Multi-level associations between opioid use and overdose: Individual, clinical, and population-based risk factors for fatality

项目摘要：在过去的二十年里，阿片类药物处方的高比例导致了广泛的 阿片类药物使用和阿片类药物相关不良后果的流行水平。早期干预措施侧重于减少 通过制定实践指南和实施方案和政策来开阿片类药物处方 加强处方阿片类药物的管理和监测。虽然总体阿片类药物处方量有所下降， 近年来，可能有助于减少处方阿片类药物涉及的过量死亡率， 在2012年和2013年，这一比率已升至新高，占2016年所有阿片类药物相关死亡的40%。 此外，处方在弱势群体和地区仍然很高，突出表明需要更好地 了解个人特征如何与卫生系统和人口水平的因素交叉， 从阿片类药物使用到致命和非致命过量的途径。采用多层次方法，拟议项目 检查从阿片类药物治疗慢性非癌症疼痛到阿片类药物过量和死亡的轨迹， 考虑：1）个体社会人口统计学和临床特征（例如，性别，年龄，种族/民族， 合并症），2）阿片类药物治疗模式（例如剂量、持续时间、制剂），3）县级卫生系统 (e.g.设施、服务）和人口特征（例如贫困、少数民族、失业、残疾人百分比）， 和4）州级政策（例如医疗补助政策、处方药监测计划）。阿片类药物治疗 将使用国家医疗补助分析提取（MAX）数据评估模式，并根据个人情况进行调整。 特色将根据个体特征和治疗模式评估药物过量风险 使用医学治疗的非致死性阿片类药物过量的MAX数据和致死性阿片类药物过量的国家死亡指数（NDI）数据， 阿片类药物过量将使用县级地区卫生资源文件进一步评估药物过量结局 （AHRF）数据和州级政策措施。在更广泛的医疗保健中考虑个人结果 系统以及社会和地理环境支持NIDA增加公共卫生影响的战略计划 研究。额外的实质性和方法培训将有助于申请人的长期目标 发展独立的学术研究生涯，并生成和传播强有力的证据， 采取有效干预措施，减少类阿片相关发病率和死亡率。培训目标包括： 研究和应用：1）创新方法，以表征临床护理模式随着时间的推移，2）社会和 空间流行病学理论和方法，研究多层次的健康影响，3）卫生政策驱动因素 4）专业发展，进行道德，独立的研究。研究 由哥伦比亚大学研究人员组成的跨学科导师团队提供支持， 药物使用和政策研究、临床和空间流行病学以及统计学方面的专业知识， 在卫生服务和政策研究方法方面得到外部合作者的支持。这个项目和职业 发展计划将准备申请人，以确保R 01资金，以扩大这条线的研究。

PROJECT SUMMARY: Over the past two decades, high rates of opioid prescribing have led to widespread opioid use and epidemic levels of adverse opioid-related outcomes. Early interventions focused on reducing opioid prescribing through the development of practice guidelines and implementation of programs and policies to increase prescription opioid management and monitoring. While overall opioid prescribing has declined in recent years and may have contributed to reductions in prescription opioid-involved overdose death rates in 2012 and 2013, the rate has since risen to a new high, comprising 40% of all opioid-related deaths in 2016. Furthermore, prescribing remains elevated in disadvantaged groups and areas, highlighting a need to better understand how individual characteristics intersect with health system and population-level factors in the pathways from opioid use to fatal and non-fatal overdose. Using a multi-level approach, the proposed project examines trajectories from opioid treatment for chronic non-cancer pain to opioid overdose and fatality, accounting for: 1) individual sociodemographic and clinical characteristics (e.g. sex, age, race/ethnicity, comorbidities), 2) opioid treatment patterns (e.g. dosage, duration, formulation), 3) county-level health system (e.g. facilities, services) and population characteristics (e.g. percent poverty, minority, unemployed, disabled), and 4) state-level policies (e.g. Medicaid policies, Prescription Drug Monitoring Programs). Opioid treatment patterns will be assessed using national Medicaid Analytic Extract (MAX) data, adjusting for individual characteristics. Risk of overdose based on individual characteristics and treatment patterns will be assessed using MAX data for medically treated non-fatal opioid overdose and National Death Index (NDI) data for fatal opioid overdose. Overdose outcomes will be further assessed using county-level Area Health Resource File (AHRF) data and state-level policy measures. Contextualizing individual outcomes within wider health care systems and social and geographic settings supports NIDA’s strategic plan to increase the public health impact of research. Additional substantive and methodological training will contribute to the applicant’s long-term goal to develop an independent academic research career and generate and disseminate robust evidence to inform effective interventions to reduce opioid-related morbidity and mortality. The training aims include advanced study and application of: 1) innovative methods to characterize clinical care patterns over time, 2) social and spatial epidemiology theory and methods to study multilevel influences on health, 3) policy drivers of health and health care, and 4) professional development for conducting ethical, independent research. The research and training are supported by an interdisciplinary mentorship team of Columbia University researchers with expertise in substance use and policy research, clinical and spatial epidemiology, and statistics with additional support from external collaborators in health services and policy research methods. This project and career development plan will prepare the applicant to secure R01 funding to extend this line of research.