Long-Term Opioid Therapy: Screen to Evaluate and Treat (Opioid-SET)

长期阿片类药物治疗：筛查、评估和治疗 (Apioid-SET)

• 批准号: 10229342
• 负责人: Katherine JoAnn Hoggatt
• 金额: --
• 依托单位: VETERANS ADMIN PALO ALTO HEALTH CARE SYS
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-09-01 至 2024-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10229342
• 关键词: Activities of Daily Living; Acute; Address; Adherence; Behavior; Caring; Clinic; Clinical; Clinical Practice Guideline; Dangerousness; Data; Diagnosis; Doctor of Philosophy; Electronic Health Record; Emergency department visit; Equilibrium; Feeling suicidal; Focus Groups; Goals; Guidelines; Healthcare; Healthcare Systems; Heroin; Hospitalization; Link; Literature; Measures; Mental Health; Methods; Modeling; Monitor; Opioid; Orphan; Overdose; Pain Clinics; Pain management; Patient Care; Patient Monitoring; Patient-Centered Care; Patient-Focused Outcomes; Patients; Physicians; Policies; Practice Guidelines; Prevalence; Primary Health Care; Program Evaluation; Provider; Recommendation; Research; Resources; Risk; Screening procedure; Self-Direction; Site; Subgroup; Substance Use Disorder; Suicide; Surveys; Telephone; Testing; Veterans; Veterans Health Administration; Violence; Withdrawal Symptom; Work; alternative treatment; caregiving; cognitive interview; comorbidity; coping; cost; data warehouse; field study; follow-up; health care settings; improved; innovation; instrument; medication-assisted treatment; non-opioid analgesic; operation; opioid mortality; opioid tapering; opioid therapy; opioid use disorder; pain catastrophizing; patient oriented; patient subsets; prescription opioid; programs; response; side effect; substance use; systematic review; therapy development; tool

Background: Despite high numbers of VHA patients (>300,000) receiving long-term opioid therapy (LTOT), evidence of its harms is growing (e.g., inadequate pain control, side effects, overdoses). Although VA/DoD Guidelines recommend frequent, multi-component monitoring of LTOT patients, monitoring is under-utilized because it does not fit with primary care’s workflow. In addition, rates of opioid discontinuation are increasing, even though discontinuation is often harmful (e.g., more use of street heroin, worsening mental health). Further, for patients for whom both continued LTOT and tapering for discontinuation are determined to be potentially harmful, a clinical practice guideline (CPG) is not available, leaving them “guideline-orphaned.” Significance: With increasing opioid overdose deaths and complications of LTOT due to comorbidities, policy emphases have shifted to reducing opioid prescribing, and monitoring and discontinuing opioids among LTOT patients. This project will help providers maintain high-quality patient care while responding to policy shifts. It addresses the VHA’s and HSR&D’s goal of offering patient-centered care by giving providers an integrated instrument to reduce harms due to LTOT continuation and discontinuation, which are widespread and severe among Veterans. Innovation: This project has the potential to change LTOT practices by giving primary care and other providers new, easy-to-use screening tools that will facilitate adherence to recommended guidelines on monitoring of LTOT patients, and discontinuation of LTOT when it is harmful. The integrated instrument may be incorporated into CPRS to facilitate its use in VA health care clinics. The project will also change practice by providing new, provisional guidelines for a challenging group of LTOT patients for whom CPGs do not exist. The work to be accomplished is complementary to VHA initiatives by contributing to components of best practices for balancing pain management and opioid prescribing, “S.T.O.P. P.A.I.N,” i.e., Stepped care model; Treatment alternatives; Ongoing monitoring of usage; and Practice guidelines. Specific Aims are to develop an integrated instrument with two screening tools, the first to indicate if LTOT is harmful to continue (yes or no; Aim 1), and the second to indicate if tapering to discontinue opioids is harmful to initiate (yes or no; Aim 2). Positive screens will indicate that providers should undertake additional, more comprehensive monitoring and examination to determine the harm of continued LTOT or tapering to discontinuation, respectively. Aim 3: Inform subsequent CPGs by determining preliminary treatment approaches for “guideline-orphaned” LTOT patients. Methods to develop the tools will involve (1) comprehensive literature searches to yield an initial item bank for each screening tool; (2) qualitative item analyses using focus groups with patients and providers, cognitive interviewing with patients, expert review, and item revision to yield small item banks for each screening tool for field testing; and (3) field testing to yield the final bank of items for each screening tool, which will include (a) linking patients’ (n=500 for each tool) telephone survey responses to their electronic health record data from the Corporate Data Warehouse, and (b) reliability testing (n=30 patients). Methods to work toward the CPG will follow the same methods used to develop the VA/DoD CPG for the Management of Substance Use Disorders, which consist of (1) conducting a systematic review, (2) obtaining input from the expert reviewers, and (3) drafting and submitting a preliminary guideline about the management of “orphaned” LTOT patients to our operations partners on this project. Next steps/Implementation: The next step in this research program will be a multi-site project to examine the extent to which use of the screening tools and potential CPG, resulting from this proposed study, is associated with improved patient outcomes (e.g., fewer overdoses), and health care system utilization and costs (e.g., fewer emergency department visits and hospitalizations for opioid-related acute crises). Next steps also include partnering on quality improvement projects to implement the screening tools and CPG in VA primary care and pain clinics.

背景：尽管大量 VHA 患者（>300,000）接受长期阿片类药物治疗（LTOT）， 越来越多的证据表明其危害（例如，疼痛控制不足、副作用、服用过量）。尽管退伍军人管理局/国防部 指南建议对 LTOT 患者进行频繁、多成分的监测，但监测未得到充分利用 因为它不符合初级保健的工作流程。此外，阿片类药物的停用率正在增加， 尽管戒断通常是有害的（例如，更多地使用街头海洛因，导致心理健康状况恶化）。 此外，对于继续 LTOT 和逐渐减量停药的患者被确定为 潜在的危害，临床实践指南（CPG）不可用，使他们成为“指南孤儿”。 意义：随着阿片类药物过量死亡和合并症导致的 LTOT 并发症的增加，政策 重点已转向减少阿片类药物处方，以及监测和停用 LTOT 中的阿片类药物 患者。该项目将帮助提供商在应对政策变化的同时保持高质量的患者护理。它 通过为提供者提供综合的解决方案，实现了 VHA 和 HSR&D 提供以患者为中心的护理的目标 减少由于 LTOT 继续和终止造成的广泛而严重的危害的工具 在退伍军人中。创新：该项目有潜力通过提供初级保健来改变 LTOT 实践 和其他提供商新的、易于使用的筛选工具，将有助于遵守推荐的指南 监测 LTOT 患者，并在 LTOT 有害时停止 LTOT。集成仪器可以 纳入 CPRS，以促进其在 VA 医疗保健诊所的使用。该项目还将改变实践 为不存在 CPG 的具有挑战性的 LTOT 患者群体提供新的临时指南。 待完成的工作是对 VHA 计划的补充，为最佳的组成部分做出贡献 平衡疼痛管理和阿片类药物处方的实践，“S.T.O.P. P.A.I.N”，即阶梯式护理模式； 治疗替代方案；持续监控使用情况；和实践指南。具体目标是开发一个 具有两个筛选工具的集成仪器，第一个表明 LTOT 是否有害于继续（是或否； 目标 1)，第二个目标表明逐渐减少以停用阿片类药物是否有害于开始使用（是或否；目标 2）。 积极的筛查将表明提供商应进行额外的、更全面的监控和 检查以确定继续 LTOT 或逐渐减少直至停药的危害。目标 3： 通过确定“指南孤儿”LTOT 的初步治疗方法，为后续 CPG 提供信息 患者。开发工具的方法将涉及 (1) 全面的文献检索以产生初始项目 每个筛选工具的银行； (2) 使用患者和提供者焦点小组进行定性项目分析， 对患者进行认知访谈、专家评审和项目修订，为每个患者生成小型项目库 用于现场测试的筛选工具； (3) 现场测试，得出每个筛选工具的最终项目库，其中 将包括 (a) 将患者（每个工具 n=500）的电话调查回复与其电子健康联系起来 记录来自公司数据仓库的数据，以及 (b) 可靠性测试（n=30 名患者）。工作方法 CPG 将遵循与开发 VA/DoD CPG 相同的方法来管理 药物使用障碍，包括 (1) 进行系统审查，(2) 获取来自 （三）起草并提交“孤儿”管理初步指南 LTOT 患者转给我们该项目的运营合作伙伴。下一步/实施：下一步 研究计划将是一个多地点项目，旨在检查筛查工具和 这项拟议研究得出的潜在 CPG 与改善患者预后相关（例如，更少 用药过量），以及医疗保健系统的利用率和成本（例如，急诊科就诊次数减少和 因阿片类药物相关的急性危机而住院）。下一步还包括合作提高质量 在 VA 初级保健和疼痛诊所实施筛查工具和 CPG 的项目。