Methadone Patient Access to Collaborative Treatment (MPACT)

美沙酮患者获得合作治疗（MPACT）是一个工作人员层面的创伤知情实践的变化 美国阿片类药物治疗计划（OTP）。它所依据的理论是，目前检察官办公室的做法和文化 可能导致广泛的美沙酮维持治疗（MMT）中断（>30%）和复发（>50%） 已知增加阿片类药物过量的比率。OTP治疗文化被描述为“carceral”和“not 医疗保健”，患者报告通过所需的每日监督药物给药而被束缚在诊所。变化 在检察官办公室的做法已经呼吁，但被认为是“几乎不可能的”。美国联邦监管的灵活性 旨在促进在COVID期间改变OTP做法的措施并未导致广泛或持续的MMT交付 变化或服务调整，例如稳定患者的多日给药增加，尿液分析频率降低， 甚至是远程医疗这些设施将非常有利于农村和居家病人。证据- 如果美国要有效应对阿片类药物过量， 危机如果这种拯救生命的治疗方法是可用的，但没有得到很好的使用，我们必须关注OTP的实践和文化。缺乏 实践的改变可能是由于工作人员的信念和经验，包括他们自己的物质使用障碍的历史 治疗，创伤经历，以及在工作中暴露于替代性创伤。当工作人员的创伤得到解决，我们 预计OTP的实践取向将从惩罚性转向减少伤害/以病人为中心。 MPACT旨在增加MMT保留率并减少治疗中药物过量，患者和工作人员报告 创伤后应激综合征（PTSS）。MPACT有四个循证组成部分：1）4个模块的CME/CEU- 经认可的OTP工作人员创伤知情心理教育培训计划，2）患者创伤导航模型 和工作人员，3）诊所创伤知情护理（TIC）自我评估，和4）单独的反射监督结构， 顾问/个案管理员和医疗服务提供者。就本提案而言，将对MPACT的组成部分进行调整，以适应检察官办公室的需要。 在亚利桑那州的指导下，在多层次，创伤知情的规划过程中与患者和提供者一起设置 由美沙酮和丁丙诺啡提供者组成的跨学科药物政策研究和宣传委员会， 患者、有吸毒经历的人、减少伤害的非政府组织、付款人、创伤专家和大学 研究人员MPACT将在第一年完成，第二年进行试点测试和完善，并在一个随机分组中进行测试。 第3-6年在美国OTP研究中心进行的对照干预试验。收集数据的主要手段是调查 推送给工作人员和患者（基线和每月）以及回顾性患者病历审查。 我们进入了一个前所未有的MMT交付监管变革时期。MPACT可以促进和支持MMT 计划中或正在进行的改革努力。OTPs和美沙酮治疗的未来取决于 以证据为基础的检察官办公室做法改变干预措施。关键的问题是：OTP能否采用创伤知情护理（TIC） 如果是的话，它能改善病人的治疗效果吗？MPACT试图在高风险/高回报提案中回答这个问题。如果 如果答案是肯定的，那么MPACT将立即在美国的任何OTP中实施和扩展。

Methadone Patient Access to Collaborative Treatment (MPACT) is a staff-level trauma-informed practice change intervention for US opioid treatment programs (OTP). It is based on the theory that current OTP practice and culture likely contribute to the wide ranging methadone maintenance treatment (MMT) interruption (>30%) and relapse (>50%) rates known to increase opioid overdoses. OTP treatment culture has been described as “carceral,” and “not healthcare,” with patients reporting being bound to the clinic by required daily supervised medication dosing. Changes in OTP practices have been called for, but are recognized as ‘almost impossible.’ US federal regulatory flexibilities intended to facilitate OTP practice change during COVID did not result in wide-spread or sustained MMT delivery changes or service accommodations such as increased multi-day dosing for stable patients, less frequent urine analyses, or even telehealth. These accommodations would be highly beneficial to rural and home-bound patients. Evidence- based OTP practice change interventions are necessary if the US is going to effectively respond to the opioid overdose crisis. If this lifesaving treatment is available but not well used, we must look to the practice and culture of OTPs. Lack of practice change may be due to staff beliefs and experiences, including their own histories of substance use disorder treatment, traumatic experiences, and on-the-job exposure to vicarious trauma. When staff trauma is addressed, we expect OTP practice orientation will shift from punitive to harm-reduction/patient-centered. MPACT is designed to increase MMT retention and decrease in-treatment overdose and patient- and staff- reported posttraumatic stress symptoms (PTSS). MPACT has four evidence-based components: 1) a 4-module CME/CEU- accredited trauma-informed psychoeducation training program for OTP staff, 2) a trauma navigation model for patients and staff, 3) clinic trauma-informed care (TIC) self-assessment, and 4) separate reflective supervisory structures for counselors/case managers and medical providers. For this proposal, MPACT components will be adapted for OTP settings with patients and providers in a multilevel, trauma-informed planning process with guidance from the Arizona transdisciplinary Drug Policy Research and Advocacy Board comprised of methadone and buprenorphine providers, patients, people with lived/ing drug use experience, harm reduction NGOs, payers, trauma experts, and university researchers. MPACT will be finalized in year 1, pilot tested and refined in year 2, and tested in a cluster-randomized controlled intervention trial in OTP sites across the US in years 3-6. The primary means of gathering data are surveys pushed to staff and patients (baseline and monthly) and retrospective patient chart reviews. We enter a period of unprecedented regulatory change for MMT delivery. MPACT can facilitate and support MMT reform efforts that are planned or already in process. The future of OTPs and methadone treatment depend upon evidence-based OTP practice change interventions. The pivotal question is: Can OTPs adopt Trauma Informed Care (TIC) and, if so, does it improve patient outcomes? MPACT seeks to answer this question in a high risk/high reward proposal. If the answer is YES, then MPACT will be immediately implementable and scalable for any OTP in the US.