Implementation to motivate physician response to opioid dependence in HIVsetting

描述（由申请人提供）：我们的国家正处于阿片类药物过量死亡的流行之中。艾滋病毒感染者（PLWH）普遍使用阿片类药物，沿着他们普遍使用苯二氮卓类药物，导致PLWH中阿片类药物过量的比例很高。3理想情况下，艾滋病毒医生将提供有效的办公室阿片类药物治疗（OBOT），以减少药物使用和过量死亡率，4-6但艾滋病毒医生一直不愿意采用丁丙诺啡/纳洛酮（Bup/Nx）。7目前的研究认为，多年来一直与艾滋病相关死亡率作斗争的艾滋病毒医生，将发现通过纳洛酮处方（NxP）预防过量死亡更有说服力，更可培训，更不复杂。8从NxP开始，当前项目将利用学术细节与动机访谈（MI），鼓励艾滋病毒医生接受在治疗原发性疾病（阿片类药物成瘾）中发挥更大作用基于办公室的Bup/Nx。 在一个阶梯式楔形设计中，拟议的研究将在20个接受Ryan白色资助的艾滋病毒实践环境中实施NxP和OBOT;治疗成人;有4个或更多的处方者;有电子病历（EMR）;来自全国阿片类药物过量死亡的前一半州。该实施将在三个9个月的阶段中在随机选择的合格实践中依次推出。实施策略将包括（1）1.5小时的现场点对点培训，提供继续医学教育学分，重点是通过NxP挽救生命，并介绍基于办公室的药物可用于治疗原发性疾病的理念（2）为医生和实践提供专家指导和技术支持;（3）在初始培训后1、3、5和7个月由接受过MI培训的临床医生进行学术详述; 以及（4）药剂师与当地药房的点对点外联，以确保药物可用。从实施科学中得出的主要结果将是从调查9、18和27个月到积极实施阶段以及9个月随访时开具纳洛酮和Bup/Nx处方的可行性、可接受性、准备程度和意图;开具纳洛酮和Bup/Nx处方的临床医生数量（即摄取）;以及从EMR数据中开具纳洛酮或Bup/Nx处方的患者数量（即渗透）。形成性评价将在定性访谈中审查实施促进因素和障碍。 艾滋病毒门诊实践是有希望的设置，其中实施纳洛酮以减少过量和Bup/Nx治疗阿片类药物使用障碍。使用点对点的医生培训，积极的专家支持，学术细节与动机访谈和药房推广，这一创新的建议将利用“拯救生命”的主要价值，在艾滋病毒医生中实施纳洛酮处方，并增加他们采用基于办公室的Bup/Nx治疗的动力。

DESCRIPTION (provided by applicant): Our nation is in the midst of an epidemic of opioid overdose deaths. The common use of opioids among persons living with HIV (PLWH), along with their common use of benzodiazepines, has resulted in high rates of opioid overdose among PLWH.3 Ideally, HIV physicians would provide effective office-based opioid treatment (OBOT) to reduce drug use and overdose mortality,4-6 but HIV physicians have been reluctant to adopt buprenorphine/naloxone (Bup/Nx).7 The current study posits that HIV physicians, who have been battling AIDS-related mortality for years, will find prevention of overdose death through naloxone prescription (NxP) more compelling, more trainable and less complex.8 Beginning with NxP, the current project will utilize academic detailing with motivational interviewing (MI) to encourage HIV physicians to accept a larger role in treating the primary disease (opioid addiction) with office-based Bup/Nx. In a stepped wedge design, the proposed study will implement NxP and OBOT in 20 HIV practice settings that receive Ryan White Funding; treat adults; have 4 or more prescribers; have an electronic medical record (EMR); and come from states in the top half nationally for opioid overdose deaths. The implementation will roll-out sequentially among randomly-selected eligible practices in three 9-month phases. The implementation strategy will include (1) a 1.5-hour, onsite peer-to-peer training with continuing medical education credits provided that will focus on saving lives through NxP and introduce the idea that office-based medication is available to treat the primary disease (opioid addiction) in their office; (2) expert mentoring and technical support for the physicians and practice; (3) academic detailing by a clinician trained in MI at 1, 3, 5 and 7 months after the initial training; and (4) pharmacist peer-to-peer outreach to local pharmacies to ensure that the medications are available. Primary outcomes drawn from implementation science will be feasibility, acceptability, readiness and intent to prescribe naloxone and Bup/Nx from surveys 9, 18, and 27 months into the active implementation phase, and at nine month follow-up; number of clinicians prescribing naloxone and Bup/Nx (i.e. uptake); and number of patients prescribed naloxone or Bup/Nx (i.e. penetration) from EMR data. Formative evaluation will examine implementation facilitators and barriers in qualitative interviews. HIV outpatient practices are promising settins in which to implement naloxone to reduce overdose and Bup/Nx to treat opioid use disorders. Using peer-to-peer physician training, proactive expert support, academic detailing with motivational interviewing, and pharmacy outreach, this innovative proposal will leverage the primary value of "saving lives" to implement naloxone prescription among HIV physicians and increase their motivation to adopt office-based Bup/Nx treatment.