Economics, Sociology, and Statistics Department, RAND Corporation, Santa Monica, California.
Drug Policy Research Center, RAND Corporation, Santa Monica, California.
JAMA Health Forum. 2022 Sep 2;3(9):e223285. doi: 10.1001/jamahealthforum.2022.3285.
In the US, recent legislation and regulations have been considered, proposed, and implemented to improve the quality of treatment for opioid use disorder (OUD). However, insufficient empirical evidence exists to identify which policies are feasible to implement and successfully improve patient and population-level outcomes.
To examine expert consensus on the effectiveness and the ability to implement state-level OUD treatment policies.
This qualitative study used the ExpertLens online platform to conduct a 3-round modified Delphi process to convene 66 stakeholders (health care clinicians, social service practitioners, addiction researchers, health policy decision-makers, policy advocates, and persons with lived experience). Stakeholders participated in 1 of 2 expert panels on 14 hypothetical state-level policies targeting treatment engagement and linkage, evidence-based and integrated care, treatment flexibility, and monitoring or support services. Participants rated policies in round 1, discussed results in round 2, and provided final ratings in round 3. Participants used 4 criteria associated with either the effectiveness or implementability to rate and discuss each policy. The effectiveness panel (n = 29) considered policy effects on treatment engagement, treatment retention, OUD remission, and opioid overdose mortality. The implementation panel (n = 34) considered the acceptability, feasibility, affordability, and equitability of each policy. We measured consensus using the interpercentile range adjusted for symmetry analysis technique from the RAND/UCLA appropriateness method.
Both panels reached consensus on all items. Experts viewed 2 policies (facilitated access to medications for OUD and automatic Medicaid enrollment for citizens returning from correctional settings) as highly implementable and highly effective in improving patient and population-level outcomes. Participants rated hub-and-spoke-type policies and provision of financial incentives to emergency departments for treatment linkage as effective; however, they also rated these policies as facing implementation barriers associated with feasibility and affordability. Coercive policies and policies levying additional requirements on individuals with OUD receiving treatment (eg, drug toxicology testing, counseling requirements) were viewed as low-value policies (ie, decreasing treatment engagement and retention, increasing overdose mortality, and increasing health inequities).
The findings of this study may provide urgently needed consensus on policies for states to consider either adopting or deimplementing in their efforts to address the opioid overdose crisis.
在美国，已经考虑、提出和实施了一些新的立法和法规，以提高阿片类药物使用障碍（OUD）的治疗质量。然而，目前还没有足够的经验证据来确定哪些政策是可行的，并成功改善患者和人群层面的结果。
检查专家对州级 OUD 治疗政策有效性和实施能力的共识。
这项定性研究使用 ExpertLens 在线平台进行了三轮修改后的 Delphi 流程，召集了 66 名利益相关者（医疗保健临床医生、社会服务从业者、成瘾研究人员、卫生政策决策者、政策倡导者和有生活经验的人）。利益相关者参加了针对治疗参与和衔接、基于证据的综合护理、治疗灵活性以及监测或支持服务的 14 项假设州级政策的 1 个专家小组或 2 个小组。参与者在第 1 轮对政策进行了评分，在第 2 轮讨论了结果，并在第 3 轮提供了最终评分。参与者使用与有效性或可实施性相关的 4 个标准对每项政策进行评分和讨论。有效性小组（n=29）考虑了政策对治疗参与、治疗保留、OUD 缓解和阿片类药物过量死亡率的影响。实施小组（n=34）考虑了每项政策的可接受性、可行性、可负担性和公平性。我们使用 RAND/UCLA 适宜性方法的对称性分析技术调整的百分位区间来衡量共识。
两个小组对所有项目都达成了共识。专家认为两项政策（促进获得治疗 OUD 的药物和公民从矫正环境返回后自动加入医疗补助计划）具有高度的可实施性和高度的有效性，可改善患者和人群层面的结果。参与者认为枢纽辐射型政策和向治疗衔接的急诊科提供财政奖励是有效的；然而，他们也认为这些政策在可行性和可负担性方面存在实施障碍。强制性政策和对接受治疗的 OUD 患者（例如，药物毒理学检测、咨询要求）施加额外要求的政策被视为低价值政策（即降低治疗参与度和保留率，增加过量死亡率，并增加健康不平等）。
这项研究的结果可能为各州提供急需的共识，以确定在应对阿片类药物过量危机时应考虑采用或不采用的政策。
