Prescription opioid use and changes in pain intensity in older Veterans

描述(申请人提供)：近年来，用于治疗慢性非癌症疼痛的阿片类药物显著增加。然而，目前尚不清楚在急性护理之外使用阿片类药物在多大程度上改善了患者的预后，以及哪些患者最有可能从阿片类药物中受益。老年人使用阿片类药物的情况也有类似的增加，但 关于阿片类药物对老年人疼痛的有效性，现有的经验性信息很少。此外，老年人可能面临与处方阿片类药物相关的副作用和不良事件的更大风险。退伍军人事务部(VA)收集疼痛强度信息作为常规护理的一部分；所有患者都在 几乎所有的门诊就诊。包括疼痛强度评分和药房信息在内的国家级数据存储在退伍军人管理局的中央数据库中。该项目直接响应了RFA-AG-12-006，“利用现有数据或纵向研究来评估老年人慢性疼痛的药理学管理的安全性和有效性(R03)”，并利用了研究人员可以从国家VA数据库中获得的一组关于疼痛强度和处方阿片类药物使用的独特纵向数据。这个项目扩展了研究团队正在进行的检查疼痛相关结果和阿片类药物处方模式的工作，以进一步了解老年人中的阿片类药物治疗结果。这项研究的具体目标是确定处方阿片类药物在多大程度上与在退伍军人管理局医疗系统接受治疗的老年人疼痛强度的改善有关。使用回溯性队列设计，我们将检查65岁及以上的全国退伍军人样本，他们在2010年接受退伍军人护理，有中等或更高的疼痛强度，以及在之前12个月内没有服用阿片类药物。在阿片类药物开始使用后，一组有新阿片类药物开始的退伍军人将接受为期12个月的检查。大部分数据将从国家退伍军人事务部数据仓库获得。我们将使用COX回归模型进行生存分析，以确定与主要结果、数字评定量表(NRS)疼痛强度评分改善时间相关的因素。我们将确定预测改善时间的患者、药物相关和地点因素，包括患者人口统计和有记录的临床诊断、阿片类药物剂量和使用频率以及VA设施类型和地理区域。倾向性分数将用于调整与阿片类药物启动相关的可测量特征，在二次分析中，我们将使用地理区域作为工具变量，调整未测量的疾病严重性和阿片类药物启动之间的关系。这项研究的结果将提供有关以下影响的重要信息 处方阿片类药物对老年人疼痛治疗结果的影响。结果将对退伍军人、患有疼痛的老年人和治疗慢性疼痛的临床医生产生相当大的兴趣。

DESCRIPTION (provided by applicant): The use of opioid medications to treat chronic non-cancer pain has increased markedly in recent years. However, it is unclear to what extent the use of opioids beyond acute care improves patient outcomes and which patients are most likely to benefit from opioids. The use of opioid medications in older adults has similarly increased, but there is very little empiric information available regarding the effectiveness of opioids for pain n older adults. In addition, older adults may be at greater risk for side effects and adverse events related to prescription opioids. The Department of Veterans Affairs (VA) collects pain intensity information as part of routine care; all patients are administered brief pain intensity measures at almost all outpatient visits. National level data including pain intensity scores and pharmacy information are stored in central VA administrative databases. This project responds directly to RFA-AG-12-006, "Leveraging Existing Data or Longitudinal Studies to Evaluate Safety and Effectiveness of Pharmacological Management of Chronic Pain in Older Adults (R03)," and takes advantage of a unique set of longitudinal data on pain intensity and prescription opioid use available to the researchers from national VA databases. This project extends the research teams' ongoing work examining pain-related outcomes and opioid prescribing patterns to further our understanding of opioid treatment outcomes among older adults. The specific objective of this study is to determine to what extent prescription opioids are associated with improvements in pain intensity among older adults treated in the VA healthcare system. Using a retrospective cohort design, we will examine a national sample of Veterans ages 65 years and older, who received VA care in 2010, who had moderate or greater pain intensity levels, and who had not been prescribed opioids in the prior 12 months. A subgroup of Veterans with new opioid starts will be examined for 12 months following opioid initiation. Most data will be obtained from the national VA Corporate Data Warehouse. We will conduct survival analysis using Cox regression models to identify factors associated with the main outcome, time to improvement in Numeric Rating Scale (NRS) pain intensity score. We will identify patient, medication-related, and site factors that predict time to improvement, including patient demographics and documented clinical diagnoses, opioid medication dose and frequency of use, and VA facility type and geographic region. Propensity scores will be used to adjust for measurable characteristics associated with opioid initiations, and in a secondary analysis, we will use geographic region as an instrumental variable to adjust for relationships between unmeasured disease severity and opioid initiations. Findings from this study will provide important information about the impact of prescription opioids on pain treatment outcomes in older adults. Results will be of considerable interest to Veterans, older adults with pain, and clinicians who treat chronic pain.