Peer-Delivered, Behavioral Activation Intervention to Improve Polysubstance Use and Retention in Mobile Telemedicine OUD Treatment in an Underserved, Rural Area

背景美国超过50%的农村县没有一个丁丙诺啡豁免提供者， 在美国，大约有10%的人住在离他们最近的处方医生10英里以上的地方。 在服务不足的农村地区，阿片类药物使用障碍（OUD）危机的破坏性影响更加严重， 多物质使用增加，特别是与OUD同时发生的兴奋剂使用障碍。自2019年以来，我们的团队 在服务不足的马里兰州农村地区， 丁丙诺啡用于OUD治疗，使用移动的治疗单元（MTU）上的远程医疗（TM）。我们 研究小组已经证明了TM-MTU模型在减少阿片类药物使用32.8%方面的有效性， 个月然而，在过去的一年中，92%的患者在摄入时使用了多种药物， 一半是OUD和兴奋剂。此外，保持治疗是一项挑战，而多种物质的使用又加剧了这一挑战; 不到60%的患者在三个月时保留。基于强化的方法，例如 应急管理，有经验支持，以改善治疗保留和兴奋剂的使用， 由于组织和提供商的障碍，包括成本，在社区环境中的采用率很低。一 基于行为激励的方法，如行为激活（BA），其目的是增加积极的 通过奖励，无物质行为的强化，可能是一个有前途的有效和可持续的 改善OUD治疗保留率和多物质使用，特别是兴奋剂使用的战略。此外，本发明还 我们的团队已经证明，在BA中培训同伴恢复专家（PRS）是可行的。初步 问题研究该提案建立在我们团队先前的研究基础上，证明了可行性、可接受性和 有效性：1）TM-MTU模式覆盖受OUD危机严重打击的农村社区， 多物质使用; 2）在TM-MTU上整合PRS支持;以及3）PRS提供的BA干预（“同行 激活”），以改善治疗保留和减少多种物质的使用，包括OUD和兴奋剂的使用。 Approach.在这项工作的基础上，我们提出了一个随机1型混合有效性实施试验 （n=180）以评估与MTU（对等激活-MTU）相比，PRS提供的BA干预 对以下12个以上的患者进行常规强化治疗（ETAU;促进转诊和一般同行支持）- 月：（1）有效性结果：a）OUD治疗保留（主要：预约病历审查 出席）; B）多种物质使用（共同主要：同时使用≥2种物质的尿分析）;和c） 丁丙诺啡依从性（次要：尿液分析和药房补充）;（2）实施结果，包括 RE-AIM指导下的可行性、可接受性、忠实性和采用性;（3）实施和维持Peer的成本 活化MTU及其相对于ETAU的经济价值。影响。这项建议旨在导致一个 潜在的可扩展模型，用于改善OUD治疗保留和多物质使用，特别是共 发生OUD和兴奋剂使用，并增加服务不足的农村地区的成瘾治疗范围。

Background. More than 50% of rural counties in the US do not have a single buprenorphine-waived provider, and approximately 10% of people in the US live more than 10 miles away from their nearest prescriber. Compounding the devastating effects of the opioid use disorder (OUD) crisis in underserved, rural areas is increasing polysubstance use, notably stimulant use disorder co-occurring with OUD. Since 2019, our team has filled a void of rural addiction treatment practitioners in underserved rural Maryland areas by providing buprenorphine for OUD treatment with the use of telemedicine (TM) aboard a mobile treatment unit (MTU). Our team has demonstrated the effectiveness of the TM-MTU model in reducing opioid use by 32.8% at three- months. Yet, 92% of patients in the past year presented with polysubstance use at intake, approximately half with OUD and stimulant use. Further, treatment retention is a challenge, amplified by polysubstance use; less than 60% of patients were retained at three-months. Reinforcement-based approaches, such as contingency management, have empirical support for improving treatment retention and stimulant use, yet have low adoption in community settings due to organizational and provider barriers, including cost. A behavioral reinforcement-based approach, such as behavioral activation (BA), which aims to increase positive reinforcement through rewarding, substance-free behaviors, may be a promising effective and sustainable strategy to improve both OUD treatment retention and polysubstance use, particularly stimulant use. Further, our team has demonstrated that it is feasible to train peer recovery specialists (PRSs) in BA. Preliminary Studies. This proposal builds upon our team’s prior studies demonstrating the feasibility, acceptability, and effectiveness of: 1) the TM-MTU model reaching rural communities hard hit by the OUD crisis and polysubstance use; 2) integrating PRS support on the TM-MTU; and 3) a PRS-delivered BA intervention (“Peer Activate”) for improving treatment retention and reducing polysubstance use, including OUD and stimulant use. Approach. Building upon this work, we propose a randomized Type 1 hybrid effectiveness-implementation trial (n=180) to evaluate the PRS-delivered BA intervention on the MTU (Peer Activate-MTU) compared to enhanced treatment as usual (ETAU; facilitated referrals and general peer support) on the following over 12- months: (1) effectiveness outcomes: a) OUD treatment retention (primary: chart review of appointment attendance); b) polysubstance use (co-primary: urinalysis of co-occurring use of ≥2 substances); and c) buprenorphine adherence (secondary: urinalysis and pharmacy refill); (2) implementation outcomes, including feasibility, acceptability, fidelity, and adoption guided by RE-AIM; (3) cost of implementing and sustaining Peer Activate-MTU and its economic value relative to ETAU. Implications. This proposal is designed to lead to a potentially scalable model for improving OUD treatment retention and polysubstance use, particularly co- occurring OUD and stimulant use, and increasing the reach of addiction treatment in underserved, rural areas.