integration of treatment for opioid use disorders into ... · funding: r36da042643 (morozova),...

Integration of treatment for opioid use disorders into primaryhealth care centers in Ukraine

Olga Morozova

Department of Epidemiology of Microbial Diseases

Yale School of Public Health

2018 CUGH Conference

Olga Morozova Integration of OUD treatment into primary health care in Ukraine

Acknowledgements

Mentors and researchers: Frederick L. Altice, Sergey Dvoriak,A. David Paltiel

Funding: R36DA042643 (Morozova), R01DA043125 (Altice),grant 380A0689/P4044-47 from Pact Inc. (USAID funded project)

Medical providers and patients at the participating institutions

No conflict on interests declared


Background

Health care system in Ukraine still operates based on Semashko model (1918)with highly specialized, largely disintegrated services

Primary care centers provide only basic services, and mainly serve as referralmechanism

The urgent need for health care reform is recognized, but faces resistance andlacks clear implementation mechanisms

Standard-of-care for opioid agonist treatment (OAT) is based on specialty caredrug addiction clinics (aka ‘narcology’)

Mutual fear about the treatment of substance use disorders in primary carecenters by addiction and primary care doctors


Treatment integration at the primary care level

AdvantagesConvenient location, accessibility

Opportunity to simultaneously address co-morbid conditions (e.g. HIV,TB, acute and preventive care)

Opportunity for reduction in stigma and police harassment

ChallengesLack of training of primary care physicians with respect to substance usedisorders

Health care system organization and financing


Pilot project

Timeframe: 2014 - 2016

Three sites: Mykolaiv (N=1) and Poltava (N=2)

Preparation phase included: training of medical providers, development ofprotocols and SOPs, installation of infrastructure

The study aims were to assess:retention in treatment and patient satisfactionthe attitudes of primary care providers towards people with opioid use disordersimplementation factors unique to Ukrainian context


Study design

Longitudinal cohort study (6 months) using mixed methods approach

Study participants:narcology patients transitioning to primary care (N=31)narcology patients continuing at narcology (N=36)patients newly enrolled in primary care (N=40)primary care providers (N=26)

Qualitative component: in-depth interviews with patients and medicalproviders

Quantitative component: structured interviews with patients and medicalproviders and medical chart reviews


Primary outcome: patient retention in treatment

MethadoneCon+nua+onSOC

N=36

MethadoneTransferN=31

MethadoneIni+atedN=40

N=32(89%) N=29(94%) N=32(80%)

Stud

yGrou

p6-mon

th

Reten+

on

1TB1Incarcerated2Discon+nued

1Death1Incarcerated

1Death1TB4Discon+nued1Moved1Hospitaliza+on

•  Male:27(75%)•  Mykolaiv:22(61%)•  Poltava:14(39%)•  Age:39.9(6.6)




Secondary outcomes: patient - level

Outcome

Transitioning patients New patients

N=29 N=38

BL 6M p-value BL 6M p-value

Days injecting (last 30) 1.31 1.45 0.547 27.87 0.21 <0.001

Satisfaction with the program (5-point) 3.76 4.45 0.016 - 4.79 -

Trust in physician (11-55) 31.07 35.5 0.007 32.39 38.47 <0.001

Health-related quality of life (0-100) 58.22 53.52 0.164 58.26 65.59 0.013

... maybe several days. I was taking methadone and still “diving” [slang word for injecting

drugs, OM], meaning was getting street drugs. And then I realized that it makes no sense,

it’s just wasting money. That’s it. And it’s fine.

New patient, Mykolaiv



Outcome


N=29 N=38






Completely satisfied with everything. Starting from the fact that the site is near my home;

and it is also close to where I work. So I have more time for my family and personal life.

Transitioned patient, Poltava



Outcome


N=29 N=38






... at Volodarskogo [address of the narcology clinic in Mykolaiv, OM] nobody asked how I

was doing, how my health was. Nobody asked those questions. And here [at the primary

care clinic, OM] when you visit, you see that people are interested, that they are not

indifferent.

Transitioned patient, Mykolaiv



Outcome


N=29 N=38






I didn’t have to run around and look for some doctors and wait in lines. [...] at least half of

these cases, I would not even go to the doctor, I mean, I understand complications of the

process [...] And here it is, well, much easier. At least for us. If you compare the primary

care and addiction treatment clinic.

Transitioned patient, Poltava


Secondary outcomes: provider - level

7.6

2.9

6.0

8.3

6.2

8.0

0

1

2

3

4

5

6

7

8

9

10

Generalpatients Drug-usingpatients HIVpatients

10-PointThe

rmom

eterScale

baseline 6-monthsfollow-up

P=0.173 P=0.004 P<0.001

Changes in Primary Care Providers’ Attitudes Toward the Three Types of Patients (N=26)

We had fears. Fears about

working with these patients. But

when we started working [with

them], it went away. Because

when you don’t do anything,

there is a fear, but when you do,

then everything can be solved.

Medical provider, Poltava


Other implementation lessons

The integrated care model was initially perceived as “foreign” concept,but accepted

Initial resistance from addiction doctors to transfer patients and fromprimary care providers to work with PWID

Not every integration model was the same


Conclusions

Integrating treatment for opioid use disorders within primary health caresettings is feasible in Ukraine:

Patient-level outcomes at the primary care were either better or not worsethan those at the specialty care

Medical providers at the primary care sites showed substantial improvementin attitudes towards POUD

Integrated care is still vague for many physicians


Next steps: multi-site cluster RCT (R01 DA043125, Altice)

Type I hybridimplementationscience study

36 sites in 12regions

1,450 patients

24 months offollow-up


Thank you!

Дякую!

Спасибо!

Questions?


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