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，但阿片类药物相关的死亡率 由于海洛因的使用和中毒率不断上升，2013年至2014年，国家 上一年非医疗使用OPR的估计数从1108万人下降到1034万人。在 相比之下，海洛因使用人数从68万增加到91万。海洛因的死亡率增加了26%， 在过去的五年里，超过300%。这种趋势的转变不仅仅是生态方面的， 的海洛因使用者报告在开始使用海洛因之前非医疗使用OPR。这是一个实质性 与海洛因使用的历史轨迹相背离。对于大多数开始使用海洛因的人来说， 在1960年代，海洛因是他们的第一种阿片类药物。虽然从非医疗使用OPR过渡到海洛因的风险是 人们对低水平、促成因素和诱发因素知之甚少。OPR和海洛因相关的负担 医疗补助计划中的个人的不良事件特别高，因为他们更有可能 药物使用障碍，在过量死亡中所占比例过高。俄勒冈州 最近开发了一个国家性能改进项目（PIP），以减少高剂量的比例 阿片类药物处方在其医疗补助计划，这是现在通过16个地区和卫生系统提供 协调护理组织（Coordinated Care Organizations，CCO）。因为每个CCO都有灵活性来解决国家的问题， PIP，跨CCO的实施构成了一个自然的实验，以研究与 OPR处方和海洛因相关结局的变化。响应RFA-CE-16-003（研究 处方阿片类药物使用，阿片类药物处方和相关的海洛因风险;优先事项#2），本研究的目的 研究旨在评价OPR处方、CCO阿片类药物剂量减少计划与 OPR使用模式，海洛因使用和阿片类药物相关过量。目标通过三个方面实现 具体目标采用混合方法。首先，使用多目录链接的数据库，其中包括 处方药监测计划（PIMDA）、医疗补助索赔、生命统计和物质使用治疗 来自俄勒冈州的数据，OPR处方模式和海洛因相关结果之间的关系将被测试。 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，执行共同体合作组织PIP倡议对 将评估高风险OPR使用和海洛因相关结果。本研究的发现将有助于 我们对过渡到海洛因和过量使用海洛因的个人风险因素的理解。此外，获得的知识 将协助地方和国家决策者制定政策杠杆，以减轻OPR和海洛因的负担- 相关的发病率和死亡率。

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.