Prescription Opioid Performance Improvement Metrics and Heroin Abuse

摘要 尽管处方阿片类止痛药(OPR)过量的比率稳定，但与阿片类药物相关的死亡率 由于海洛因使用率和中毒率的增加，这一数字继续上升。2013至2014年间，全国 据估计，前一年口服避孕药的非医疗用途从1108万人下降到1034万人。在……里面 相比之下，海洛因使用量从68万人增加到91万人。海洛因的死亡率上升了26%。 去年和过去五年超过300%。趋势的转变不仅仅是生态方面的，比如40%到70% 吸食海洛因的个人报告说，在开始吸食海洛因之前使用了非医疗用途的OPR。这是一个实质性的 背离了海洛因使用的历史轨迹。对于绝大多数开始吸食海洛因的人来说 在20世纪60年代，海洛因是他们的第一个阿片类药物。而从非医疗用途的口服避孕药转向海洛因的风险是 人们对低、起作用和预处置因素知之甚少。OPR的负担与海洛因相关 对于参加医疗补助计划的个人来说，不良事件特别高，因为他们更有可能患有 药物使用障碍，并在过量死亡中所占比例不成比例。俄勒冈州 最近制定了一项国家绩效改善项目(PIP)，以降低高剂量 其医疗补助计划中的阿片类药物处方，目前通过16个地区和卫生系统提供 定义的协调护理组织(CCOS)。因为每个CCO都可以灵活地处理州政府的 PIP，跨CCO实施构成了研究与以下方面相关的政策因素的自然实验 口服避孕药处方和海洛因相关结果的变化。响应RFA-CE-16-003(研究 处方阿片类药物的使用、阿片类药物的使用和相关的海洛因风险；优先事项2)，这项研究的目标 研究目的是评估OPR处方、CCO阿片类药物剂量减少举措之间的关系 OPR使用、海洛因使用和阿片类药物相关过量的模式。这一目标是通过三个方面实现的 使用混合方法的具体目标。首先，使用多源链接数据库，该数据库包括 处方药监测计划(PDMP)、医疗补助报销、生命统计和药物使用治疗 来自俄勒冈州的数据将测试OPR处方模式和海洛因相关结果之间的关系。 第二，使用定性研究方法、政策和程序，旨在提高全州的高 将描述每个CCO的剂量PIP。最后，实施CCO PIP倡议对以下方面的影响 将评估高风险口服避孕药的使用和与海洛因有关的结果。这项研究的发现将有助于 我们对转化为海洛因和过量吸食海洛因的个人风险因素的理解。此外，还获得了知识 将协助地方和国家决策者了解政策杠杆，以减轻OPR和海洛因的负担- 相关发病率和死亡率。

ABSTRACT Despite stabilizing rates of prescription opioid pain reliever (OPR) overdoses, opioid-related mortality continues to rise because of increasing rates of heroin use and poisoning. Between 2013 and 2014, national estimates of nonmedical use of OPRs in the previous year declined from 11.08 to 10.34 million individuals. In contrast, heroin use increased from 0.68 to 0.91 million individuals. Mortality from heroin increased 26% in the last year and more than 300% over the last five years. The shift in trend is more than ecologic, as 40% to 70% of individuals who use heroin report nonmedical use of an OPR prior to initiating heroin. This is a substantial departure from historical trajectories of heroin use. For the great majority of individuals who began heroin use in the 1960s, heroin was their first opioid. While the risk of transition to heroin from nonmedical use of OPRs is low, contributing and pre-disposing factors are poorly understood. The burden of OPR and heroin-related adverse events is particularly high for individuals in Medicaid programs because they are more likely to have substance use disorders and are disproportionately represented among overdose deaths. The state of Oregon recently developed a state Performance Improvement Project (PIP) to reduce the proportion of high-dose opioid prescriptions in its Medicaid program, which is now delivered through 16 regionally and health system defined Coordinated Care Organizations (CCOs). Because each CCO has flexibility to address the state's PIP, implementation across CCOs constitutes a natural experiment to study policy factors associated with change in OPR prescribing and heroin-related outcomes. In response to RFA-CE-16-003 (Research on Prescription Opioid Use, Opioid Prescribing, and Associated Heroin Risk; Priority #2), the objective of this study is to evaluate the relationships between OPR prescribing, CCO opioid dose reduction initiatives on patterns of OPR utilization, heroin use, and opioid-related overdoses. The objective is achieved through three Specific Aims using a mixed methods approach. First, using a multisource linked database that includes prescription drug monitoring program (PDMP), Medicaid claims, vital statistics, and substance use treatment data from Oregon, relationships between OPR prescribing patterns and heroin-related outcomes will be tested. Second, using qualitative research methods, policies and procedures directed at improving the statewide high dose PIP by each CCO will be characterized. Finally, the effect of implementation of CCO PIP initiatives on high-risk OPR use and heroin-related outcomes will be evaluated. Findings from this study will contribute to our understanding of individual risk factors for transition to and overdose with heroin. Also, knowledge gained will assist local and national decision makers about policy levers to reduce the burden of OPR and heroin- related morbidity and mortality.