Substance use outcomes of opioid dose reduction and discontinuation

项目摘要 为了解决RFA-CE-16-003的优先事项2，我们建议海洛因和其他非法阿片类药物的使用和过量 在疼痛患者中(Hopp)：一项对接受阿片类疼痛患者的纵向回顾研究 在转换阿片类药物处方政策的背景下，治疗慢性非癌症疼痛(CNCP)的缓解剂(OPR)。许多 卫生系统，包括旧金山卫生网络(SFHN)的安全网初级保健诊所，是 实施阿片类药物处方政策的实质性变化。这些变化包括剂量限制、限制 向有物质使用障碍(SODS)的人开处方，并要求进行尿液测试，疼痛协议， 以及对处方药监测计划(PDMP)的检查。这些变化中的许多旨在 减少OPR分流，预计将导致许多患者终止OPR治疗。其影响 这些变化对那些已经依赖阿片类药物的人来说是未知的，尽管坊间证据表明 随着处方阿片类药物的终止，一些患者开始或恢复使用海洛因或其他非法阿片类药物。在……里面 此外，人们担心这些处方的变化可能会增加与海洛因和其他药物有关的死亡率 非法阿片类药物过量。为了解决这些知识上的重大差距，我们将招募600名开出门诊处方的患者 从SFHN慢性阿片类止痛患者登记中获得的CNCP长期治疗，包括150名患者 OPR已经停止、减少、维护和增加。霍普计划的参与者将接受详细的 采访涉及自2012年以来他们的物质使用模式的历史重建和一项独立的 电子病历图表提取以识别OPR和其他受控物质处方模式， 暴露于阿片类药物管理干预和医疗并存，以表征这种联系 毒品和犯罪问题办公室处方的变化以及海洛因和其他非法阿片类药物的启动和使用(目标1)和 涉及海洛因和其他非法阿片类药物的过量(目标2)。在存在的情况下捕捉整体效果 从早期结果到暴露的反馈，我们将使用嵌套队列方法来估计直接和 OPR剂量变化的间接影响。探索性分析将包括评估 OPR剂量和医疗依从性以及与阿片类药物相关的急诊科就诊情况的变化， 临床一级阿片类药物管理政策与海洛因和其他非法阿片类药物使用协会 在疼痛的全部队列中，OPR剂量的变化与随后阿片类药物过量死亡之间的关系 管理病人。

Project Abstract To address Priority #2 of RFA-CE-16-003, we propose Heroin and Other Illicit Opioid Use and Overdose Among Pain Patients (HOPP), a longitudinal retrospective study of patients who have received opioid pain relievers (OPRs) for chronic non-cancer pain (CNCP) in the setting of shifting opioid prescribing policies. Many health systems, including the safety net primary care clinics of the San Francisco Health Network (SFHN), are implementing substantial changes in opioid prescribing policy. These changes include dose limits, restrictions on prescribing to persons with substance use disorders (SUDs), and required urine testing, pain agreements, and checks of the prescription drug monitoring program (PDMP). Many of these changes are designed to reduce OPR diversion and are expected to lead to termination of OPR therapy for many patients. The impact of these changes on those already reliant upon opioids is unknown, although anecdotal evidence suggests that some patients initiate or resume heroin or other illicit opioid use as prescribed opioids are terminated. In addition, there is concern that these prescribing changes could increase mortality related to heroin and other illicit opioid overdose. To address these major gaps in knowledge, we will recruit 600 patients prescribed OPRs long-term for CNCP from the SFHN registry of patients on chronic opioids for pain, including 150 each whose OPRs have been discontinued, reduced, maintained, and increased. HOPP participants will undergo a detailed interview involving historical reconstruction of their substance use patterns since 2012 and an independent electronic medical record chart extraction to identify OPR and other controlled substance prescription patterns, exposure to opioid stewardship interventions, and medical co-morbidities to characterize the association between changes in OPR prescribing and initiation and use of heroin and other illicit opioids (Aim 1) and overdose involving heroin and other illicit opioids (Aim 2). To capture overall effects in the presence of feedback from earlier outcomes to exposure, we will use a nested cohorts approach to estimate the direct and indirect effects of change in OPR dose. Exploratory analyses will include assessing the association between changes in OPR dose and medical care adherence as well as opioid-related emergency department visits, the association of clinic-level opioid stewardship policy and heroin and other illicit opioid use, and the association between change in OPR dose as subsequent opioid overdose mortality among the full cohort of pain management patients.