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

患有肌肉骨骼疾病 (MSD) 和创伤后应激障碍 (PTSD) 退伍军人中阿片类药物使用及相关风险的补充和综合健康 (CIH) 干预协会

• 批准号: 9729450
• 负责人: Joseph Lucien Goulet
• 金额: --
• 依托单位: VA CONNECTICUT HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-05-01 至 2022-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9729450
• 关键词: Acupuncture Therapy; Adopted; Adverse event; Algorithms; Area; Attention; Back; Benzodiazepines; Caring; Cause of Death; Centers for Disease Control and Prevention (U.S.); Characteristics; Clinic; Clinical; Cohort Studies; Complementary Health; Congresses; Current Procedural Terminology Codes; Data; Depressive disorder; Diagnosis; Disease; Documentation; Education; Effectiveness; Electronic Health Record; Event; Future; Guidelines; Health; Health Services; High Prevalence; Incidence; Integrative Medicine; International Classification of Disease Codes; Intervention; Laws; Massage; Meditation; Mental Depression; Modality; Modeling; Morbidity - disease rate; Musculoskeletal Diseases; Neck; Opioid; Outcome; Overdose; Pain; Pain management; Pain quality; Patients; Pattern; Pharmaceutical Preparations; Pharmacy facility; Population; Post-Traumatic Stress Disorders; Provider; Psychological reinforcement; Public Health; Recovery; Reporting; Research; Risk; Role; Series; Services; Standardization; Statistical Data Interpretation; Subgroup; Surveys; Symptoms; Time; Title IX; Veterans; Woman; Yoga; addiction; adverse outcome; base; chronic pain; cohort; comorbidity; evidence base; experience; health data; high risk; improved; informatics tool; interest; mindfulness meditation; mortality; musculoskeletal disorder diagnosis; non-cancer chronic pain; opioid misuse; opioid policy; opioid therapy; opioid use; pain outcome; pain relief; pain symptom; personalized medicine; prescription opioid; programs; response; side effect; structured data; theories; treatment optimization; unstructured data; willingness

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.

阿片类药物滥用、滥用、成瘾和过量是严重的公共卫生危机，也是导致 在美国死亡。补充和综合健康 (CIH) 治疗疼痛的方法可能有助于减少阿片类药物的使用 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效果极其有限。”此外， 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补充性和综合性的 为了退伍军人的健康。” （第九章，副标题 C，第 931 节）。 CIH 对 VA 中阿片类药物使用和疼痛相关结果的影响知之甚少。肌肉骨骼 疾病 (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，他们的症状 合并症很高：两者都在增加，特别是在女性中。患有创伤后应激障碍 (PTSD) 的退伍军人面临高风险 阿片类药物相关的危害。患有疼痛和创伤后应激障碍 (PTSD) 的退伍军人更有可能服用阿片类药物 苯二氮卓类药物，并经历不良后果。因为 PTSD 可能相互强化 和疼痛症状，CIH 可能有助于减少阿片类药物的使用和对许多患有 PTSD 退伍军人的伤害。弗吉尼亚州/国防部 指南建议选择 CIH 对疼痛和 PTSD 都有作用。 CDC 阿片类药物治疗指南 慢性疼痛促进了非药物治疗，使得对慢性疼痛的需求可能会增加。 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 包含在无法立即量化的非结构化电子健康记录 (EHR) 字段中。我们将 检查患有 MSD 的退伍军人中 CIH 使用和不使用的情况，并通过 PTSD 比较阿片类药物和疼痛结果 地位。这是一个预测 CIH 未来需求并检查利弊模式的机会。 我们将使用肌肉骨骼疾病队列研究 (CRE12-012) 的算法来识别患有以下疾病的退伍军人 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识别 CIH 的使用 数据（例如临床记录）。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 护理中。 Using structured data only, we identified 7,621 CIH 2011 财年至 2013 财年默沙东队列进入者中的用户 (n= 309,277)；其中，21% 的人患有创伤后应激障碍 (PTSD)。阿片类药物 和其他药物将从药房数据中识别。根据临床观察，CIH 的益处 不统一。有些患者的疼痛得到显着且长期的缓解，而另一些患者却没有。一些好处 一种特定 CIH 模式与另一种模式的比较。支持个性化治疗并优化未来 为了研究结果，我们还将比较预先定义的人口统计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 的退伍军人开始使用阿片类药物的影响，估计 效果是否因退伍军人人口统计和临床特征而异，特别要注意 患有 PTSD 诊断的退伍军人，并检查使用 CIH 的潜在危害，包括新诊断的 抑郁症。