The Hemodialysis Opioid Prescription Effort Consortium

项目摘要/摘要 阿片类药物的流行并没有让血液透析人群幸免于难。慢性疼痛和阿片类药物使用率 在接受血液透析治疗的患者中比普通医疗保险人群更高，并且 与肝癌患者的发病率相当。在一项对接受治疗的患者的症状调查中 血液透析、骨骼和关节疼痛是最常见的(约50%)，也是最令人烦恼的 报告了症状。此外，疼痛与较低的与健康相关的生活质量和较高的 抑郁情绪的可能性，缩短的透析时间，急诊科(ED)遇到的情况， 住院和死亡率。最近使用Medicare Part D处方药数据的研究发现，超过60%的 透析患者在一年的过程中至少接受了一种阿片类药物的处方。 不幸的是，阿片类药物的广泛使用并不是良性的；接受阿片类药物治疗的患者比例较高。 因精神状态改变、跌倒、骨折和各种原因死亡而住院或ED的风险。 尽管阿片类镇痛剂在透析人群中普遍使用，但它们存在巨大的风险 因此，它们在治疗常见慢性疼痛方面的疗效有限，大多数患者接受长期的 长期阿片类药物治疗继续经历严重的疼痛和功能限制。此外，尽管 在普通慢性疼痛人群中的研究已经确定了成功的干预措施来管理疼痛和 为了改善功能状态，很少有研究解决透析人群中这一紧迫的问题。 因为接受维持性血液透析的患者被独特的治疗组合所拖累 负担、合并症和心理社会挑战，在非透析中可能有效的策略 人群可能不会在透析人群中提供好处。此外，鉴于……的多样性和复杂性 维持性血液透析、个体化护理对慢性疼痛患者的挑战 在这一群体中，方法可能特别重要。 同时解决美国血液透析中与慢性疼痛和阿片类药物使用有关的问题 我们建议评估量身定做的、以患者为中心的干预措施，以控制疼痛和减少阿片类药物 使用。具体地说，我们建议以1：2：2的方式将患者随机分配到三组中的一组，每组12- 月研究期：1)疼痛护理管理(PCM)，包括协作性阿片类药物逐渐减少支持，非阿片类药物 药物管理和护理协调，而不是PCM加上在线疼痛自我管理 计划(PSM)，包括认知行为培训，并在透析过程中提供，而不是 3)用药复习和教育进行控制。我们还建议评估提供服务的有效性 丁丙诺啡。我们将随机分配两个积极治疗部门的参与者提供 丁丙诺啡旋转与不选择丁丙诺啡的持续标准阿片类药物减少支持。

PROJECT SUMMARY/ABSTRACT The opioid epidemic has not spared the hemodialysis population. Rates of chronic pain and opioid use are higher among patients treated with hemodialysis than in the general Medicare population and are comparable to rates for individuals with liver cancer. In a survey of symptoms among patients receiving hemodialysis, bone and joint pain was among the most prevalent (approximately 50%) and most bothersome symptoms reported. In addition, pain was associated with lower health-related quality of life and higher likelihood of depressive affect, abbreviated dialysis sessions, emergency department (ED) encounters, hospitalizations, and mortality. Recent studies using Medicare Part D prescription data found that over 60% of dialysis patients received at least one prescription for an opioid medication over the course of 1 year. Unfortunately, this widespread use of opioid medications is not benign; patients receiving opioids are at higher risk of hospitalization or ED encounters for altered mental status, falls, and fractures, and all-cause mortality. Despite the pervasive use of opioid analgesics in the dialysis population and the substantial risks they engender, their efficacy is limited in treating common chronic pain conditions, and most patients receiving long- term opioid therapy continue to experience severe pain and functional limitations. Furthermore, although studies in the general chronic pain population have identified successful interventions to manage pain and improve functional status, few studies have addressed this pressing problem in the dialysis population. Because patients receiving maintenance hemodialysis are encumbered by a unique combination of treatment burden, comorbid conditions, and psychosocial challenges, strategies that may be effective in non-dialysis populations may not provide benefit in the dialysis population. Further, given the diversity and complexity of challenges faced by patients with chronic pain receiving maintenance hemodialysis, individualized care approaches are likely to be especially important in this population. To simultaneously address problems related to chronic pain and opioid use in the U.S. hemodialysis population, we propose to evaluate tailored, patient-centered interventions to manage pain and reduce opioid use. Specifically, we propose to randomly assign patients in a 1:2:2 fashion to one of three groups over a 12- month study period: 1) pain care management (PCM), including collaborative opioid taper support, non-opioid medication management, and care coordination, versus 2) PCM plus an on-line pain self-management program (PSM) that incorporates cognitive behavioral training and is delivered during dialysis sessions, versus 3) control with medication review and education. We also propose to evaluate the effectiveness of offering buprenorphine. We will randomly assign participants in both active treatment arms to being offered buprenorphine rotation versus continued standard opioid taper support without the option of buprenorphine.