Correlates and outcomes of opioid dose escalation among chronic pain patients

描述(由申请人提供)：近年来，长期阿片类药物治疗慢性非癌症疼痛(CNCP)的使用急剧增加。虽然慢性阿片类药物治疗越来越常见，但患者之间的治疗结果存在显著差异。在疼痛恶化期间，提供者通常会增加阿片类药物的剂量，这有可能降低疼痛强度，但可能会增加与药物有关的不良反应或阿片类药物滥用的风险。此外，阿片类药物的副作用可能与剂量有关。这项研究将确定预测哪些患者阿片类药物剂量增加的临床因素。此外， 我们将研究阿片类药物剂量增加的好处和坏处，并预测哪些患者最有可能从这种干预中受益。这项多地点前瞻性队列研究将包括600名慢性疼痛患者，他们目前正在服用阿片类药物。患者将在基线上进行评估，并在总共24个月内每6个月进行一次评估。阿片类药物剂量增加的患者(初步数据显示样本的30%-35%)将在剂量增加后1个月内进行评估，并继续进行定期6个月的随访。这项建议的具体目的是：(1)评估哪些患者和临床医生因素可预测阿片类药物剂量增加，(2)确定阿片类药物剂量增加患者与非阿片类药物剂量增加患者之间疼痛结局和不良反应轨迹的差异，以及(3)在控制剂量变化后，评估与疼痛强度和疼痛相关功能随时间变化相关的因素。我们将确定阿片类药物剂量增加的患者疼痛强度和功能持续改善的程度，以及阿片类药物滥用行为和药物相关不良反应的问题。我们还假设，恐惧避免、疼痛灾变和自我效能的基线测量将预测哪些患者受益于阿片类药物剂量的增加。这项研究对临床护理具有广泛的影响，提供了新的数据来确定哪些患者的阿片类药物剂量最有可能增加，与阿片类药物剂量增加有关的临床医生和机构因素，剂量增加产生积极和消极结果的可能性(包括处方阿片类药物滥用)，以及确定表明最有可能从剂量增加中受益的患者因素。这项研究的长期目标是通过检查增加疼痛的效用来改善慢性疼痛的治疗 阿片类药物剂量在功能变化和潜在危害方面的作用。

DESCRIPTION (provided by applicant): The use of long-term opioid therapy for chronic non-cancer pain (CNCP) has increased dramatically in recent years. Although chronic opioid therapy is increasingly common, there are marked differences among patients in treatment outcomes. Providers often increase opioid dose during times of worsening pain, which has the potential to decrease pain intensity, but may increase risk of medication-related adverse effects or opioid misuse. Further, side effects of opioid medications may be dose-dependent. This research will identify clinical factors that predict which patients will have increases in opioid doses. Further, we will examine the benefits and harms of opioid dose escalation and predict which patients are most likely to benefit from this intervention. This multi-site prospective cohort study will includ 600 patients with chronic pain who are currently prescribed opioids. Patients will be evaluated at baseline and every six months for 24 total months. Patients who have an increase in opioid dose (preliminary data indicates 30-35% of the sample) will be evaluated within 1 month of their dose increase and continue with regular six month follow-ups. The Specific Aims of this proposal are to: (1) Evaluate which patient and clinician factors predict opioid dose increases, (2) Determine the differences in trajectories of pain outcomes and adverse effects between patients with and without opioid dose increases, and (3) Assess factors associated with changes in pain intensity and pain-related function over time after controlling for dose changes. We will determine the degree to which patients with opioid dose increases have sustained improvement in pain intensity and function, as well as problems with opioid misuse behaviors and medication-related adverse effects. We also hypothesize that baseline measures of fear avoidance, pain catastrophizing, and self-efficacy will predict which patients benefit from increases in opioid dose. This research has broad implications for clinical care, providing novel data to identify those patients most likely to have increases in their opioid doses, clinician and institutional factors associated with opioid dose increases, the likelihood of positive and negativ outcomes from dose increases (including prescription opioid misuse), and identification of patient factors indicating greatest likelihood of benefit from dose increases. The long-term goal of this research is to improve the treatment of chronic pain by examining the utility of increasing opioid doses in terms of changes in function and potential harms.