Ukraine is a middle-income country profoundly impacted by opioid use disorders. Despite opioid agonist therapies (OAT) like buprenorphine and methadone being available since 2004, treatment outcomes have been undermined by a number of patient-, clinic- and structural-level barriers. Currently, OAT is prescribed in Narcology Centers, an addiction subspecialty of Psychiatry. Despite similar training by Narcologists and Psychiatrists, the siloed and fragmented Semashko Soviet-style healthcare system legacy has resulted in OAT patients not receiving treatment for co-occurring psychiatric disorders (COD) unless they are referred offsite to Psychiatric Centers. Depression severe enough to warrant pharmacotherapy with first-line selective serotonin reuptake inhibitors (SSRI) now exceeds 50% of OAT patients, yet only 11% have been diagnosed and 1.2% are prescribed SSRIs. This leaves considerable room for improvement in managing COD. This application seeks to use implementation science and the PARIHS framework to overcome obstacles to the COD continuum of care (service-level outcomes) by introducing a modified Screening, Brief Intervention and Referral to Treatment (mSBIRT), an evidence-based practice (EBP) that improves mental health outcomes. In this framework, mSBIRT is the EBP that we hypothesize will result in SSRI prescription to treat depression. Effectively treating depression in OAT clients with COD is associated with a number of patient-level outcomes like reduced OAT dropout and drug use, improved psychological quality of life, and lower criminal activities and HIV risk behaviors. Current standard of care (SOC) is for Narcologists to refer OAT patients offsite for psychiatric assessment, despite their ability to prescribe SSRIs. SOC clinics and their patients will be compared OAT clinics/patients integrating mSBIRT practices with ongoing coaching using Project ECHO. Our ECHO-COD is evidence-based facilitation practice that will provide skills and ongoing support for Narcologists to provide onsite and integrated psychiatric treatment for depression. Clinics implementing mSBIRT will be further stratified using pay-for-performance (P4P) incentives, which we have studied in Ukraine to determine their motivation for achieving pre-specified quality indicators (elements of the COD continuum of care). Integrating treatments for managing COD through healthcare integration and P4P economic incentives are prioritized and aligned with Ukraine?s new healthcare reform plan and this proposal is supportive by the Ministry of Health.
The specific aims are: 1) To compare both service-level (mSBIRT elements) and patient-level (SSRI initiation, OAT drop-out and psychiatric quality of life) outcomes in 1,350 patients with opioid use disorders receiving OAT from 4 regions (clusters) and 12 clinical settings using a randomized, cluster-controlled design over 24 months. Before site randomization, all OAT clients at each participating site will have baseline assessments followed by site randomization to receive standard of care (N=450) versus integrated care using ECHO-COD facilitation with (N=450) or without (N=450) P4P incentives; 2) Using a multi-level implementation science framework, to examine the contribution of patient, clinician and organizational factors that contribute to the service-level and patient-level outcomes; and 3) To use data from aims 1 and 2 alongside national data to conduct a cost-effectiveness analysis of integrating COD services into OAT clinics, with or without P4P, compared to SOC OAT sites. This proposal brings together experts in the Ukrainian content with a longstanding collaborative research experience with implementation science, healthcare integration, mSBIRT, P4P, Project ECHO, clinical addiction and psychiatry, clinical trials and cost-effectiveness.
This proposed study is designed to spur innovation in healthcare service delivery, specifically by deploying 3 evidence-based practices: 1) integration of services for co-occurring psychiatric disorders (COD) through scale-up of modified Screening, Brief Intervention, Referral to Treatment in clinics providing opioid agonist treatment; 2) facilitated coaching using Project ECHO-based collaborative learning environments to promote specialty service delivery for psychiatric disorders (ECHO-COD); and 3) introducing and testing pay-for-performance strategies. The project combines both a cluster RCT with a multi-level implementation science framework to explain the contribution of newly introduced EBPs like blended ECHO-COD methods enhanced with P4P incentives to achieve comprehensive health outcomes associated with integrated care. If successful, the public health impact of these findings should improve the access to and expansion of COD treatment, improve the health status in OAT patients and better engage them in treatment and advance implementation science through measurement of service- and patient-level outcomes.
