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

阿片类药物误用、滥用、成瘾和过量是一种严重的公共卫生危机，也是导致 死亡在美国补充和综合健康（CIH）方法疼痛可能有助于减少阿片类药物 相关危害。然而，2016年VA QUERI ESP报告指出，“关于 选择CIH干预措施减少阿片类药物使用的有效性非常有限。此外该 综合成瘾和康复法案（CARA; PL 114-198）由国会于2016年7月22日签署成为法律 明确呼吁“扩大研究和教育，并提供互补和综合的 “老兵的健康”（标题IX，副标题C，SEC。931）。 CIH对VA中阿片类药物使用和疼痛相关结局的影响知之甚少。肌肉骨骼 创伤后应激障碍（MSD）和创伤后应激障碍（PTSD）是退伍军人管理局护理的退伍军人中最常见的两种疾病，而且他们的 科摩罗比例很高：两者都在增加，特别是在妇女中。患有创伤后应激障碍的退伍军人有很高的风险， 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被处方阿片类药物， 苯二氮卓类药物，并经历不良后果。由于创伤后应激障碍的潜在相互强化 和疼痛症状，CIH可能有助于减少阿片类药物的启动和伤害许多退伍军人与创伤后应激障碍。VA/DoD 指南建议选择CIH在疼痛和PTSD中的作用。CDC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VA护理中使用CIH的程度并不为人所知，部分原因是大多数CIH数据 包含在非结构化的电子健康记录（EHR）字段中，这些字段无法进行量化。我们将 检查患有MSD的退伍军人使用和不使用CIH，并比较PTSD的阿片类药物和疼痛结局 status.这是一个预测CIH未来需求并检查利益和危害模式的机会。 我们将使用肌肉骨骼疾病队列研究（CRE 12 -012）的算法来识别退伍军人， MSD，并通过结构化数据（例如CPT和ICD代码）和非结构化信息学工具确定CIH的使用情况 数据（如临床记录）。我们将研究针灸，按摩，冥想/正念和瑜伽，因为它们 目前或可能被纳入常规VA护理。仅使用结构化数据，我们确定了7，621个CIH 在2011 - 2013财年，MSD队列进入者中的使用者（n= 309，277）;其中，21%有PTSD诊断。阿片 其他药物将从药房数据中识别。根据临床观察，CIH的益处 并不统一。一些患者经历了戏剧性和长期的疼痛缓解，而另一些则没有。一些益处 从一种特定的CIH模式到另一种。支持个性化治疗，优化未来 结果，我们还将比较预定义的人口统计学和临床亚组之间的反应。 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， 影响是否因退伍军人的人口统计学和临床特征而异，特别注意 退伍军人与创伤后应激障碍的诊断，并检查CIH使用的潜在危害，包括新的诊断 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.