Examining the Consequences of Reductions in Opioid Prescribing on Patients, Clinical Care, and Community Health

检查减少阿片类药物处方对患者、临床护理和社区健康的影响

• 批准号: 10094209
• 负责人: Kelly Ray Knight
• 金额: $ 51.49万
• 依托单位: UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-05-01 至 2024-02-29
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10094209
• 关键词: Address; Administrator; Affect; American; American Medical Association; Area; Caring; Centers for Disease Control and Prevention (U.S.); Chronic; Clinic; Clinical; Clinical Nursing; Communities; Community Health; Complex; Consult; County; Crime; Criminal Justice; Data; Diagnosis; Disclosure; Enrollment; Environment; Ethnography; General Population; Goals; Health; Health Personnel; Home; Home environment; Human Resources; Income; Individual; Interdisciplinary Study; Interview; Lead; Longitudinal Studies; Mediation; Medicaid; Medical; Modeling; Monitor; Morbidity - disease rate; Non-Malignant; Opioid; Pain; Pain management; Patient Monitoring; Patients; Physicians; Policies; Primary Health Care; Public Health; Qualitative Methods; Qualitative Research; Recommendation; Recording of previous events; Reporting; Research; Research Personnel; Sampling; San Francisco; Social Impacts; Social Problems; Societies; Source; care delivery; clinical care; clinical encounter; clinical pain; community setting; end of life; experience; follow-up; heroin use; improved; mortality; non-cancer chronic pain; opioid misuse; opioid tapering; opioid therapy; opioid withdrawal; pain patient; pain symptom; patient population; prescription monitoring program; prescription opioid; prescription opioid misuse; psychologic; research study; response; safety net; social; substance use

We propose to use qualitative methods to examine the consequences of reductions in opioid prescribing for chronic non-cancer pain (CNCP) on patients, clinical care delivery, and community health. Over 80 million Americans report CNCP, defined as non-malignant pain that lasts longer than three months, not associated with end of life. Escalations in opioid prescribing for CNCP over the past two decades have been associated with dramatic increases in opioid-associated morbidity and mortality. In response, the Centers for Disease Control and Prevention, the American Pain Society, and the American Medical Association developed recommendations to limit reliance on opioids, by encouraging clinicians to (1) consult statewide prescription drug monitoring programs when prescribing opioids; (2) not initiate opioid therapy for CNCP; and (3) monitor, taper, and/or discontinue opioids in CNCP patients. These recommendations are being implemented nationwide and evidence suggests a concomitant decrease in the total number of opioid prescriptions. Yet, little data exist documenting the long term consequences, positive or negative, of reductions in opioid prescribing. The proposed study builds on our previous R01 (DA034625), Pain Management in the Clinic and Community (PMCC), that examined the management of CNCP in patients with a history of substance use who received pain care in safety net clinical settings. Medicaid insured patients with a CNCP diagnosis are more likely than their privately insured counterparts with CNCP to receive opioid prescriptions. Patients with a history of substance use are more likely to receive a diagnosis of CNCP, to be prescribed opioids, and to transition to chronic opioid therapy than patients without substance use histories. The proposed study will use the social-ecological model of health to address the following specific aims: (SA1) To examine the consequences of reductions in opioid prescribing on patients' experiences of CNCP; (SA2) To examine the consequences of reductions in opioid prescribing on patient-clinician relationships and clinical care delivery in primary care safety net settings; (SA3) To examine the consequences of reductions in opioid prescribing from the perspectives of community stakeholders. The proposed longitudinal study will take place in four safety-net clinics and patients' home/community environments in two diverse San Francisco Bay Area Counties. We will conduct qualitative enrollment and follow-up interviews with 30 primary care clinicians and 60 of their CNCP patients with a history of substance use, and clinical observations between clinicians and matched patients (SA1&2). We will theoretically sample 30 of the 60 CNCP patients and conduct ethnography in patients' home environments, and interview 40 community stakeholders (SA1&3). The multidisciplinary research team, consisting of a medical anthropologist, a physician investigator who studies opioid misuse and practices in the safety net, and a nurse/clinical pain policy expert will synthesize the data with the goal of improving our understanding of the consequences of opioid prescription reductions to make clinical and policy recommendations.

我们建议使用定性方法来检查减少阿片类药物处方的后果 慢性非癌性疼痛 (CNCP) 对患者、临床护理服务和社区健康的影响。超过8000万 美国人报告 CNCP，定义为持续超过三个月的非恶性疼痛，与以下疾病无关 生命的终结。过去 20 年来，CNCP 的阿片类药物处方不断增加，与以下因素有关： 阿片类药物相关的发病率和死亡率急剧增加。对此，疾病控制中心 和预防、美国疼痛协会和美国医学会制定了 通过鼓励临床医生 (1) 咨询全州处方来限制对阿片类药物的依赖的建议 开阿片类药物处方时的药物监测计划； (2) 不启动 CNCP 的阿片类药物治疗； (3) 监测， CNCP 患者逐渐减少和/或停用阿片类药物。这些建议正在落实中 全国范围内，有证据表明阿片类药物处方总数随之减少。然而，很少 现有数据记录了减少阿片类药物处方所产生的长期影响，无论是积极的还是消极的。 拟议的研究建立在我们之前的 R01 (DA034625)“诊所和社区疼痛管理”的基础上 (PMCC)，检查了有药物使用史且接受疼痛的患者的 CNCP 管理 安全网临床环境中的护理。接受医疗补助保险的患者被诊断为 CNCP 的可能性比他们自己的患者高 CNCP 的私人保险同行可以接受阿片类药物处方。有物质史的患者 使用阿片类药物的人更有可能被诊断为 CNCP、开阿片类药物并转为慢性阿片类药物 治疗效果优于没有药物使用史的患者。拟议的研究将使用社会生态模型 卫生部门旨在实现以下具体目标： (SA1) 检查阿片类药物减少的后果 根据患者的 CNCP 经历开出处方； (SA2) 检查阿片类药物减少的后果 规定初级保健安全网环境中的患者与临床医生关系和临床护理服务； (SA3) 从社区的角度研究减少阿片类药物处方的后果 利益相关者。拟议的纵向研究将在四个安全网诊所和患者的诊所进行 旧金山湾区两个不同县的家庭/社区环境。我们将进行定性 对 30 名初级保健临床医生和 60 名有病史的 CNCP 患者进行登记和随访访谈 物质使用情况以及临床医生和匹配患者之间的临床观察 (SA1&2)。我们将 理论上对 60 名 CNCP 患者中的 30 名进行抽样，并在患者的家庭环境中进行民族志研究，以及 采访 40 个社区利益相关者 (SA1&3)。由医学专家组成的多学科研究团队 人类学家、研究阿片类药物滥用和安全网实践的医师调查员以及 护士/临床疼痛政策专家将综合数据，目的是提高我们对疼痛的理解 减少阿片类药物处方的后果，以提出临床和政策建议。

项目成果

Race, pain, and opioids among patients with chronic pain in a safety-net health system.

• DOI: 10.1016/j.drugalcdep.2021.108671
• 发表时间: 2021-05-01
• 期刊: Drug and alcohol dependence
• 影响因子: 4.2
• 作者: Haq N;McMahan VM;Torres A;Santos GM;Knight K;Kushel M;Coffin PO
• 通讯作者: Coffin PO

Opioid pharmacovigilance: A clinical-social history of the changes in opioid prescribing for patients with co-occurring chronic non-cancer pain and substance use.

• DOI: 10.1016/j.socscimed.2017.05.043
• 发表时间: 2017-08
• 期刊: Social science & medicine (1982)
• 作者: Knight KR;Kushel M;Chang JS;Zamora K;Ceasar R;Hurstak E;Miaskowski C
• 通讯作者: Miaskowski C

Accounting for the interplay of interpersonal and structural trauma in the treatment of chronic non-cancer pain, opioid use disorder, and mental health in urban safety-net primary care clinics.

考虑到城市安全网初级保健诊所中慢性非癌症疼痛、阿片类药物使用障碍和心理健康治疗中人际和结构性创伤的相互作用。

• DOI: 10.1016/j.ssmmh.2023.100243
• 发表时间: 2023
• 期刊: SSM. Mental health
• 作者: Castellanos,Stacy;Cooke,Alexis;Koenders,Sedona;Joshi,Neena;Miaskowski,Christine;Kushel,Margot;Knight,KellyRay
• 通讯作者: Knight,KellyRay

Telehealth for management of chronic non-cancer pain and opioid use disorder in safety net primary care.

• DOI: 10.1186/s12913-023-09330-w
• 发表时间: 2023-04-01
• 期刊: BMC HEALTH SERVICES RESEARCH
• 影响因子: 2.8
• 作者: Cooke, Alexis;Castellanos, Stacy;Enriquez, Celeste;Olsen, Pamela;Miaskowski, Christine;Kushel, Margot;Knight, Kelly Ray
• 通讯作者: Knight, Kelly Ray

Women on the Edge: Opioids, Benzodiazepines, and the Social Anxieties Surrounding Women's Reproduction in the U.S. "Opioid Epidemic".

• DOI: 10.1177/0091450917740359
• 发表时间: 2017-12-01
• 期刊: Contemporary drug problems
• 作者: Knight, Kelly R