Willenbring Mark L, Hagedorn Hildi J, Postier Andrea C, Kenny Marie
Minneapolis VA Medical Center, One Veterans Drive, Minneapolis, MN 55417, USA.
Drug Alcohol Depend. 2004 Jul 15;75(1):97-106. doi: 10.1016/j.drugalcdep.2004.01.009.
Opioid agonist therapy (OAT) for opioid dependence has a strong evidence base, but clinical practice often does not conform to evidence-based practices. The goal of the OpiATE Initiative is to improve patient outcomes by implementing four evidence-based practices in United States Veterans Administration OAT clinics: (1) long-term maintenance orientation, (2) adequate dosing, (3) adequate counseling, and (4) use of contingency management.
The OpiATE monitoring system (OMS) was developed to help clinics assess concordance with evidence-based practices. For each patient, counselors record current agonist dose, recent counseling frequency, length of treatment, and urine toxicology results. For patients with sub-standard agonist doses, an algorithm was used to determine if the current dose was clinically appropriate. Maintenance orientation was assessed using the abstinence orientation scale.
Concordance with counseling recommendations was uniformly high, concordance with maintenance orientation and dosing recommendations varied widely across clinics, and concordance with contingency management principles was low. Abstinence orientation scores were negatively correlated with dose and patient retention. Dose was negatively correlated with percent of urine screens positive for non-medical opioids and other illicit substances.
The OMS was well accepted by clinic staff. Wide variability in clinical practices and outcomes across clinics supports the importance of individualizing quality improvement strategies to address specific performance gaps.
阿片类激动剂疗法（OAT）用于治疗阿片类药物依赖有坚实的证据基础，但临床实践往往不符合循证实践。阿片类药物治疗与强化治疗计划（OpiATE）倡议的目标是通过在美国退伍军人事务部的阿片类激动剂疗法诊所实施四项循证实践来改善患者预后：（1）长期维持导向，（2）适当剂量，（3）充分咨询，以及（4）使用应急管理。
开发了阿片类药物治疗与强化治疗监测系统（OMS），以帮助诊所评估与循证实践的一致性。对于每位患者，咨询人员记录当前激动剂剂量、近期咨询频率、治疗时长以及尿液毒理学结果。对于激动剂剂量未达标准的患者，使用一种算法来确定当前剂量在临床上是否合适。使用禁欲导向量表评估维持导向。
与咨询建议的一致性普遍较高，与维持导向和剂量建议的一致性在各诊所间差异很大，与应急管理原则的一致性较低。禁欲导向得分与剂量和患者留存率呈负相关。剂量与非医疗用阿片类药物和其他非法物质尿液筛查呈阳性的百分比呈负相关。
诊所工作人员对OMS接受度良好。各诊所临床实践和结果差异很大，这支持了针对特定绩效差距制定个性化质量改进策略的重要性。
