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

背景：患有阿片类药物使用障碍（OUD）的生活可以使寻找和维持就业成为一种可能。 这是一个重大挑战，在COVID-19的环境下只会变得更糟。各国报告 失业率高达15 - 20%，失业对OUD治疗结果的负面影响是 预计会恶化。COVID-19大流行进一步导致治疗中断， 由于失业、社会孤立、中断获得药物治疗， OUD治疗（MOUD），以及为许多人提供必要结构的日常生活的干扰 关于OUD我们的小组进行了研究，表明个人安置和支持（IPS）是有效的 为有创伤后压力的退伍军人提供更多的工作周数和更高的稳定就业率 疾病和退伍军人被诊断患有广泛的精神疾病（包括物质使用）， 在初级保健环境中治疗;然而，很少有人知道它在退伍军人与OUD的疗效。只有一个小 在患有OUD的平民（n = 45）中进行了一项研究，其中50%分配到IPS的参与者获得了 6个月随访时，就业率为5%，而等待名单对照组为5%（p <0.001）。的系统评价 IPS对除严重精神病以外的其他疾病的有效性显示了以下主要局限性： 许多研究，包括小样本量、IPS模型的重大修改、弱对照和短随访 时期IPS用于从OUD中恢复的退伍军人的大型随机对照试验，随访时间更长 期间，强有力的治疗控制，并严格遵守IPS保真度，如我们提出的，是必要的。 方法：本研究是一项前瞻性、多中心、随机对照试验，旨在确定IPS的疗效， 在120名退伍军人的样本中， OUD（目标1）。研究人员假设，OUD的退伍军人随机分配到IPS将显着更多的工作 与非IPS TAU-VR组相比，此外，与 非IPS TAU-VR，IPS接收者将从竞争性工作中获得更多收入， 更有可能实现稳定就业。研究人员还将评估自我报告的弹性措施， 生活质量，感知压力，社区参与，抑郁，焦虑，禁欲自我效能感和 自杀风险作为目标2，使用基于社区的前瞻性研究（CBRP）方法，研究人员 将确定背景的障碍和促进者实施职业服务的退伍军人在这两个 IPS和非IPS TAU-VR研究组，包括就业挑战评估、最佳职业 功能和OUD治疗依从性，特别强调COVID-19和社会的影响 疏远为了解决目标2，调查人员将对患有OUD的退伍军人进行半结构化访谈 随机分配至IPS或非IPS TAU-VR。这些访谈将得到一个定性调查结果的补充。 正在进行的康复研发试点研究，包括与IPS专家就同一主题进行的定性访谈， 供应商，失业退伍军人与OUD，和潜在的雇主。与CBPR指导委员会合作， 将汇总调查结果，以便就在这一新人群中实施IPS的最佳做法达成共识。 在探索性目标3中，将比较IPS与非IPS TAU-VR对参与者依从性的影响， MOUD和OUD复发率。 意义：本研究旨在找到成功康复和功能重新融合的最佳干预措施 从OUD中恢复的退伍军人。鉴于COVID-19的社会影响，这项研究特别及时 大流行病对一般人群的就业和心理健康问题，特别是退伍军人。 此外，随着新的VHA计划扩大对使用药物的退伍军人的支持就业服务， 在未来几年的疾病，我们的研究是及时的，可以显着有助于所需的证据， 成功地为这一新的优先人群实施和维持支持性就业服务。

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.