The impact of chronic pain on buprenorphine treatment retention among patients with opioid use disorder.

摘要 减少全国类阿片相关发病率和死亡率流行的一个关键方法包括 最大限度地提高OUD患者中阿片类激动剂治疗（OAT）的保留率。特别是，OAT 与美沙酮相比，使用丁丙诺啡可能是许多OUD患者的合适起点 鉴于其相对较宽的安全性（例如，过量的可能性较低），并增加了可及性， 降低相关的耻辱感，因为它可以在办公室的医疗环境中开处方。然而，在 使用丁丙诺啡的比例，长期治疗保留率，这对促进 最好的结果是低。因此，更好地了解充分丁丙诺啡治疗的障碍 为了使目前的有效治疗实践最优化，需要保留这些数据。一 许多OUD患者中可能对丁丙诺啡治疗保留产生负面影响的常见因素是 慢性非癌性疼痛（CNCP）。目前的研究表明， 大约三分之二的OUD患者在医疗环境中，丁丙诺啡治疗可以 适用，具有共同发生的CNCP条件。然而，尽管CNCP在患者中流行， 对于OUD，关于其对丁丙诺啡治疗保留的影响知之甚少。目前R03 一项提案将通过对大型电子健康记录的二次分析来解决文献中的这一空白 接受丁丙诺啡治疗OUD的患者数据库。该应用程序的总体目标是更好地 了解CNCP如何作为降低丁丙诺啡保留的风险因素，以及如何 可以优化丁丙诺啡治疗，以改善同时发生 OUD和CNCP。具体而言，我们将首先确定CNCP对治疗的影响程度 保留取决于通过多级生长曲线建模表征的治疗期间不受控制的疼痛。 为了补充这些发现，我们将进行回顾性病历审查，以确定 报告了持续疼痛与其他原因导致提前停药。原因也将是 通过临床定义的丁丙诺啡依从性轨迹组进行识别，以指示 停止的原因。此外，我们的目标是阐明丁丙诺啡剂量与 同时发生OUD和CNCP的患者中的治疗保留，这可能代表了一种可改变的 这是一个可以用来提高保留率的因素。总之，这项研究的结果可能会告诉我们， 有针对性的努力，以提高现有治疗OUD的临床效果，面对快速 类阿片流行病日益严重，这最终可能导致类阿片相关发病率进一步下降， 死亡率和昂贵的医疗保健利用。

Abstract A critical approach to reducing the national epidemic of opioid-related morbidity and mortality includes maximizing retention rates of opioid agonist therapy (OAT) among individuals with OUD. In particular, OAT using buprenorphine, compared to methadone, may be a suitable starting point for many patients with OUD given its relatively broader safety profile (e.g., lower likelihood of overdose), and increased accessibility and lower associated stigma given that it can be prescribed in office-based medical settings. Nevertheless, among the fraction that do utilize buprenorphine, rates of long-term treatment retention, which are crucial to facilitating best outcomes, are low. Thus, a better understanding of the barriers to sufficient buprenorphine treatment retention are needed in order to inform efforts at optimizing current practice of an effective treatment. One factor common among many patients with OUD that may negatively affect buprenorphine treatment retention is the co-occurring presence of chronic non-cancer pain (CNCP). Current research shows that up to approximately two-thirds of patients with OUD in medical settings, for whom buprenorphine treatment could be applicable, have a co-occurring CNCP condition. However, despite the prevalence of CNCP among patients with OUD, remarkably little is known about its impact on buprenorphine treatment retention. The present R03 proposal will address this gap in the literature through secondary analysis of a large electronic health record database of patients receiving buprenorphine treatment for OUD. The overall goal of this application is to better understand how CNCP may operate as a risk factor for lower buprenorphine retention, and in turn, how buprenorphine treatment can be optimized to improve retention outcomes among patients with co-occurring OUD and CNCP. Specifically, we will first determine the extent to which the impact of CNCP on treatment retention depends on uncontrolled pain during treatment characterized via multi-level growth curve modeling. To supplement these findings, we will conduct retrospective chart reviews to identify the extent to which ongoing pain vs. other reasons were reported for premature treatment discontinuation. Reasons will also be identified by empirically-defined buprenorphine adherence trajectory groups to indicate temporal specificity of discontinuation reasons. Furthermore, we aim to elucidate the association between buprenorphine dose and treatment retention among patients with co-occurring OUD and CNCP, which may represent a modifiable factor that could be targeted to improve retention. Together, the findings from this research may inform targeted efforts to enhance the clinical impact of an already existing treatment for OUD in the face of a rapidly increasing opioid epidemic, which could ultimately lead to greater reductions in opioid-related morbidity and mortality and costly healthcare utilization.