METHODS: This sub-analysis included patients randomized to receive methadone in PCCs as part of an implementation trial in which the control group received methadone in specialty addiction clinics in Ukraine. Methadone integration in PCCs was supported through continuous tele-education for providers. Provider stigma towards people who inject drugs, methadone, and attitudes towards evidence-based practices were assessed at baseline, 12, and 24 months using standardized scales (range 1-10). Patient-level outcomes were measured bi-annually over 24 months using a quality health indicator (QHI) score, a percentage of guideline-concordant primary and specialty health services accessed. Linear mixed-effects models examined the changes in provider stigma and attitudes, and the association of these measures with patient outcomes.
RESULTS: The sample included 583 patients and the 112 providers in 24 clinics. Provider fear and stereotypes toward people who inject drugs improved significantly, by 0.6 (95 % CI 0.2-1.1) and 0.4 points (95 % CI 0.1-0.8), respectively, as did preference for methadone over abstinence-based treatment (0.7 points, 95 % CI 0.2-1.1). A 1-point improvement in provider prejudice correlated with a 7.0-point increase (95 % CI: 1.1-13.0) in patient primary care QHI scores at 12 months, while improved attitudes towards evidence-based practices were associated with an 8.3-point increase (95 % CI: 1.1-13.0). Preference for methadone maintenance over abstinence was associated with a 3.7-point increase (95 % CI: 0.6-6.7) in specialty care QHI scores at 12 months, and reduced stereotypes were associated with a 10.9-point increase (95 % CI: 1.2-20.7) at 24 months.
CONCLUSIONS: Integrating methadone into PCCs with the support of provider tele-education may reduce provider stigma, particularly fear and stereotypes, toward people who inject drugs and methadone maintenance. Reducing provider stigma has the potential to improve patient outcomes through increased access to preventive care and screenings.
METHODS: Nominal Group Technique (NGT), a key ingredient of the NIATx toolkit, was directed by three trained coaches within a learning collaborative of 18 OAT clinicians and administrators to identify barriers to increase OAT capacity at the regional "oblast" level, develop solutions, and prioritize local change projects. NGT findings were supplemented from detailed notes collected during the NGT discussion.
RESULTS: The top three identified barriers included: (1) Strict regulations and inflexible policies dictating distribution and dispensing of OAT; (2) No systematic approach to assessing OAT needs on regional or local level; and (3) Limited funding and financing mechanisms combined with a lack of local/regional control over funding for OAT treatment services.
CONCLUSIONS: NGT provides a rapid strategy for individuals at multiple levels to work collaboratively to identify and address structural barriers to OAT scale-up. This technique creates a transparent process to address and prioritize complex issues. Targeting these priorities allowed leaders at the regional and national level to advocate collectively for approaches to minimize obstacles and create policies to improve OAT services.