Psychological Risk Factors for Persistent Opioid Use and Prevention of Chronic Opioid Use and Misuse After Surgery: Postoperative Motivational Interviewing and Guided Opioid Weaning

摘要 本项目涉及PA-16-233“处方药滥用”中描述的需求领域， 从治疗用途向滥用的过渡，以及处方的有效预防或降低风险的方法 阿片类药物每年有超过5100万美国人接受手术，阿片类药物是止痛的主要药物 管理用于手术的阿片类药物往往会导致长期使用，并导致阿片类药物滥用。 手术是一个关键事件，其中大多数患者需要阿片类药物，无论既往是否使用阿片类药物。 相关不良事件，手术前服用阿片类药物的患者需要在较长时间内服用更高剂量 复合风险。先前的研究将抑郁症状的升高确定为 术后长期使用阿片类药物。此外，患有术前抑郁症或使用阿片类药物的患者可能在 手术后阿片类药物滥用的风险增加。项目的目标1）将描述 术前抑郁症状和阿片类药物使用/滥用手术后通过利用围手术期学习 医疗保健系统。该项目旨在广泛评估术前患者的抑郁症状，并 通过协作健康跟踪纵向结果来描述随后的阿片类药物相关风险 成果信息登记册-CHOIR系统。一个前瞻性队列的558例患者，接受任何选择性 手术，将通过CHOIR进行基线和纵向测试（包括NIH PROMIS测量， 情绪困扰）。手术后，参与者将报告阿片类药物使用，阿片类药物滥用，疼痛， 不良事件1年。我们将比较通过CHOIR进行的有针对性的心理筛查和对 电子健康记录（EHR）中有关抑郁症和抗抑郁药使用的常规可用数据。我们将 使用数据挖掘算法利用EHR中存在的自由文本，并将自我报告的阿片类药物戒断与 和阿片类药物滥用与数据从加州的处方药监测计划（治愈2.0）。（2）将 评估增强型常规护理（EUC）与动机性访谈和指导性阿片类药物的相对疗效 撤机（MI+GOW），以促进阿片类药物戒断并预防高风险队列中手术后阿片类药物滥用 （术前阿片类药物使用者）和目标3）将描述治疗与受试者属性的相互作用 （改变的动机，抑郁症状），和抑郁的纵向变化（自我厌恶 在整个治疗过程中。这种新的干预填补了关于证据的关键知识空白- 基于术后阿片类药物减量的方法。220例接受全髋关节或膝关节置换术的患者， 术前和术后2周接受阿片类药物，术后将随机分配至EUC或MI+GOW， 跟踪了一年。拟议中的研究将对公共卫生产生显著影响， 实施术前心理筛查、术前心理优化， 为有手术后长期使用和误用阿片类药物风险的患者制定额外的干预措施。

Abstract This project addresses areas of need described in PA-16-233 “Prescription Drug Abuse” examining risks for transition from therapeutic use to misuse, and effective prevention or risk reduction approaches for prescription opioids. Over 51 million Americans undergo surgery annually, and opioids are a mainstay for pain management. Opioids prescribed for surgery often instigate long-term use, and precipitate opioid misuse. Surgery represents a critical event where the majority of patients require opioids regardless of prior opioid- related adverse events, and patients taking opioids prior to surgery require higher doses over extended periods compounding risks. Prior research identifies elevated depressive symptoms as a significant predictor of prolonged postoperative opioid use. Also, patients with preoperative depression or opioid use may be at increased risk for opioid misuse after surgery. Aim 1) of the project will characterize the relationship between preoperative depressive symptoms and opioid use/misuse after surgery by utilizing a perioperative learning healthcare system. The project aims to broadly assess pre-surgical patients for depressive symptoms, and to characterize subsequent opioid-related risks by tracking longitudinal outcomes via the Collaborative Health Outcomes Information Registry-CHOIR system. A prospective cohort of 558 patients, undergoing any elective surgery, will undergo baseline and longitudinal testing via CHOIR (including NIH PROMIS measures of emotional distress). After surgery, participants will report weekly changes in opioid use, opioid misuse, pain, and adverse events for 1 year. We will compare targeted psychological screening via CHOIR to surveillance of routinely available data on depression and antidepressant use in electronic health records (EHRs). We will leverage free text existing in EHRs using data mining algorithms, and correlate self-reported opioid cessation and opioid misuse with data from California’s prescription drug monitoring program (CURES 2.0). Aim 2) will evaluate the relative efficacy of enhanced usual care (EUC) vs. motivational interviewing and guided opioid weaning (MI+GOW) to promote opioid cessation and prevent opioid misuse after surgery in a high-risk cohort (preoperative opioid users) and Aim 3) will characterize treatment interactions with participant attributes (motivation for change, depressive symptoms), and longitudinal changes in depressive (self-loathing symptoms) throughout treatment. This novel intervention fills a critical knowledge gap regarding evidence- based methods for postoperative opioid tapering. 220 patients undergoing total hip or knee replacement taking opioids both prior to and 2 weeks after surgery, will be randomized to EUC or MI+GOW after surgery and followed for one year. The proposed research will have a marked impact on public health laying the foundation for implementation of preoperative psychological screening, preoperative psychological optimization, and development of additional interventions for patients at risk for chronic opioid use and misuse after surgery.