Barriers to and Health Consequences of Non- Pharmacological Chronic Pain Treatment among Patients Tapering Prescription Opioids in a Large Integrated Healthcare System

项目摘要/摘要 意义重大。长期阿片类药物治疗(LTOT)，以前是慢性疼痛的标准护理，导致巨大的 与阿片类药物相关的发病率和死亡率增加。因此，疾控中心发布了阿片类药物处方指南 2016年，紧随其后的是退伍军人健康等医疗系统的LTOT下降了70% 管理(VHA)。LTOT缩减或停产的风险尚不清楚，而且知识有限 关于用于补充LTOT缩减的治疗的障碍和临床有效性，例如 非药物疗法(NPM)。职业发展计划。曼尼斯博士的培训计划将 包括研讨会、研讨会、课程作业和会议，以发展他在电子产品方面的技能和专长 健康记录(EHR)研究方法、纵向和因果建模以及健康服务研究， 这些都是执行他提出的研究计划和实现他成为 一位独立的卫生服务科学家，他进行大型观察性研究，将向 慢性疼痛患者的临床护理。师徒关系。一个非常有成就的导师团队，他们 是生物统计学、慢性疼痛管理和物质使用流行病学的专家，将支持Dr。 曼内斯的研究和培训目标。研究计划。曼尼斯博士将进行临床流行病学研究 受Andersen卫生服务利用模型启发的研究，该模型利用 VHA EHR(每年约500万名患者)回答以下问题：1)有哪些健康风险 自CDC阿片类药物处方指南发布以来，LTOT缩减或停止使用的人，2)是退伍军人 谁逐步减少或停止LTOT更有可能获得NPM？3)哪些障碍阻碍了NPM的利用 缩减或停止LTOT的患者？4)使用NPM是否改善了以下患者的健康结果 缩减还是停止LTOT？为了回答这些重要的问题，曼尼斯博士将利用回顾 采用2016-2027年数据的纵向队列和横断面研究设计。广义线性 调整Kaplan-Meier生存曲线的模型和Cox-比例风险模型 将使用社会人口学、临床和医疗保健设施的特征来检查关联 LTOT缩减和NPM之间的护理终止、阿片类药物或疼痛相关的急诊科就诊 或住院，以及自杀或服药过量死亡。他的研究结果将通知R01将是 在第一批使用国家、电子健康记录数据来检查非营利组织的障碍、吸收和健康影响的国家中，使用 改造后的医疗补助统计信息系统。公共卫生影响。增加对NPM的访问 为慢性疼痛易感人群确定临床有效的NPM是优先考虑的领域 NCCIH。这项研究将提供与政策相关的信息，说明LTOT缩减的后果和 NPM是在慢性疼痛的非阿片类药物越来越多地被使用的时候。

PROJECT SUMMARY/ABSTRACT Significance. Long-term opioid therapy (LTOT), previously standard care for chronic pain, led to enormous increases in opioid-related morbidity and mortality. The CDC therefore issued opioid prescribing guidelines in 2016, which was followed by a 70% decline in LTOT in healthcare systems such as the Veterans Health Administration (VHA). Risks of LTOT taper or discontinuation are unclear and there is limited knowledge about the barriers to and clinical effectiveness of the treatments used to supplement LTOT taper, such as non-pharmacological modalities (NPM). Career Development Plan. Dr. Mannes’ training program will include seminars, workshops, coursework, and conferences to develop his skills and expertise in electronic health record (EHR) research methods, longitudinal and causal modeling, and health services research, which are necessary for conducting his proposed research plan and achieving his career goals of becoming an independent health services scientist who conducts large observational studies that will inform the clinical care of people living with chronic pain. Mentorship. A highly accomplished team of mentors who are experts in biostatistics, chronic pain management, and substance use epidemiology, will support Dr. Mannes’ research and training goals. Research Plan. Dr. Mannes will conduct a clinical epidemiological study informed by Andersen’s Model of Health Service Utilization that leverages the size and scope of the VHA EHR (~5,000,000 patients each year) to answer the following questions: 1) What are the health risks of LTOT taper or discontinuation since release of the CDC opioid prescribing guidelines, 2) Are veterans who taper or discontinue LTOT more likely to receive NPM? 3) What are barriers to NPM utilization among patients who taper or discontinue LTOT? and 4) Does NPM use improve health outcomes for patients who taper or discontinue LTOT? To answer these important questions, Dr. Mannes will utilize retrospective longitudinal cohort and cross-sectional study designs using data from 2016-2027. Generalized linear models and Cox-proportional hazard models with Kaplan-Meier survival curves adjusted for sociodemographic, clinical, and healthcare facility characteristics will be used to examine associations between LTOT taper and NPM with care termination, opioid or pain-related emergency department visits or hospitalization, and suicide or overdose mortality. Findings from his study will inform an R01 that will be among the first to use national, EHR data to examine barriers, uptake, and health effects of NPM using the Transformed Medicaid Statistical Information System. Public Health Impact. Increasing access to NPM and identifying clinically effective NPM for people vulnerable to chronic pain are high priority areas for NCCIH. This research will provide policy-relevant information on the consequences of LTOT tapering and NPM at a time when non-opioid therapies for chronic pain are becoming increasingly utilized.