Multilevel Interventions to Reduce Harm and Improve Quality of Life for Patients on Long Term Opioid Therapy - Yale Resource Center (MIRHIQL-YRC)

即使在全国范围内长期阿片类药物治疗(LTOT)处方大幅减少后， 大约有1300万美国成年人接受LTOT，使他们面临一系列伤害的风险，通常没有 足够的福利。由于LTOT的风险-收益状况往往不佳，目前的共识指南 促进1)持续重新评估LTOT的风险和收益，以及2)减少或停止LTOT 同时支持疼痛自我管理策略和非阿片类疼痛护理，当收益不再超过 伤害。然而，指导方针缺乏关键的细节--例如如何评估风险与收益--这阻碍了质量 改进的努力。由于在重要问题上缺乏共识，临床研究进展缓慢。 例如：在LTOT中，确定弊大于利的门槛是什么？是否应该有一个新的 诊断实体，以描述危害大于收益的临床场景？如果是，其 有什么显著特征吗？这些研究和临床差距转化为潜在的低质量疼痛护理 对于使用LTOT的患者，包括弱势人群中的低疗效和高风险。根据 RFA-DA-23-042，我们建议建立多层次的干预措施，以减少危害和改善 长期接受阿片类药物治疗的患者的生活质量-耶鲁资源中心(MIRHIQL-YRC)要解决的问题 国家阿片类药物公共卫生危机--通过关注经常被忽视的长期服用阿片类药物的患者 风险可能大于收益，但没有阿片类药物使用障碍的人。我们提出了一种综合的、多方面的 MIRHIQL-YRC的层次结构仿照我们高功能的IMPOWR-You研究中心，具有 位于中心的社区指导委员会(CSC)和几个规模较小的敏捷工作组，专注于特定的 任务，但以高度相互关联的方式向前推进。CSC的影响将因其存在而增强 历来被排除在建立共识项目之外的合作伙伴：有生活经验和第一线的人 临床医生，开发的工具和其他产品对他们至关重要的群体是以患者为中心的，而不是 污名化、可行性和实践性。通过这一结构，由CSC管理的MIRHIQL-YRC将追求 四个目标：(1)通过这里详述的各种机制，促进成功地执行 配套的MIRHIQL网络R01临床试验；(2)创建一个风险-收益决策工具，以帮助提供者 在确定阿片类药物何时应按处方继续、逐渐减少或逐渐减少并停止使用时； 创建临床定义，识别相关症状/行为，并生成筛查 对使用LTOT的弊大于利的个人进行评估；以及(4)验证临床 独立前瞻性队列中的定义、相关症状/行为和筛查评估 学习。我们的多学科团队有着长期的成功合作记录和深入而广泛的 慢性疼痛和阿片类药物管理方面的专业知识非常适合实现这些目标。

Even after significant reductions in long-term opioid therapy (LTOT) prescribing for chronic pain nationally, approximately 13 million US adults receive LTOT, putting them at risk for an array of harms often without adequate benefit. Due to the often unfavorable risk-benefit profile of LTOT, current consensus guidelines promote 1) continuous re-assessment of risk and benefit of LTOT and 2) reduction or discontinuation of LTOT while supporting pain self-management strategies and non-opioid pain care when benefit no longer outweighs harm. However, the guidelines lack crucial details--such as how to assess risk vs. benefit--hampering quality improvement efforts. Clinical research has been slowed by lack of consensus related to important questions such as: what is the threshold for determining that harm outweighs benefit in LTOT?, Should there be a new diagnostic entity to characterize the clinical scenario of harm outweighing benefit?, and, if so, What are its distinguishing characteristics? These research and clinical gaps translate into potentially poor quality pain care for patients on LTOT, including low efficacy and heightened risk in a vulnerable population. In accordance with RFA-DA-23-042, we propose the establishment of the Multilevel Interventions to Reduce Harm and Improve Quality of Life for Patients on Long Term Opioid Therapy – Yale Resource Center (MIRHIQL-YRC) to address the national opioid public health crisis via a focus on the oft-overlooked population of patients on LTOT for whom risk may outweigh benefit but who do not have opioid use disorder. We propose an integrated, multi- level structure of the MIRHIQL-YRC modeled after our high-functioning IMPOWR-YOU Research Center, with a Community Steering Committee (CSC) at the hub and several smaller, agile workgroups focusing on specific tasks but moving forward in a highly inter-related fashion. The CSC's impact will be bolstered by the presence of partners historically left out of consensus-building projects: persons with lived experience and frontline clinicians, groups for whom it is crucial the tools and other products developed are patient-centered, non- stigmatizing, feasible and practical. Via this structure, the MIRHIQL-YRC, governed by the CSC, will pursue four objectives: (1) Facilitating, through a variety of mechanisms detailed herein, the successful execution of the companion MIRHIQL network R01 clinical trials; (2) Creating a risk-benefit decision tool to assist providers in determining when opioids should be continued as prescribed, tapered, or tapered and discontinued; (3) Creating a clinical definition, identifying associated symptoms/behaviors, and generating a screening assessment for individuals on LTOT for whom harms outweigh the benefits; and (4) Validating the clinical definition, associated symptoms/behaviors, and screening assessment in an independent prospective cohort study. Our multi-disciplinary team with a long track record of successful collaboration and deep and broad expertise in chronic pain and opioid management is exceptionally well-positioned to meet these objectives.