ASSOCIATION OF COMPLEMENTARY AND INTEGRATIVE HEALTH (CIH)INTERVENTIONS WITH OPIOID USE AND RELATED RISKS AMONG VETERANS WITH MUSCULOSKELETAL DISORDERS (MSD) AND PTSD

阿片类药物的滥用、滥用、成瘾和过量是一种严重的公共卫生危机，也是 美国的死亡案例。治疗疼痛的互补和综合健康(CIH)方法可能有助于减少阿片类药物 相关伤害。然而，2016年退伍军人管理局QUERI ESP的一份报告称，“关于 选定的CIH干预措施减少阿片类药物使用的有效性极其有限。“此外， 《全面成瘾和康复法案》(CARA；PL 114-198)于2016年7月22日由国会签署成为法律 明确要求“扩大对补充性和综合性的研究和教育 为退伍军人的健康干杯。(标题IX，副标题C，第二节931)。 CIH对退伍军人中阿片类药物使用和疼痛相关结局的影响还知之甚少。肌肉骨骼 精神障碍(MSD)和创伤后应激障碍(PTSD)是退伍军人中最常见的两种疾病，他们 合并症很高：两者都在增加，特别是在女性中。患有创伤后应激障碍的退伍军人有很高的风险 与阿片类药物相关的危害。患有疼痛和创伤后应激障碍的退伍军人更有可能服用阿片类药物和 苯二氮卓类药物，并经历不良后果。由于创伤后应激障碍潜在的相互强化作用 和疼痛症状，CIH可能有助于减少阿片类药物的启动和许多患有创伤后应激障碍的退伍军人的伤害。退伍军人事务部/国防部 指南建议选择CIH治疗疼痛和创伤后应激障碍。美国疾病控制与预防中心阿片类药物治疗指南 慢性疼痛促进了非药物治疗，使得对CIH的需求可能会增加。 然而，退伍军人在退伍军人中使用CIH的程度并不为人所知，部分原因是大多数CIH数据 包含在非结构化电子健康记录(EHR)字段中，无法立即量化。我们会 检查患有MSD的退伍军人中使用和未使用CIH的情况，并比较创伤后应激障碍对阿片类药物和疼痛的影响 状态。这是一个预测未来对CIH的需求并检查益处和危害模式的机会。 我们将使用肌肉骨骼疾病队列研究(CRE12-012)中的算法来识别患有 MSD，并通过结构化数据(例如CPT和ICD代码)和非结构化信息工具确定CIH的使用 数据(例如，临床记录)。我们将研究针灸、按摩、冥想/正念和瑜伽 目前或可能被纳入常规退伍军人管理局的护理。仅使用结构化数据，我们确定了7621个CIH 2011-2013财年MSD队列参与者中的用户(n=309,277)；其中21%被诊断为创伤后应激障碍。阿片类药物 其他药物将从药房数据中识别出来。根据临床观察，CIH的益处 是不统一的。一些患者经历了戏剧性的、长期的疼痛缓解，而另一些患者则没有。一些好处 从一种特定的CIH模式与另一种模式。支持个性化治疗，优化未来 结果，我们还将比较预先定义的人口学和临床子组之间的反应。 我们的具体目标是评估CIH对患有MSD的退伍军人中阿片类药物启动的影响，估计 效果是否因退伍军人的人口统计和临床特征而异，并特别注意 诊断为创伤后应激障碍的退伍军人，并检查使用CIH的潜在危害，包括新诊断的 抑郁症。

Opioids misuse, abuse, addiction, and overdose are a serious public health crisis, and a leading cause of death in the USA. Complementary and integrative health (CIH) approaches to pain may help reduce opioid related harms. However, a 2016 VA QUERI ESP report stated that “the evidence base regarding the effectiveness of select CIH interventions for reducing opioid use is extremely limited.” In addition, the Comprehensive Addiction and Recovery Act (CARA; PL 114-198) signed by Congress in to law on 7/22/2016 explicitly calls for “expansion of research and education on and delivery of complementary and integrative health to veterans.” (Title IX, Subtitle C, Sec. 931). The impact of CIH on opioid use and pain-related outcomes in VA is poorly understood. Musculoskeletal disorders (MSD) and PTSD are two of the most prevalent disorders among Veterans in VA care, and their comorbidity is high: both are increasing, especially among women. Veterans with PTSD are at high risk for opioid related harms. Veterans with pain and PTSD are more likely to be prescribed opioids and benzodiazepines, and experience adverse outcomes. Because of the potential mutual reinforcement of PTSD and pain symptoms, CIH may help reduce opioid initiation and harms for many Veterans with PTSD. VA/DOD guidelines suggest a role for select CIH for both pain and for PTSD. The CDC Guideline for Opioid Therapy for Chronic Pain promotes non-pharmacologic treatments, making it likely that the demand for CIH will increase. However, the extent of CIH use among Veterans in VA care is not well-known, in part because most CIH data are contained in unstructured electronic health record (EHR) fields that defy ready quantification. We will examine CIH use and non-use among Veterans with MSD and compare opioid and pain outcomes by PTSD status. This is an opportunity to anticipate future needs for CIH and to examine patterns of benefit and harms. We will use algorithms from the Musculoskeletal Disorders cohort study (CRE12-012) to identify Veterans with MSD, and identify CIH use via structured data (e.g. CPT and ICD codes) and informatics tools on unstructured data (e.g. clinical notes). We will examine acupuncture, massage, meditation/mindfulness and yoga as they are currently or likely to be integrated into routine VA care. Using structured data only, we identified 7,621 CIH users among MSD cohort entrants in FY11-FY13 (n= 309,277); of which, 21% had a PTSD diagnosis. Opioid and other medications will be identified from pharmacy data. Based on clinical observations, the benefit of CIH is not uniform. Some patients experience dramatic and long term pain relief, while others do not. Some benefit from one specific CIH modality versus another. To support personalized treatment and optimize future outcomes, we will also compare responses among pre-defined demographic and clinical sub-groups. Our specific aims are to assess the impact of CIH on opioid initiation among Veterans with MSD, estimate whether the effect varies by Veterans demographic and clinical characteristics, with particular attention to Veterans with a PTSD diagnosis, and to examine potential harms of CIH use, including new diagnoses of depressive disorders.