Evaluation of the Washington State Guidelines on Opioid Dosing for Chronic Pain

描述（由申请人提供）： 目标：该项目广泛的长期目标是促进对预防无意处方阿片类药物中毒方法的理解。具体而言，目标（FOA CE-10-002目标#6）是检查公共赞助的医生教育计划有助于改变医生处方模式并降低处方阿片类药物相关发病率和死亡率的能力。重要性：华盛顿州（WA）是美国意外中毒死亡率较高的州（2005年为10.8/100，000）。为了应对这一公共卫生流行病，华盛顿州机构和疼痛管理临床专家联合制定了华盛顿州阿片类药物治疗慢性非癌症疼痛的机构间指南，并于2007年4月实施。该指南主要关注慢性非癌症疼痛的剂量指南，其剂量等于或高于120 mg/天吗啡当量（MED）的“黄旗”剂量。知识上的差距是该指南在多大程度上影响了医生的阿片类药物处方实践，以及它是否减少了阿片类药物相关中毒。通过评价该指南与阿片类药物处方实践（包括具体的给药模式）以及与阿片类药物相关的发病率和死亡率的关联，拟议项目将进一步了解预防非故意处方阿片类药物中毒的有效手段。目的：具体目标1：确定指南的传播程度、最佳阿片类药物处方实践的调整以及对给药“黄旗”的接受程度。假设1：与实施后1.5年相比，在指南实施后3.5年，指南的传播和最佳阿片类药物处方实践的调整都将增加。具体目标二：检查指南传播后WA Medicaid和工人补偿人群中阿片类药物给药模式的变化假设2a：与之前相比，指南传播后三年内，接受阿片类药物处方的慢性非癌症疼痛患者接受每日阿片类药物剂量超过120 mg/天MED的可能性较小。假设2b：在指南实施后的第1年至第3年，接受>120 mg MED处方的患者百分比将下降。假设2c：指南发布后，与之前相比，已经接受每日阿片类药物剂量超过120 mg/天MED的患者在未来三年内的平均剂量将降低，第1年至第3年的平均每日MED将逐渐降低。具体目标3：比较指南发布后三年与发布前三年，非致命性阿片类药物过量发病率（如阿片类药物相关住院和急诊所示）和WA医疗补助和工人赔偿人群的死亡率，以及全州普通人群中阿片类药物相关住院和死亡率。研究设计：目标1：基于网络的医生调查目标2和3：回顾性队列设计，包括分析阿片类药物使用者的事件和流行病例的独立队列，以及检查阿片类药物相关发病率和死亡率的时间序列分析。设置：西澳州参与者：所有西澳医疗补助登记者和工人赔偿索赔人，从行政数据库中识别，他们正在接受处方阿片类药物治疗慢性非癌症疼痛。每年有超过30，000名医疗补助患者和超过10，000名工人赔偿患者开始接受阿片类药物处方治疗慢性疼痛。大约5%至10%的医疗补助和工人赔偿患者处方阿片类药物接受剂量> 120 mg/天MED. Interventions：全州范围内实施和传播华盛顿州关于慢性非癌症疼痛结局措施阿片类药物给药的机构间指南：使用指南和使用阿片类药物处方最佳实践的医生百分比;西澳大利亚州医疗补助和工人补偿队列中处方120 mg/天MED的百分比;急诊室和非致命性阿片类药物过量住院的趋势;死亡率趋势1 公共卫生相关性： 与处方阿片类药物有关的意外中毒死亡在过去十年中急剧上升，特别是在35-54岁的成年人中。为了解决这一公共卫生危机，2007年，所有华盛顿州公共支付者实施了美国第一个关于阿片类药物安全给药实践的指南。本提案的目的是评估准则的影响。该项目将检验以下假设：与实施前的三年相比，在指南实施后的三年中，阿片类药物处方最佳实践的使用增加，高剂量（>120 mg/天吗啡等效剂量）阿片类药物处方的发生率和流行率降低，阿片类药物相关的发病率和死亡率降低。

DESCRIPTION (provided by applicant): PROJECT SUMMARY Objective: The broad, long-term objective of this project is to advance understanding of ways to prevent unintentional prescription opioid poisoning. Specifically, the objective (FOA CE-10-002 objective #6) is to examine the ability of a publicly-sponsored physician education initiative to contribute to change in physician prescribing patterns, and to reduction in prescription opioid-related morbidity and mortality. Importance: Washington State (WA) is in the upper tier (10.8/100,000 in 2005) of unintentional poisoning mortality in the U.S.. In response to this public health epidemic, the Washington State Interagency Guideline on Opioid Dosing for Chronic, Non-Cancer Pain was developed by a consortium of Washington State agencies and clinical experts in pain management, and implemented in April, 2007. The Guideline focused primarily on dosing guidance for chronic non-cancer pain at or above a "yellow flag" dose of 120 mg/day morphine equivalent (MED). A gap in knowledge is the extent to which the Guideline has affected physician opioid prescribing practices, and whether it has reduced opioid-related poisonings. By evaluating the association of the Guideline with opioid prescribing practice, including specific dosing patterns, and with opioid-related morbidity and mortality, the proposed project will further understanding of effective means of preventing unintentional prescription opioid poisonings . Objectives: Specific Aim 1: Determine the extent of Guideline diffusion, adaptation of best opioid prescribing practices, and acceptance of the dosing "yellow flag". Hypothesis 1: At 3.5 years post-Guideline implementation, compared to 1.5 years post-implementation, both diffusion of the Guideline and adaptation of best opioid prescribing practices will have increased. Specific Aim 2: Examine changes in opioid dosing patterns within the WA Medicaid and workers' compensation populations after dissemination of the Guideline Hypothesis 2a: Over the three years after dissemination of the Guideline, as compared with before, chronic non-cancer pain patients receiving opioid prescriptions will be less likely to receive daily opioid doses exceeding 120 mg/day MED. Hypothesis 2b: The percent of patients receiving prescriptions >120 mg MED will decrease from year 1 to year 3 post-Guideline implementation. Hypothesis 2c: After dissemination of the Guideline, as compared with before, patients already on daily opioid doses above 120 mg/day MED will show lower average doses over the next three years, with a progressive reduction in average daily MED between year 1 and year 3. Specific Aim 3: Compare rates of non-fatal opioid overdose morbidity (as indicated by opioid-related hospital admissions and emergency department visits) and mortality within the WA Medicaid and workers' compensation populations, and of opioid-related hospitalizations and mortality within the statewide general population, in the three years after Guideline dissemination versus the three years before. Study Design: For Aim 1: Web-based physician survey For Aims 2 and 3: Retrospective cohort design involving analyses of independent cohorts of incident and prevalent cases of opioid users, and time series analyses to examine opiate-related morbidity and mortality Setting: WA State Participants: All WA Medicaid enrollees and workers' compensation claimants, identified from administrative databases, who are receiving prescription opioids for chronic, non-cancer pain. Over 30,000 Medicaid patients and over 10,000 workers' compensation patients begin receiving opiate prescriptions for chronic pain each year. Approximately 5% to 10% of Medicaid and workers' compensation patients prescribed opioids receive doses > 120 mg/day MED. Interventions: Statewide implementation and diffusion of the Washington State Interagency Guideline on Opioid Dosing for Chronic, Non-Cancer Pain Outcome Measures: Percent of physicians using the Guideline and using opioid prescribing best practices; percent of WA Medicaid and workers' compensation cohorts prescribed 120 mg/day MED; trends in emergency department and hospital admissions for non-fatal opioid overdose; mortality trends 1 PUBLIC HEALTH RELEVANCE: Unintentional poisoning deaths related to prescription opioids have risen dramatically in the past decade, particularly among 35-54 year old adults. To address this public health crisis, the first Guideline in the US to address safe opioid dosing practice was implemented by all Washington State public payers in 2007. The goal of this proposal is to evaluate the impact of the Guideline. The project will test the hypotheses that in the three years post-Guideline implementation, compared to the three years pre- implementation, there is increased use of opioid prescribing best practices, a reduction in the incidence and prevalence of prescriptions of high dose (>120 mg/day morphine equivalent dose) opioids, and a decrease in opioid-asscoiated morbidity and mortality.