Opioid Dose Trajectories and Associations With Mortality, Opioid Use Disorder, Continued Opioid Therapy, and Health Plan Disenrollment.
Opioid Dose Trajectories and Associations With Mortality, Opioid Use Disorder, Continued Opioid Therapy, and Health Plan Disenrollment.
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DOI：
10.1001/jamanetworkopen.2022.34671
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发表时间：
2022-10-03
影响因子：
13.8
通讯作者：
Glanz, Jason M.
中科院分区：
文献类型：
--
作者：
Binswanger, Ingrid A.;Shetterly, Susan M.;Xu, Stanley;Narwaney, Komal J.;McClure, David L.;Rinehart, Deborah J.;Nguyen, Anh P.;Glanz, Jason M.
该队列研究评估了阿片类药物剂量轨迹与死亡率、阿片类药物使用障碍、持续阿片类药物治疗和健康计划退出之间的关联。 1 年阿片类药物给药轨迹与死亡率、阿片类药物使用障碍、持续阿片类药物治疗以及给药轨迹结束后退出健康计划有何相关性？在这项包含 3913 名患者的队列研究中，与稳定的剂量轨迹相比，阿片类药物剂量轨迹的减少与阿片类药物使用障碍和持续阿片类药物治疗的风险降低相关，但也与退出风险增加相关。减少剂量与轨迹期结束后一年的死亡率无关；然而，增加剂量轨迹与死亡率和阿片类药物使用障碍风险增加相关，但与持续阿片类药物治疗或退出无关。这些发现表明，与维持稳定的阿片类药物剂量相比，临床医生和患者应仔细权衡阿片类药物剂量增加和减少的长期风险和益处。不同阿片类药物管理策略（例如逐渐减少和剂量递增）的长期益处和危害仍然存在不确定性。例如，逐渐减少阿片类药物可以帮助患者减少阿片类药物的暴露，以预防阿片类药物使用障碍，但患者也可能在其他地方寻求治疗并进行非处方阿片类药物使用。评估实践中观察到的阿片类药物剂量轨迹与患者结果之间的关联。这项回顾性队列研究是在科罗拉多州和威斯康星州的 3 个卫生系统中进行的。研究人群包括在2014年8月1日至2017年7月31日期间接受50至200吗啡毫克当量长期阿片类药物治疗的患者。随访于2019年12月31日结束。对2020年1月至2022年8月的数据进行分析。基于组的轨迹模型确定了1年内的5个给药轨迹：1个减少，1个高剂量增加，3 稳定。轨迹期后评估的主要结局是 1 年全因死亡率、阿片类药物使用障碍事件、1 年持续阿片类药物治疗以及健康计划退出。使用 Cox 比例风险回归和对数二项式模型测试关联，并调整基线协变量。该研究共纳入 3913 名患者（平均 [SD] 年龄 59.2 [14.4] 岁；2767 名非西班牙裔白人 [70.7%]；2237 名女性患者 [57.2%]）。与稳定轨迹相比，剂量下降轨迹与阿片类药物使用障碍（调整后风险比[aHR]，0.40；95% CI，0.29-0.55）和持续阿片类药物治疗（部位1：调整后相对风险[aRR]，0.39；95% CI，0.34-0.44）呈负相关，但与健康计划退出呈正相关（aHR， 1.66；95% CI，1.24-2.22）。下降轨迹与死亡率无关（aHR，1.28；95% CI，0.87-1.86）。相比之下，高剂量增加轨迹与死亡率（aHR，2.19；95% CI，1.44-3.32）和阿片类药物使用障碍（aHR，1.81；95% CI，1.39-2.37）呈正相关，但与退出（aHR，0.90；95% CI，0.56-1.42）或继续使用阿片类药物无关治疗（部位 1：aRR，0.98；95% CI，0.94-1.03）。在这项队列研究中，减少阿片类药物剂量与阿片类药物使用障碍和持续阿片类药物治疗的风险降低相关，但与稳定剂量相比，退出风险增加，而高剂量增加轨迹与死亡率和阿片类药物使用障碍风险增加相关。这些发现可以为阿片类药物管理决策提供信息。
This cohort study evaluates the association between opioid dose trajectory and mortality, opioid use disorder, continued opioid therapy, and health plan disenrollment. How are 1-year opioid dosing trajectories associated with mortality, opioid use disorder, continued opioid therapy, and health plan disenrollment after the end of the dosing trajectory? In this cohort study of 3913 patients, a decreasing opioid dose trajectory was associated with a lower risk of opioid use disorder and continued opioid therapy compared with stable dosing trajectories, but also was associated with an increased risk of disenrollment. Decreasing dose was not associated with mortality in the year after the end of the trajectory period; however, an increasing dose trajectory was associated with an increased risk of mortality and opioid use disorder but had no association with continued opioid therapy or disenrollment. These findings suggest clinicians and patients should carefully weigh the long-term risks and benefits of opioid dose increases and decreases compared with maintaining stable opioid dosing. Uncertainty remains about the longer-term benefits and harms of different opioid management strategies, such as tapering and dose escalation. For instance, opioid tapering could help patients reduce opioid exposure to prevent opioid use disorder, but patients may also seek care elsewhere and engage in nonprescribed opioid use. To evaluate the association between opioid dose trajectories observed in practice and patient outcomes. This retrospective cohort study was conducted in 3 health systems in Colorado and Wisconsin. The study population included patients receiving long-term opioid therapy between 50 and 200 morphine milligram equivalents between August 1, 2014, and July 31, 2017. Follow-up ended on December 31, 2019. Data were analyzed from January 2020 to August 2022. Group-based trajectory modeling identified 5 dosing trajectories over 1 year: 1 decreasing, 1 high-dose increasing, and 3 stable. Primary outcomes assessed after the trajectory period were 1-year all-cause mortality, incident opioid use disorder, continued opioid therapy at 1 year, and health plan disenrollment. Associations were tested using Cox proportional hazards regression and log-binomial models, adjusting for baseline covariates. A total of 3913 patients (mean [SD] age, 59.2 [14.4] years; 2767 White non-Hispanic [70.7%]; 2237 female patients [57.2%]) were included in the study. Compared with stable trajectories, the decreasing dose trajectory was negatively associated with opioid use disorder (adjusted hazard ratio [aHR], 0.40; 95% CI, 0.29-0.55) and continued opioid therapy (site 1: adjusted relative risk [aRR], 0.39; 95% CI, 0.34-0.44), but was positively associated with health plan disenrollment (aHR, 1.66; 95% CI, 1.24-2.22). The decreasing trajectory was not associated with mortality (aHR, 1.28; 95% CI, 0.87-1.86). In contrast, the high-dose increasing trajectory was positively associated with mortality (aHR, 2.19; 95% CI, 1.44-3.32) and opioid use disorder (aHR, 1.81; 95% CI, 1.39-2.37) but was not associated with disenrollment (aHR, 0.90; 95% CI, 0.56-1.42) or continued opioid therapy (site 1: aRR, 0.98; 95% CI, 0.94-1.03). In this cohort study, decreasing opioid dose was associated with reduced risk of opioid use disorder and continued opioid therapy but increased risk of disenrollment compared with stable dosing, whereas the high-dose increasing trajectory was associated with an increased risk of mortality and opioid use disorder. These findings can inform opioid management decision-making.
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