INDIVIDUAL PLACEMENT AND SUPPORT FOR VETERANS WITH OPIOID USE DISORDER: A MIXED METHODS STUDY

背景：与阿片类药物使用障碍(OUD)生活在一起可以使寻找和维持就业成为一种 这是一个巨大的挑战，在新冠肺炎的环境下只会变得更糟。各州报告 失业率高达15%-20%，失业对我们的治疗结果的负面影响是 预计会恶化。新冠肺炎大流行进一步导致治疗中断， 由于失业、社会孤立、无法获得治疗药物而加剧了不良后果 Moud治疗(Moud)，以及为许多人提供必要结构的日常生活的干扰 和乌德在一起。我们小组进行的研究表明，个人安置和支持(IPS)是有效的 为患有创伤后应激障碍的退伍军人提供更多的工作周和更高的稳定就业率 精神障碍和退伍军人被诊断为广泛的精神疾病(包括药物使用) 在初级保健环境中接受治疗；然而，对其在患有OUD的退伍军人中的疗效知之甚少。只有一个小的 已经在45名患有OUD的平民中进行了研究，其中分配到IPS的参与者中有50%获得了 在6个月的随访期(p&lt；0.001)，受试者的就业率为5%。对……的系统回顾 IPS对严重精神疾病以外的疾病的有效性在以下方面显示出主要限制 许多研究，包括样本量小、对IPS模型的重大修改、弱对照和短期随访 句号。一项更大规模的IPS随机对照试验，用于退伍军人从OUD中恢复，并进行更长时间的随访 在此期间，严格的治疗控制和严格遵守IPS保真度，如我们建议的那样，是必要的。 方法：这是一项前瞻性、多点、随机对照试验，以确定IPS的疗效。 对120名正在康复的退伍军人进行非IPS照常治疗(TAU-VR) (目标1)。调查人员假设，患有OUD的退伍军人随机加入IPS将显著提高工作效率 与非IPS TAU-VR组相比，在竞争激烈的工作岗位上工作超过15个月需要数周时间。此外，与 非IPS TAU-VR、IPS接受者将从竞争激烈的工作中获得显著更多的收入，并显著 更有可能实现稳定就业。调查人员还将评估自我报告的复原力测量， 生活质量、感知压力、社区参与、抑郁、焦虑、节欲自我效能感 自杀风险。作为目标2，使用基于社区的参与性研究(CBRP)方法，调查人员 将确定为退伍军人实施职业服务的背景障碍和促进者 IPS和非IPS TAU-VR研究部门，包括评估就业挑战、最佳职业 运作，坚持治疗，并特别强调新冠肺炎和社会的影响 疏远。为了解决目标2，调查人员将与退伍军人进行半结构化面谈 随机到IPS或非IPS TAU-VR。这些面谈将得到来自 正在进行的康复研发试点研究，包括就同一主题与IPS专家进行定性访谈， 提供者、失业的退伍军人和潜在的雇主。与CBPR指导委员会合作， 将汇总调查结果，以就在这一新人群中实施IPS的最佳实践达成共识。 在探索性目标3中，将比较IPS和非IPS TAU-VR对参与者遵守 Moud和OUD复发率。 意义：这项研究试图找到成功康复和功能重新融合的最佳干预措施 为正在恢复中的退伍军人准备的。考虑到新冠肺炎的社会影响，这项研究尤为及时 对一般人群，特别是退伍军人的就业和心理健康问题的大流行。 此外，随着新的VHA计划将支助就业服务扩大到有物质使用的退伍军人 在未来几年，我们的研究是及时的，可以大大有助于提供所需的证据 在这一新的优先人口中成功地实施和维持支助就业服务。

Background: Living with an opioid use disorder (OUD) can make finding and sustaining employment a significant challenge and is only getting worse in the COVID-19 environment. With states reporting unemployment rates as high as 15-20%, the negative effects of unemployment on OUD treatment outcomes are expected to deteriorate. The COVID-19 pandemic has further resulted in treatment disruptions that are exacerbating poor outcomes, because of unemployment, social isolation, interrupted access to medication for OUD treatment (MOUD), and interference of daily routines that provide the necessary structure for many people with OUD. Our group has conducted research that shows Individual Placement and Support (IPS) is efficacious in yielding more weeks worked and higher steady employment rates for Veterans with posttraumatic stress disorder and Veterans diagnosed with a broad range of mental conditions (including substance use) being treated in a primary care setting; however, little is known about its efficacy in Veterans with OUD. Only one small study in civilians (n=45) with OUD has been conducted, in which 50% of the participants assigned to IPS gained employment compared to 5% of waitlist control at 6 months follow-up (p<0.001). A systematic review of effectiveness of IPS with conditions other than serious psychiatric mental illness revealed major limitations in many studies, including small sample sizes, major modifications to IPS model, weak control, and short follow-up periods. A larger randomized controlled trial of IPS for Veterans recovering from OUD with longer follow-up period, strong treatment control, and strict adherence to IPS fidelity, such as the one we propose, is warranted. Methods: This is a prospective, multi-site, randomized controlled trial to determine the efficacy of IPS compared to non-IPS Treatment-as-Usual Vocational Rehabilitation (TAU-VR) in a sample of 120 Veterans recovering from OUD (Aim 1). Investigators hypothesize that Veterans with OUD randomized to IPS will work significantly more weeks in a competitive job over 15 months compared to the non-IPS TAU-VR group. Additionally, compared to non-IPS TAU-VR, IPS recipients will earn significantly more income from competitive jobs and be significantly more likely to achieve steady employment. The investigators will also evaluate self-report measures of resilience, quality of life, perceived stress, community engagement, depression, anxiety, abstinence self-efficacy and suicide risk. As Aim 2, using a Community Based Participatory Research (CBRP) approach, the investigators will identify the contextual barriers to and facilitators of implementing vocational services for Veterans in both the IPS and non-IPS TAU-VR study arms, including evaluation of employment challenges, optimal occupational functioning, and OUD treatment adherence, with specific emphasis on the impact of COVID-19 and social distancing. To address Aim 2, the investigators will conduct semi-structured interviews with Veterans with OUD randomized to IPS or non-IPS TAU-VR. These interviews will be supplemented by qualitative findings from an ongoing Rehabilitation R&D pilot study that includes qualitative interviews on the same topic with IPS specialists, providers, unemployed veterans with OUD, and potential employers. Working with a CBPR Steering Committee, findings will be aggregated to reach consensus on best practices for IPS implementation in this new population. In an Exploratory Aim 3, the impact of IPS will be compared to non-IPS TAU-VR on participants’ adherence to MOUD and rates of OUD relapse. Significance: This study seeks to find the best intervention for successful recovery and functional reintegration for Veterans recovering from OUD. This study is especially timely given the societal impact of the COVID-19 pandemic on employment and mental health problems of the general population, and Veterans specifically. Additionally, with the new VHA plan to expand supported employment services to Veterans with substance use disorders in the coming years, our study is timely and can significantly contribute to the evidence required to successfully implement and sustain supported employment services in this new priority population.