Risks of Cannabis Use Among Veterans on Long-term Opioid Therapy

背景：尽管大麻在普通人群中的使用量有所增加，但关于大麻的数据很少 与使用相关的潜在危害。在随机对照试验中检验以THC为基础的 药物对疼痛的管理，不良反应包括头晕、镇静、神志不清、失神。 平衡、恶心、呕吐和幻觉。这些副作用表明，大麻与大麻联合使用 使用阿片类药物--这也会导致头晕、镇静、精神错乱、呼吸抑制、恶心、呕吐和 便秘--可能特别有害。年龄较大的退伍军人，以及有潜在呼吸系统和心脏疾病的人 在某些情况下，阿片类药物和大麻的联合使用可能有更高的不良反应风险。另一方面 另一方面，一些生态研究表明，以州为基础的娱乐合法化可能与 与阿片类药物有关的死亡人数减少。因此，大麻的使用，通过减少阿片类药物的使用， 减少呼吸抑制和过量用药的风险。然而，生态研究检验了 阿片类药物相关死亡合法化无助于我们理解联合使用阿片类药物的影响 大麻和阿片类药物对个人健康的影响。了解联合使用大麻和大麻的影响 阿片类药物对个体患者预后的影响至关重要。目前尚无证据可供参考 退伍军人管理局关于接受阿片类药物的慢性疼痛患者使用大麻的指南。 意义：虽然大麻的使用在患有慢性疼痛的退伍军人中很常见，但风险或好处 退伍军人在长期阿片类药物治疗(LTOT)中使用大麻的情况尚不清楚。这项建议是直接 回应退伍军人事务部实践指南和重点关注的HSR&D优先领域确定的研究差距 研究老年退伍军人和退伍军人长期阿片类药物治疗的安全性和有效性问题 精神健康(非疼痛)状况“。我们的建议亦回应高铁及发展的优先范畴： “使用数据挖掘策略评估LTOT队列研究的可行性。” 创新：弥补文献中关于大麻使用的潜在危害(或益处)的空白 在接受长期阿片类药物治疗的患者中，我们提出了一种创新的方法来建立队列，使用 尿药筛查数据、文本处理算法(由我们团队开发)和国家VA的组合 和医疗保险数据对暴露状态进行分类(伴随的大麻加阿片类药物与不加阿片的阿片类药物 (大麻)，以实现以下目标： 具体目标：目标1：审查大麻使用与所有原因的结果之间的联系 长期使用阿片类药物的18岁退伍军人≥死亡率。目标2：检查两者之间的关联 大麻使用对全因死亡的主要后果和住院的次要后果的影响 在65岁的退伍军人中，≥患有慢性阻塞性肺疾病、充血性心力衰竭或 睡眠呼吸暂停。目的3：研究大麻与全因死亡和非吸食大麻之间的关系。 任何住院、与跌倒相关的伤害、任何伤害和因情绪而住院的次要结果 65岁的退伍军人精神障碍≥长期服药。 方法：我们将利用VA数据源，并使用从进度笔记、尿液中提取的数据 毒理学数据，以及国家退伍军人管理局和医疗保险管理数据，以回答一个临床相关的问题。我们 将使用倾向计分方法比较大麻使用者和非使用者的一年结果。 下一步：下一步包括向退伍军人管理局研究人员和临床和 运营领导。研究结果将为退伍军人管理局指南和临床实践提供信息。

Background: Despite increasing cannabis use among the general population, very little data exists on potential harms associated with use. In randomized controlled trials examining the effect of THC-based pharmaceuticals on the management of pain, adverse events included dizziness, sedation, confusion, loss of balance, nausea, vomiting, and hallucination. These side effects suggest that cannabis used in combination with opioids—which also cause, dizziness, sedation, confusion, respiratory depression, nausea, vomiting and constipation—may be particularly harmful. Older Veterans, and those with underlying respiratory and cardiac conditions, may be at higher risk of adverse effects from combined opioid and cannabis use. On the other hand, several ecological studies suggest that state-based recreational legalization may be associated with a decrease in opioid related deaths. Thus, it is plausible that cannabis use, by reducing the use of opioids, reduces respiratory depression and the risk of overdose. However, ecological studies examining the effect of legalization on opioid related deaths do not inform our understanding of the effects of combined use of cannabis and opioids on individual health. Understanding the effects of the combined use of cannabis and opioids on individual patient outcomes is critically important. No evidence base is currently available to inform VA guidelines on cannabis use among chronic pain patients who receive opiates. Significance: Although cannabis use is common among Veterans with chronic pain, the risk or benefits of cannabis use among Veterans on long-term opioid therapy (LTOT) is unknown. This proposal is directly responsive to research gaps identified by VA practice guidelines and the HSR&D priority area focused on “Studying safety and efficacy issues related to long-term opioid therapy among aging Veterans and Veterans with mental health (non-pain) conditions”. Our proposal is also responsive to the HSR&D priority area: “Assessing the feasibility of LTOT cohort studies using data-mining strategies.” Innovation: To address the gaps in the literature on the potential harms (or benefits) of cannabis use among patients on long-term opioid therapy, we propose an innovative approach to cohort construction using a combination of urine drug screen data, text processing algorithms (developed by our team), and national VA and Medicare data to categorize exposure status (concomitant cannabis plus opioid vs. opioid without cannabis) to address the following aims: Specific Aims: Aim 1: To examine the association of cannabis use on the outcome of all-cause mortality among Veterans ≥18 years-old who use long-term opioids. Aim 2: To examine the association of cannabis use on the primary outcome of all-cause mortality and the secondary outcomes of hospitalization among Veterans ≥65 years-old on LTOT with chronic obstructive lung disease, congestive heart failure or sleep apnea. Aim 3: To examine the association of cannabis on the primary outcome of all-cause mortality and the secondary outcomes of any hospitalization, fall-related injury, any injury, and hospitalization for mood disorders among Veterans ≥65 years-old on LTOT. Methodology: We will leverage VA data sources and use data extracted from progress notes, urine toxicology data, and national VA and Medicare administrative data to answer a clinically relevant question. We will use propensity score methods to compare one-year outcomes among cannabis users and non-users. Next Steps: Next steps include dissemination of the findings to VA researchers and clinical and operational leaders. Study findings will be informative to VA guidelines and clinical practice.