Substance use outcomes of opioid dose reduction and discontinuation

项目摘要 为了解决RFA-CE-16 - 003的优先级#2，我们建议海洛因和其他非法阿片类药物使用和过量 在疼痛患者中（HOPP），对接受阿片类药物疼痛的患者进行的纵向回顾性研究 在阿片类药物处方政策转变的背景下，缓解慢性非癌症疼痛（CNCP）的OPR。许多 卫生系统，包括旧金山弗朗西斯科卫生网络（SFHN）的安全网初级保健诊所， 实施阿片类药物处方政策的重大变化。这些变化包括剂量限制， 对物质使用障碍（SUD）患者开处方，并要求进行尿检，疼痛协议， 检查处方药监测计划（PAPs）。这些变化中有许多是为了 减少OPR转移，预计将导致许多患者终止OPR治疗。的影响 这些变化对那些已经依赖阿片类药物的人来说是未知的，尽管轶事证据表明， 一些患者开始或恢复海洛因或其他非法阿片类药物的使用，因为处方阿片类药物被终止。在 此外，人们担心，这些处方变化可能会增加与海洛因和其他毒品有关的死亡率。 非法阿片类药物过量为了解决这些主要的知识缺口，我们将招募600名开OPR的患者， 来自SFHN慢性阿片类药物疼痛患者登记处的CNCP长期治疗，包括150例患者， OPR已经停止、减少、维持和增加。HOPP参与者将接受详细的 采访涉及自2012年以来他们的物质使用模式的历史重建和一个独立的 电子医疗记录图表提取以识别OPR和其他受控物质处方模式， 暴露于阿片类药物管理干预和医学共病，以表征相关性 OPR处方的变化与海洛因和其他非法阿片类药物的开始和使用之间的关系（目标1）， 海洛因和其他非法阿片类药物过量（目标2）。为了捕捉在存在以下因素的情况下的整体效果， 从早期结果到暴露的反馈，我们将使用嵌套队列方法来估计直接和 OPR剂量变化的间接影响。探索性分析将包括评估 OPR剂量和医疗护理依从性的变化以及阿片类药物相关的急诊科就诊， 临床一级阿片类药物管理政策与海洛因和其他非法阿片类药物使用之间的关联， 在整个疼痛队列中，OPR剂量的变化与随后的阿片类药物过量死亡率之间 管理病人。

Project Abstract To address Priority #2 of RFA-CE-16-003, we propose Heroin and Other Illicit Opioid Use and Overdose Among Pain Patients (HOPP), a longitudinal retrospective study of patients who have received opioid pain relievers (OPRs) for chronic non-cancer pain (CNCP) in the setting of shifting opioid prescribing policies. Many health systems, including the safety net primary care clinics of the San Francisco Health Network (SFHN), are implementing substantial changes in opioid prescribing policy. These changes include dose limits, restrictions on prescribing to persons with substance use disorders (SUDs), and required urine testing, pain agreements, and checks of the prescription drug monitoring program (PDMP). Many of these changes are designed to reduce OPR diversion and are expected to lead to termination of OPR therapy for many patients. The impact of these changes on those already reliant upon opioids is unknown, although anecdotal evidence suggests that some patients initiate or resume heroin or other illicit opioid use as prescribed opioids are terminated. In addition, there is concern that these prescribing changes could increase mortality related to heroin and other illicit opioid overdose. To address these major gaps in knowledge, we will recruit 600 patients prescribed OPRs long-term for CNCP from the SFHN registry of patients on chronic opioids for pain, including 150 each whose OPRs have been discontinued, reduced, maintained, and increased. HOPP participants will undergo a detailed interview involving historical reconstruction of their substance use patterns since 2012 and an independent electronic medical record chart extraction to identify OPR and other controlled substance prescription patterns, exposure to opioid stewardship interventions, and medical co-morbidities to characterize the association between changes in OPR prescribing and initiation and use of heroin and other illicit opioids (Aim 1) and overdose involving heroin and other illicit opioids (Aim 2). To capture overall effects in the presence of feedback from earlier outcomes to exposure, we will use a nested cohorts approach to estimate the direct and indirect effects of change in OPR dose. Exploratory analyses will include assessing the association between changes in OPR dose and medical care adherence as well as opioid-related emergency department visits, the association of clinic-level opioid stewardship policy and heroin and other illicit opioid use, and the association between change in OPR dose as subsequent opioid overdose mortality among the full cohort of pain management patients.