密苏里州采用药物优先方法治疗阿片类药物使用障碍的头五年：停滞、倒退与进展中的薄弱环节。
The first five years of implementing Missouri's medication first approach to opioid use disorder treatment: Plateaus, regressions, and underbellies of progress.
作者信息
Winograd Rachel P, Park Brandon, Coffey Bridget, Ghonasgi Rashmi, Blanchard Brittany, Thater Paul, Brown Katherine C
机构信息
University of Missouri-St. Louis, Psychological Sciences, 325 Stadler Hall, St. Louis, MO 63121, USA; University of Missouri-St. Louis, Addiction Science, Missouri Institute of Mental Health, 1 University Blvd., Benton Hall, Room 206, St. Louis, MO 63121, USA.
University of Missouri-St. Louis, Psychological Sciences, 325 Stadler Hall, St. Louis, MO 63121, USA.
出版信息
J Subst Use Addict Treat. 2025 Mar;170:209622. doi: 10.1016/j.josat.2025.209622. Epub 2025 Jan 10.
INTRODUCTION
Missouri's Medication First ("MedFirst") approach promotes same-day and long-term low-threshold access to medications for opioid use disorder (MOUD). Since 2017, Missouri's SAMHSA-funded State Targeted and State Opioid Response (STR/SOR) grants have supported MedFirst services (both medical and psychosocial) for uninsured individuals with opioid use disorder at state-contracted treatment programs. Though MedFirst demonstrated early success, results - with attention to possible racial disparities - must be revisited after five years of implementation.
METHODS
Using state behavioral health claims, we examined four outcomes: (1) MOUD utilization, (2) time-to-medication, (3) psychosocial service volume, and (4) substance use disorder (SUD) treatment retention. Models compared four groups: (a) individuals in MedFirst during the first and fifth year of implementation (2018 vs. 2022), (b) individuals in MedFirst compared to non-MedFirst, (c) individuals prior to MedFirst (2017) compared to individuals during MedFirst's fifth year (2022), and (d) White compared to Black individuals within and outside MedFirst.
RESULTS
Overall, MedFirst outcomes were superior to non-MedFirst outcomes. Among individuals in MedFirst, however, outcomes were generally poorer in 2022 than in 2018, and Black individuals had shorter treatment episodes and were less likely to receive MOUD than White individuals. Overall, Missourians had only slightly better outcomes in 2022 than prior to STR/SOR initiation.
CONCLUSIONS
Since Missouri's initial implementation of STR/SOR-funded MedFirst, select overall treatment outcomes have improved. Within MedFirst programs, however, outcomes worsened over time, and racial disparities were evident. Though fentanyl's dominance of the drug supply alongside the COVID-19 pandemic contributed to these results, fidelity drift, particularly due to financial implications of MedFirst, likely also negatively impacted sustainability.
引言
密苏里州的“药物优先”（“MedFirst”）方法促进了阿片类药物使用障碍（MOUD）患者当天及长期的低门槛药物获取。自2017年以来，密苏里州由药物滥用和精神健康服务管理局（SAMHSA）资助的州针对性和州阿片类药物应对（STR/SOR）拨款，在州合同治疗项目中为患有阿片类药物使用障碍的未参保个人提供了MedFirst服务（包括医疗和心理社会服务）。尽管MedFirst早期取得了成功，但在实施五年后，必须重新审视其结果，同时关注可能存在的种族差异。
方法
我们利用该州的行为健康索赔数据，研究了四个结果：（1）MOUD的使用情况，（2）开始用药的时间，（3）心理社会服务量，以及（4）物质使用障碍（SUD）治疗的持续率。模型比较了四组人群：（a）实施第一年和第五年（2018年与2022年）参与MedFirst的个体，（b）参与MedFirst的个体与未参与MedFirst的个体，（c）MedFirst实施前（2017年）的个体与MedFirst第五年（2022年）的个体，以及（d）MedFirst内部和外部的白人个体与黑人个体。
结果
总体而言，MedFirst的结果优于未参与MedFirst的结果。然而，在参与MedFirst的个体中，2022年的结果总体上比2018年差，而且黑人个体的治疗疗程较短，接受MOUD治疗的可能性低于白人个体。总体而言，2022年密苏里州居民的结果仅比STR/SOR启动前略好。
结论
自密苏里州最初实施由STR/SOR资助的MedFirst以来，部分总体治疗结果有所改善。然而，在MedFirst项目中，随着时间的推移结果恶化，种族差异明显。尽管芬太尼在毒品供应中的主导地位以及新冠疫情导致了这些结果，但保真度漂移，特别是由于MedFirst的财务影响，可能也对可持续性产生了负面影响。
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