Comparing Interventions for Opioid Dependent Patients Presenting in Medical EDs

描述(由申请人提供)：随着成瘾治疗越来越多地融入医疗保健系统，两种模式理所当然地受到了极大的关注。首先是使用SBIRT模型来识别病例，提供治疗接触，并将更严重的病例转介到长期护理。第二是使用医疗模式治疗成瘾，包括那些可以在初级保健环境中实施的治疗模式。对于SBIRT和对严重疾病患者的更密集/更长期治疗之间的差距，对优化策略的关注要少得多。这一因素对阿片依赖患者至关重要，他们的需求不是通过短暂的干预或短暂的治疗就能满足的。对药物使用障碍的急诊室干预在很大程度上限于短暂干预/SBIRT模式，这些模式主要侧重于酒精。虽然有大量文献记载病例管理在将吸毒者与治疗联系起来方面的价值，但这种方法尚未应用于ED环境中的吸毒者。在医学急诊室中看到的目前没有参与治疗的阿片依赖患者的样本中，这项研究将比较基于强度的简要病例管理(SBCM)和基于激励增强疗法(MET)的短暂干预(BIB)的效果，以及仅进行筛查、评估和转诊(SAR)的效果。之所以选择这些治疗模式，是因为它们有证据基础，而且在急诊室实施是可行的。符合DSM-IV阿片依赖标准的参与者将被随机分配(每组150人)接受1)BIB干预，包括在ED进行30分钟的激励性面谈，然后是两次20分钟的助推器电话会议；2)根据Rapp和他的同事在先前研究中实施的模型，最多进行6次SBCM；或3)SAR。对治疗情况视而不见的工作人员将在3个月和6个月后完成随访评估。这项研究的目的是确定SBCM和BIB对药物滥用治疗的开始和参与、阿片类药物和其他药物的使用以及健康和生活功能的更广泛衡量的主要影响；检查治疗分配和选定的参与者属性在预测治疗开始、参与和物质使用结果方面的相互作用；并检查三个治疗组中治疗参与对物质使用结果的影响。这项拟议的研究将是第一次使用病例管理方法将急诊室出现的药物依赖患者与长期成瘾治疗联系起来的试验。这将是首批专门针对医疗急诊室中的阿片依赖患者的试验之一。另一个创新特征是，病例管理方法将强调与药物治疗的联系，特别是将为希望接受这种治疗的患者促进与办公室丁丙诺啡的联系。

DESCRIPTION (provided by applicant): As addiction treatment becomes increasingly integrated into the medical care system, two models have rightly received a great deal of attention. The first is the use of SBIRT models to identify cases, provide therapeutic contact, and refer the more severe cases to longer-term care. The second is the treatment of addictions using medical models of treatment, including those that can be implemented in primary care settings. Much less attention has been paid to optimizing strategies for bridging the gap between SBIRT and more intensive/longer-term treatment for those on the severe end of the spectrum. This factor is of critical importance for opioid dependent patients, whose needs are not met by brief interventions or brief treatment. Emergency room interventions for substance use disorders have been largely limited to brief interventions/SBIRT models, and these have focused primarily on alcohol. Although there is a substantial literature documenting the value of case management in linking drug users to treatment, this approach has not been applied to drug users in the ED setting. In a sample of opioid dependent patients seen in a medical ED who are not currently engaged in treatment, this study will compare the effects of brief strengths-based case management (SBCM) and those of a brief intervention with booster sessions (BIB), based on Motivational Enhancement Therapy (MET), to the effects of screening, assessment and referral alone (SAR). These treatment models were selected because of their evidence base and because they are feasible to implement in the ED. Participants meeting DSM-IV criteria for opioid dependence will be randomly assigned (150 per group) to receive 1) the BIB intervention including a 30-minute motivational interviewing session in the ED, followed by two 20-minute booster phone sessions; 2) up to 6 sessions of SBCM based on the model previously implemented by Rapp and colleagues in prior studies; or 3) SAR. Staffs that are blinded to treatment condition will complete follow-up assessments at 3 and 6 months. Aims of the study are to identify the main effects of SBCM and BIB on substance abuse treatment initiation and engagement, use of opioids and other drugs, and broader measures of health and life functioning; to examine the interactions between treatment assignment and selected participant attributes in predicting treatment initiation, engagement, and substance use outcomes; and to examine effects of treatment involvement on substance use outcomes in the three treatment groups. The proposed study will be the first trial using a case management approach to link drug dependent patients presenting in EDs to longer-term addiction treatment. It will be one of the first trials focusing specifically on opioid dependent patients in medical EDs. A further innovative feature is that the case management approach will emphasize linkage to pharmacotherapy, and in particular will facilitate linkage to office-based buprenorphine for patients who desire this treatment.