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

背景：尽管接受长期阿片类药物治疗(LTOT)的VHA患者(&gt；30万)数量很高， 其危害的证据正在增加(例如，疼痛控制不足、副作用、过量服用)。尽管退伍军人事务部/国防部 指南建议对LTOT患者进行频繁、多成分的监测，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上升， 尽管戒毒往往是有害的(例如，更多地使用街头海洛因，恶化精神健康)。 此外，对于继续LTOT和逐渐停止治疗两者都被确定为 潜在的有害因素是，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LTOT并发症的增加，政策 重点已转向减少阿片类药物处方，并监测和停止长期服用阿片类药物 病人。该项目将帮助提供者在应对政策变化的同时保持高质量的患者护理。它 满足VHA和HSR&D的目标，即通过为提供者提供集成的 减少长期持续和中止造成的危害的手段，这是普遍和严重的 在退伍军人中。创新：该项目有可能通过提供初级保健来改变LTOT做法 和其他提供商新的、易于使用的筛查工具，将有助于遵守推荐的指南 对LTOT患者进行监测，并在有害的情况下停止LTOT。集成仪器可以 纳入CPRS，以便于在退伍军人保健诊所使用。该项目还将通过以下方式改变做法 为一组不存在CPG的具有挑战性的LTOT患者提供新的临时指南。 要完成的工作是对VHA倡议的补充，为最佳做法的组成部分作出贡献 平衡疼痛管理和阿片类药物处方的做法，“S.T.O.P.P.A.I.N”，即分级护理模式； 治疗替代方案；持续监测使用情况；以及实施指南。具体目标是开发一种 具有两个筛选工具的综合仪器，第一个指示LTOT是否有害于继续(是或否； 目标1)，以及第二个表明逐步停止使用阿片类药物是否有害于启动(是或否；目标2)。 正面筛查将表明提供商应进行额外的、更全面的监测和 检查以确定继续长期治疗或逐渐停止治疗的危害。目标3： 通过确定“指南孤儿”LTOT的初步治疗方法，通知后续CPG 病人。开发工具的方法将包括(1)全面的文献搜索以产生初始项目 每种筛查工具的银行；(2)使用患者和提供者的焦点小组进行定性项目分析， 与患者进行认知访谈、专家评审和项目修改，为每个项目建立小型题库 用于现场测试的筛选工具；以及(3)现场测试，以产生每个筛选工具的最终题库， 将包括：(A)将患者的电话调查答复与他们的电子健康相联系(每个工具500个) 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 朝向CPG将遵循与开发VA/DoD CPG用于管理的相同方法 物质使用障碍，包括(1)进行系统审查，(2)从 专家审查员，以及(3)起草和提交关于“孤儿”管理的初步指导方针 LTOT患者给我们在这个项目上的手术合作伙伴。下一步/实施：这方面的下一步 研究计划将是一个多地点项目，以检查筛查工具和 这项拟议的研究产生的潜在CPG与改善患者结局(例如，更少)相关 过量)、医疗保健系统利用率和成本(例如，急诊科就诊次数减少和 阿片类药物相关急性危象的住院治疗)。下一步还包括在质量改进方面进行合作 在退伍军人事务部初级保健和疼痛诊所实施筛查工具和CPG的项目。

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.