INDIVIDUAL PLACEMENT AND SUPPORT FOR VETERANS WITH OPIOID USE DISORDER: A MIXED METHODS STUDY

Background: Living with an opioid use disorder (OUD) can make finding and sustaining employment a significant challenge and is only getting worse in the COVID-19 environment. With states reporting unemployment rates as high as 15-20%, the negative effects of unemployment on OUD treatment outcomes are expected to deteriorate. The COVID-19 pandemic has further resulted in treatment disruptions that are exacerbating poor outcomes, because of unemployment, social isolation, interrupted access to medication for OUD treatment (MOUD), and interference of daily routines that provide the necessary structure for many people with OUD. Our group has conducted research that shows Individual Placement and Support (IPS) is efficacious in yielding more weeks worked and higher steady employment rates for Veterans with posttraumatic stress disorder and Veterans diagnosed with a broad range of mental conditions (including substance use) being treated in a primary care setting; however, little is known about its efficacy in Veterans with OUD. Only one small study in civilians (n=45) with OUD has been conducted, in which 50% of the participants assigned to IPS gained employment compared to 5% of waitlist control at 6 months follow-up (p<0.001). A systematic review of effectiveness of IPS with conditions other than serious psychiatric mental illness revealed major limitations in many studies, including small sample sizes, major modifications to IPS model, weak control, and short follow-up periods. A larger randomized controlled trial of IPS for Veterans recovering from OUD with longer follow-up period, strong treatment control, and strict adherence to IPS fidelity, such as the one we propose, is warranted. Methods: This is a prospective, multi-site, randomized controlled trial to determine the efficacy of IPS compared to non-IPS Treatment-as-Usual Vocational Rehabilitation (TAU-VR) in a sample of 120 Veterans recovering from OUD (Aim 1). Investigators hypothesize that Veterans with OUD randomized to IPS will work significantly more weeks in a competitive job over 15 months compared to the non-IPS TAU-VR group. Additionally, compared to non-IPS TAU-VR, IPS recipients will earn significantly more income from competitive jobs and be significantly more likely to achieve steady employment. The investigators will also evaluate self-report measures of resilience, quality of life, perceived stress, community engagement, depression, anxiety, abstinence self-efficacy and suicide risk. As Aim 2, using a Community Based Participatory Research (CBRP) approach, the investigators will identify the contextual barriers to and facilitators of implementing vocational services for Veterans in both the IPS and non-IPS TAU-VR study arms, including evaluation of employment challenges, optimal occupational functioning, and OUD treatment adherence, with specific emphasis on the impact of COVID-19 and social distancing. To address Aim 2, the investigators will conduct semi-structured interviews with Veterans with OUD randomized to IPS or non-IPS TAU-VR. These interviews will be supplemented by qualitative findings from an ongoing Rehabilitation R&D pilot study that includes qualitative interviews on the same topic with IPS specialists, providers, unemployed veterans with OUD, and potential employers. Working with a CBPR Steering Committee, findings will be aggregated to reach consensus on best practices for IPS implementation in this new population. In an Exploratory Aim 3, the impact of IPS will be compared to non-IPS TAU-VR on participants' adherence to MOUD and rates of OUD relapse. Significance: This study seeks to find the best intervention for successful recovery and functional reintegration for Veterans recovering from OUD. This study is especially timely given the societal impact of the COVID-19 pandemic on employment and mental health problems of the general population, and Veterans specifically. Additionally, with the new VHA plan to expand supported employment services to Veterans with substance use disorders in the coming years, our study is timely and can significantly contribute to the evidence required to successfully implement and sustain supported employment services in this new priority population.