系 CA Bridge 的早期采用者。急诊科提供者通常为急诊科的急性问题提供限时护理， 在关键的过渡点强制进行不切实际且高风险的交接。测试不同的服务- 交付干预措施并主动解决这一转变的关键性质，具有创新性，并提出 提出 ED 护理的新愿景。我们的研究与 NOT-NS-20-005 中概述的 NIDA 优先事项保持一致，并且 将为多个关键问题提供明确的答案，这些问题是构建具有以下特征的最佳人工智能所必需的： 潜在增加 MOUD 的长期使用并挽救因过量服用、自杀和未经治疗的 OUD 而丧生的生命。