Improving Access and Treatment for Co-occurring Opioid Use Disorders and Mental Illness

项目摘要/摘要 阿片类药物使用障碍，与抑郁症或创伤后应激障碍共同出现，非常普遍，负担沉重，而且过于频繁 不治身亡。在2015-16年间，有超过200万成年人患有当前的先天性巨结肠；62%的人同时患有先天性巨结肠 精神疾病和24%的人同时患有严重的精神疾病。然而，尽管 在接受治疗的情况下，许多人从未接受过治疗；而且，提供治疗时，质量很低。这是一个 在易受伤害和受歧视的人群中，关键治疗和质量差距。 协作护理(CC)旨在解决这些差距，我们团队进行的开创性研究已经 显示CC改善了具有普通精神健康的初级保健患者的机会、质量和结果 条件，包括上瘾。然而，CC从未接受过共生疾病(COD)的测试， 尽管我们团队的研究表明它可能是有效的。CC由一组提供商组成，其中包括 护理经理(CM)、初级保健提供者(PCP)和行为健康顾问(BHC)，他们提供 使用临床登记向一组患者提供基于证据和测量的护理。在我们的CC模型中 COD(CC-COD)，CC团队还包括一名行为健康心理治疗师(BHP)；基于证据的 支持的治疗包括针对OUD(Moud)的药物，针对抑郁症和创伤后应激障碍的药物治疗， 动机访谈(MI)、问题解决疗法(PST)和寻求安全(SS)。我们建立在我们的 通过强调患者参与并使用协作规划和开发进行的先前研究 调整干预措施以适应资源匮乏、医疗和行为健康状况不佳的环境的过程 提供者，以及高度污名化的患有多种相互作用的复杂疾病的患者群体。 我们建议在11家位于健康中心的农村和城市初级保健诊所进行多点、随机、务实的试验 新墨西哥州专业缺陷区(HPSA)适应、协调后再测试CC-COD 改善合并抑郁症和/或OUD的初级保健患者的机会、质量和结局 创伤后应激障碍。新墨西哥州是阿片类药物过量死亡率最高的国家之一，疾控中心预计新墨西哥州将有 到2025年，毒品、酒精和自杀的死亡率将达到全国最高水平。这是一个以农村为主的州， 多数是西班牙裔。我们将与新墨西哥大学健康科学中心合作，首选 卫生保健系统、新墨西哥州北谷卫生中心和伊达尔戈医疗服务公司共同开展了这项研究。 我们将随机选择1000名同时患有OUD和/或抑郁症/创伤后应激障碍的患者接受CC- CoD或增强日常护理(EUC)。我们的主要结果是Moud启动率(访问)、质量 照顾肥胖、抑郁和创伤后应激障碍(质量)、自我报告的身体状况、MH和幸福感，以及禁欲 来自阿片类药物(结果)。我们还将检查治疗质量和结果的调解人和主持人， 并评估影响执行和可持续性的背景因素。

Project Summary/Abstract Opioid use disorders, co-occurring with either depression or PTSD, are prevalent, burdensome, and too often left untreated. In 2015-16, there were over two million adults with a current OUD; 62% had a co-occurring mental illness and 24% had a co-occurring serious mental illness. However, despite the effectiveness of treatment, many individuals never receive treatment; and, when treatment is provided, quality is low. This is a critical treatment and quality gap in a vulnerable and stigmatized population. Collaborative care (CC) aims to address these gaps, and ground-breaking studies conducted by our team have shown that CC improves access, quality and outcomes in primary care patients with common mental health conditions, including addiction. However, CC has never been tested with co-occurring disorders (COD), despite research by our team suggesting it may be effective. CC consists of a team of providers that includes a care manager (CM), a primary care provider (PCP) and a behavioral health consultant (BHC), who provide evidence- and measurement-based care to a panel of patients using a clinical registry. In our CC model for COD (CC-COD), the CC team also includes a behavioral health psychotherapist (BHP); the evidence-based treatments supported include medications for OUD (MOUD), pharmacotherapy for depression and PTSD, motivational interviewing (MI), problem solving therapy (PST) and Seeking Safety (SS). We build upon our prior research by emphasizing patient engagement and using a collaborative planning and development process to adapt the intervention for a setting that is resource-poor with few medical and behavioral health providers, and a highly stigmatized patient population with multiple interacting complex disorders. We propose a multi-site, randomized pragmatic trial in 11 rural and urban primary care clinics located in Health Professional Shortage Areas (HPSA) of New Mexico to adapt, harmonize and then test whether CC-COD improves access, quality and outcomes for primary care patients with co-morbid OUD and depression and/or PTSD. New Mexico has one of the highest opioid overdose death rates, and the CDC projects it will have the highest rates of death from drugs, alcohol and suicide in the nation by 2025. A primarily rural state, it is majority Hispanic. We will collaborate with the University of New Mexico Health Sciences Center, First Choice Health Care system, UNM’s North Valley Health Center, and Hidalgo Medical Services to conduct the study. We will randomize 1,000 patients with co-occurring OUD and and/or depression/PTSD to receive either CC- COD or enhanced usual care (EUC). Our primary outcomes are rates of MOUD initiation (access), quality of care for OUD, depression and PTSD (quality), self-reported physical and MH and wellbeing, and abstinence from opioids (outcomes). We will also examine mediators and moderators of treatment quality and outcomes, and assess contextual factors affecting implementation and sustainability.