Assessing the Unintended Consequences of Restrictive Opioid Pain Reliever Policies

阿片类止痛药（OPR）的过量使用在美国已达到流行病的比例。在 为了应对这场公共卫生危机，地方，州和国家都在努力减少不适当的 阿片类药物处方2012- 2013年OPR死亡率的最近小幅下降表明，这些努力可能 有效。然而，最近海洛因使用、海洛因使用障碍和海洛因滥用的空前增加， 还观察到过量。有人建议，努力遏制不适当的OPR处方 正在产生海洛因使用及其不良事件增加的意外后果。低成本、宽 可获得性是从OPR转向海洛因使用的常见原因。有效管理 海洛因开始的风险，卫生系统，保险计划和医疗提供者需要了解， 这些风险如何以及对谁受到OPR处方实践的影响。 科罗拉多的几项政策都是针对遏制阿片类药物处方的。2014年8月，科罗拉多 医疗补助计划将短效阿片类药物的月用量限制在120片。2016年2月，医疗补助计划限制了 平均每日覆盖吗啡等效剂量（MED），以300 MED. Kaiser Permanente科罗拉多（KPCO） 遵循医疗补助在阿片类药物政策上的领先地位。这些政策旨在鼓励医疗服务提供者逐渐减少病人的摄入量 从高剂量阿片类药物治疗，从而降低OPR过量的风险。然而，到目前为止，这些影响 关于医生处方行为、OPR过量、海洛因使用和海洛因过量的政策尚不清楚。 本项目的总体目标是进行一项大型纵向队列研究，以检查OPR的影响 2012年至2017年关于海洛因使用和海洛因过量的政策和处方做法。研究将包括 来自大型管理式医疗机构（Kaiser Permanente科罗拉多）和科罗拉多医疗补助计划的患者 程序.这些系统加在一起覆盖了科罗拉多约200万人，占全国人口的40%。 州的人口。暴露和结局以及协变量将通过将患者水平数据与来自 药房记录、诊断、毒理学发现、卫生保健利用和州生命记录。暴露 并将通过病历审查确认结局。分析将采用线性和 非线性混合效应回归模型，使用倾向评分来解释混杂因素。的结果 这些分析将对州和国家层面的OPR处方政策产生影响。

Overdoses from opioid pain relievers (OPR) have reached epidemic proportions in the United States. In response to this public health crisis, there have been local, state and national efforts to reduce inappropriate opioid prescribing. Recent small reductions in OPR deaths rates in 2012-3 suggest that these efforts may have been effective. However, unprecedented recent increases in heroin use, heroin use disorders, and heroin overdoses have also been observed. It has been suggested that efforts to curb inappropriate OPR prescribing are having the unintended consequence of increasing heroin use and its adverse events. Low cost and wide availability are common reasons provided for the switch from OPR to heroin use. To effectively manage the risk of heroin initiation, health systems, insurance plans, and medical providers need to understand whether, how, and for whom these risks are affected by OPR prescribing practices. Several policies in Colorado have been directed at curbing opioid prescribing. In August of 2014, Colorado Medicaid limited monthly quantities of short-acting opioid pills to 120. In February 2016, Medicaid limited the average daily covered morphine equivalent dose (MED) to 300 MED. Kaiser Permanente Colorado (KPCO) follows Medicaid's lead on opioid policy. These policies were intended to encourage providers to taper patients from high-dose opioid therapy, thus reducing the risk of OPR overdose. To date, however, the effect of these policies on physician prescribing behavior, OPR overdose, heroin use, and heroin overdose is not known. The overall goal of this project is to conduct a large, longitudinal cohort study to examine the impact of OPR policies and prescribing practices on heroin use and heroin overdose from 2012 to 2017. The study will include patients from a large managed care organization (Kaiser Permanente Colorado) and Colorado's Medicaid program. Together these systems cover approximately 2 million people in Colorado, representing 40% of the state's population. Exposures and outcomes, and covariates will be measured by linking patient-level data from pharmacy records, diagnoses, toxicology findings, health care utilization, and state vital records. Exposures and outcomes will be validated with medical record review. Analyses will be conducted with linear and nonlinear mixed effects regression models, with propensity scores to account for confounding. The results of these analyses will have implications for OPR prescribing policies at the state and national level.