Opioid Treatment of Pain in People with Cancer: Intended and unintended consequences of state policies addressing opioid prescribing

摘要 慢性癌症相关疼痛非常普遍，国际指南长期以来一直支持使用 阿片类药物治疗与活动性疾病相关的中度至重度疼痛。这种共识的力量在于 对于患有晚期疾病和预期寿命有限的患者最强。对于出现以下症状的患者 长期缓解或稳定或惰性疾病，而不需要持续的抗癌治疗（“长期- 术语生存率”），正在形成的共识是，阿片类药物治疗应在类似的 对于慢性非癌痛患者，关于以下方面的最佳做法， 正在接受积极抗癌治疗的患者。在阿片类药物流行之后，国家 为了减少不安全的阿片类药物处方，政策激增。最近的主要政策包括 州政府要求处方者参与处方药监测计划（PDMP）， 立法限制阿片类药物处方治疗急性疼痛的持续时间和/或剂量。这些政策在其 预期适用于癌症患者的亚群，并且，再加上关于临床 最佳做法，可能无意中影响了阿片类药物的使用和相关结果， 癌症患者的亚群。我们提出了一项研究，以评估预期和非预期的后果， 在阿片类药物处方和疼痛及阿片类药物相关不良健康事件的两种国家政策中， 在晚期癌症患者、长期存活者和接受活动性癌症治疗的患者中， 治疗为了帮助阐明政策变化背后的机制，我们还将探讨 使用创新模式， 采矿方法。我们将使用SEER-Medicare链接数据库和大型国家商业保险 数据库，以达到研究目的。调查结果将为建立共识、指导方针和干预措施提供信息 发展，以及提供者、医疗保健组织和决策者在以下方面的政策和实践变化： 优化阿片类药物处方和癌症患者的疼痛管理。

ABSTRACT Chronic cancer-related pain is highly prevalent and international guidelines have long supported the use of opioid therapy for moderate to severe pain related to active disease. The strength of such consensus is strongest for patients experiencing advanced disease and limited life expectancy. For patients experiencing long-term remission, or, stable or indolent disease without the need for ongoing anti-cancer treatment (“long- term survivorship”), there is emerging consensus that opioid therapies should be addressed in a similar manner as for patients with chronic non-cancer pain. There is mounting ambiguity regarding best practices for patients receiving active anti-cancer treatment intended for cure. In the wake of the opioid epidemic, state policies have proliferated in an effort to reduce unsafe opioid prescribing. Prominent recent policies include state mandates for prescriber participation in the Prescription Drug Monitoring Programs (PDMPs) and state legislative limits on duration and/or dosage of opioid prescriptions for acute pain. These policies vary in their intended applicability to subpopulations of cancer patients, and, coupled with the ambiguity regarding clinical best practices, may have inadvertently impacted opioid use and related outcomes among the different subpopulations of people with cancer. We propose a study to evaluate intended and unintended consequences of the two types of state policies for opioid prescriptions and pain- and opioid-related adverse health events among cancer patients with advanced disease, long-term survivors, and patients receiving active cancer treatment. To help elucidate mechanisms underlying changes in response to policies, we will also explore the trajectories of opioids dispensed and clinical encounters within each subpopulation, using an innovative pattern mining approach. We will use the SEER-Medicare linked database and a large national commercial insurance database to achieve study aims. Findings will inform consensus-building, guideline and intervention development, and policy and practice changes by providers, health care organizations, and policymakers in optimizing opioid prescribing and pain management for cancer patients.