Integrating Treatment for Mental Disorders in Methadone Clinics in Ukraine

项目摘要 乌克兰是深受类阿片使用障碍影响的中等收入国家。尽管阿片类激动剂治疗（OAT），如 自2004年以来，丁丙诺啡和美沙酮一直在使用，但治疗结果却因患者、诊所和结构层面的一些障碍而受到影响。目前，OAT是精神病学的一个成瘾子专业，麻醉学中心的处方。尽管麻醉学家和精神病学家进行了类似的培训，但孤立和分散的Semashko苏联式医疗保健系统遗产导致OAT患者无法接受共发精神疾病（COD）的治疗，除非他们被转诊到精神病中心。抑郁症严重到足以保证一线选择性5-羟色胺再摄取抑制剂（SSRI）药物治疗，现在超过50%的OAT患者，但只有11%被诊断，1.2%被处方SSRI。这为COD的管理留下了相当大的改进空间。该申请旨在利用实施科学和PARIHS框架，通过引入经修改的筛查，简短干预和转诊治疗（mSBIRT），改善心理健康结果的循证实践（EBP），克服COD连续护理（服务水平成果）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。有效治疗OAT客户的抑郁症与COD 与许多患者水平的结果相关，如减少OAT脱落和药物使用，改善心理生活质量，降低犯罪活动和HIV风险行为。目前的护理标准（SOC）是麻醉科医生将OAT患者转诊到异地进行精神病评估，尽管他们有能力开SSRIs。将SOC诊所及其患者与OAT诊所/患者进行比较，OAT诊所/患者将mSBIRT实践与使用项目ECHO进行的持续指导相结合。我们的ECHO-COD是以证据为基础的促进实践，将为麻醉学家提供技能和持续的支持，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付费（P4P）激励措施进一步分层，我们在乌克兰进行了研究， 确定他们实现预先规定的质量指标（COD连续护理的要素）的动机。整合 通过医疗保健一体化和P4P经济激励措施管理COD的治疗方法被列为优先事项，并与乌克兰新的医疗保健改革计划保持一致，该提案得到了卫生部的支持。具体目标是：1）使用随机、群集对照设计，在24个月内比较来自4个地区（群集）和12个临床环境的1，350名接受OAT的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脱落和精神生活质量）结局。在研究中心随机化之前，每个参与研究中心的所有OAT客户将进行基线评估，然后进行研究中心随机化，以接受标准治疗（N = 450）与使用ECHO-COD促进（N=450）或不使用（N=450）P4P激励的综合治疗; 2）使用多层次的实施科学框架，检查患者的贡献，有助于服务水平和患者水平结果的临床医生和组织因素;以及3）使用目标1和2的数据以及国家数据，对将COD服务纳入OAT诊所进行成本效益分析，与P4P相比， SOC OAT网站。该提案汇集了乌克兰内容的专家，他们在实施科学，医疗保健整合，mSBIRT，P4P，ECHO项目，临床成瘾和精神病学，临床试验和成本效益方面具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.