Improving Physician Opioid Prescribing for Chronic Pain in HIV-infected Persons

描述（由申请人提供）：处方阿片类药物是美国第二大最常见的滥用物质（仅次于大麻），与处方阿片类药物相关的过量死亡人数现在超过了机动车事故死亡人数。处方类阿片滥用似乎在艾滋病毒感染患者中更为常见，这可能是已知的艾滋病毒与药物使用共同发病的结果。研究表明，所有艾滋病毒感染患者中有五分之一接受了慢性阿片类药物治疗，艾滋病毒感染患者比未感染艾滋病毒的患者更有可能接受阿片类药物治疗。鉴于艾滋病毒感染患者中疼痛的高患病率（约50%），疼痛管理必然是治疗艾滋病毒患者的医生的主要责任。然而，为艾滋病毒感染患者提供初级保健的大多数医生和高级实践提供者（以下简称艾滋病毒医生）在慢性疼痛管理方面几乎没有受过培训。因此，艾滋病医生经常不遵循现有的阿片类药物处方指南，对这一重要且有时令人烦恼的临床护理方面的满意度低，信心有限。拟议的“针对艾滋病毒临床有效镇痛”（TEACH）研究将测试针对艾滋病毒医生的协作护理干预的有效性，以改善COT管理并减少艾滋病毒感染者中处方阿片类药物的滥用。干预由以下要素组成：1)与护理经理（NCM）合作；2)医师教育和学术细化；3)便利了与成瘾问题专家的接触，以帮助管理接受COT治疗的最具挑战性的艾滋病毒感染患者。NCM将利用电子注册来协助医生实施指南驱动的护理，包括阿片类药物治疗协议、尿液药物检测（UDT）、随机药片计数和在线处方监测项目（pmp）的检查。对照组的医生将收到COT指南总结信息，但不能获得TEACH干预的支持。本研究将采用聚类随机试验设计，在医生水平上随机化，并比较一年内的主要结果。具体目标是测试TEACH合作护理项目的有效性，以实现以下目标：目标1 -与标准实践相比，提高艾滋病医生对COT指南的遵守程度；目标2 -提高HIV医生对处方COT的满意度和信心；目标3 -减少在COT治疗的hiv感染患者中处方阿片类药物的异常使用；目标4 -改善接受COT治疗的hiv感染患者的病毒学控制。如果有效，在艾滋病毒诊所实施干预将使临床医生能够根据既定指南更有信心地提供慢性阿片类药物治疗，从而可能减少处方药滥用并改善艾滋病毒治疗结果。

DESCRIPTION (provided by applicant): Prescription opioids are the second most commonly abused substances in the U.S. (after marijuana), and overdose deaths related to prescription opioids now exceed deaths from motor vehicle crashes. Prescription opioid abuse appears to be even more common among HIV-infected patients, presumably a consequence of the known co-morbidity between HIV and substance use. Studies suggest that one-fifth of all HIV-infected patients are prescribed chronic opioid therapy (COT) for pain and that HIV-infected patients are more likely to be prescribed opioids for pain than HIV-uninfected patients. Given the high prevalence of pain (~50%) among HIV-infected patients, pain management is by necessity a major responsibility of physicians treating patients with HIV. However, most physicians and advanced practice providers providing primary care for HIV-infected patients (henceforth referred to as HIV physicians) have little training in the management of chronic pain. Therefore, HIV physicians frequently do not follow existing guidelines for prescribing opioids and report low satisfaction and limited confidence with this important and at times vexing aspect of clinical care. The proposed "Targeting Effective Analgesia in Clinics for HIV" (TEACH) Study will test the effectiveness of a collaborative care intervention directed toward HIV physicians to improve the management of COT and reduce the misuse of prescription opioids among HIV-infected persons. The intervention is composed of the following elements: 1) collaboration with a nurse care manager (NCM); 2) physician education and academic detailing; and 3) facilitated access to a specialist in addictions to help manage the most challenging HIV-infected patients on COT. The NCM will utilize an electronic registry to assist physicians in implementing guideline-driven care including opioid treatment agreements, urine drug testing (UDT), random pill counts and checking of online Prescription Monitoring Programs (PMPs). Physicians in the control group will receive information summarizing guidelines for COT but will not have access to the support of the TEACH intervention. This 3-site study will use a cluster randomized trial design, randomized at the level of the physician, and compare primary outcomes over one year. The Specific Aims are to test the effectiveness of the TEACH collaborative care program to achieve the following: Aim 1 - Improve HIV physicians' adherence to guidelines for COT compared to standard practice; Aim 2 - Increase HIV physicians' satisfaction and confidence in prescribing COT; Aim 3 - Reduce aberrant use of prescription opioids among HIV-infected patients who are on COT; and Aim 4 - Improve virologic control among HIV-infected patients who are on COT. If effective, implementation of the intervention in HIV clinics will enable physicians in clinical teas to deliver chronic opioid therapy according to established guidelines with more confidence, potentially resulting in less prescription drug abuse and improved HIV outcomes.