Safety and Effectiveness of Opioid Tapering among Older Adults

项目摘要/摘要 2016年疾病控制和预防中心(CDC)关于阿片类药物治疗慢性疼痛的指南 鼓励临床医生与患者合作，降低处方阿片类药物剂量或停止阿片类药物治疗 当持续的阿片类药物治疗的好处不超过危害时。从2012年到2018年，阿片类药物总量 处方率下降37%；同时，每天服用大剂量阿片类药物和吗啡毫克的处方 2011年至2018年，相当于(MME)90或更高的客户数量下降了61%。患有慢性疼痛的老年人，他们经常 器官功能下降，多种并存，并服用多种药物，已越来越多 以剂量缩减为目标，减少或停止阿片类药物治疗。然而，尽管处方数量下降，但 阿片类药物，与阿片类药物有关的死亡率没有出现平行下降，不适当的剂量逐渐减少(即，迅速 阿片类药物减少)可能是导致与阿片类药物有关的死亡率未能降低的原因之一。我们建议(1) 评估阿片类药物逐渐减少的趋势；(2)研究老年CNCP患者减少阿片类药物的安全性 正在接受LTOT；以及(3)评估阿片类药物逐渐减少对患者报告的结果的影响(疼痛、功能性 接受家庭医疗护理的接受LTOT治疗的老年CNCP患者的性别、性别、性别和心理状况)。 我们将使用2012-2018年5%的全国代表性医疗保险管理索赔数据和 2012-2018年医疗保险家庭健康结果和评估信息集(OASIS)数据 学习。具体地说，我们假设：(1)快速减少阿片类药物剂量的患者更有可能 经历与阿片类药物相关的不良事件；(2)在高阿片类药物处方连续性的患者中， 快速减少阿片类药物剂量和阿片类药物相关不良事件之间的关联将随着 与阿片类药物处方连续性差的患者相比；以及(3)快速缩减阿片类药物的患者 更有可能经历剧烈疼痛、功能受限、焦虑和抑郁。 通过这三个具体目标，我们能够评估阿片类药物治疗的安全性和有效性 在老年人中，通过评估阿片类药物剂量减少的模式以及通过评估 阿片类药物剂量缩减的利与弊。为了调查具体目标，一系列回溯性队列 并进行嵌套式病例对照研究。虽然阿片类药物缩减显示出作为一种方法的前景， 为了降低患者风险并帮助缓解部分阿片类药物危机，没有明确的证据表明 阿片类药物缩减的好处和坏处。这在老年人口中尤其明显，因为他们的 与阿片类药物使用相关的不良事件风险增加。这项拟议的研究意义重大，因为它 将有助于我们了解阿片类药物在老年人中逐渐减少的安全性和有效性，这将 对国家平衡长期TOT的利弊和减少污染的努力产生重大影响 安全使用处方阿片类药物。

PROJECT SUMMARY/ABSTRACT The 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain encourages clinicians to work with patients to lower prescribed opioid doses or to discontinue opioid therapy when the benefits of continued opioid therapy do not overweigh harms. From 2012 to 2018, the overall opioid prescribing rate dropped by 37%; meanwhile, prescriptions for high-dose opioids with daily morphine milligram equivalent (MME) 90 or greater declined by 61% from 2011 to 2018. Older adults with chronic pain, who often have declining organ function, multiple comorbidities, and taking multiple medications, have been increasingly targeted for dose tapering to reduce or discontinue opioid therapy. However, despite declining prescriptions for opioids, opioid-related mortality has not shown a parallel decline, and inappropriate dose tapering (i.e., rapid opioid tapering) may have contributed to the lack of reduction in opioid-related mortality. We propose to (1) assess trends in opioid tapering; (2) study the safety of opioid tapering among older patients with CNCP who were receiving LTOT; and (3) evaluate the effect of opioid tapering on patient-reported outcomes (pain, functional limitations, and psychological status) among older CNCP patients on LTOT who received home health care. We will to use the 2012-2018 5% national representative Medicare administrative claims data and the 2012-2018 Medicare Home Health Outcomes and Assessment Information Set (OASIS) data for the proposed study. Specifically, we hypothesize that: (1) patients undergoing rapid opioid dose tapering are more likely to experience opioid-related adverse events; (2) among patients with high opioid prescribing continuity, the association between rapid opioid dose tapering and opioid-related adverse events will be attenuated as compared to those with poor opioid prescribing continuity; and (3) patients undergoing rapid opioid tapering are more likely to experience severe pain, functional limitations, anxiety and depression. Through the three Specific Aims, we are able to evaluate the safety and effectiveness of opioid therapy among older adults through assessing the patterns of opioid dose tapering as well as through assessing the benefits and harms of opioid dose tapering. To investigate the Specific Aims, a series of retrospective cohort and nested case-control studies will be conducted. While opioid tapering shows promise as a method with which to reduce patient risks and help to alleviate part of the opioid crisis, there is no clear evidence regarding the benefits and harms of opioid tapering. This is especially apparent in the older adult population due to their increased risks of adverse events associated with opioid use. The proposed research is significant because it will contribute to our understanding of the safety and effectiveness of opioid tapering in older adults, which would have a significant impact on the national efforts in balancing the benefits and harms of LTOT and reducing prescription opioid use safely.