The Hemodialysis Opioid Prescription Effort Consortium

项目总结/摘要 阿片类药物的流行并没有放过血液透析人群。慢性疼痛和阿片类药物使用率 在接受血液透析治疗的患者中， 与肝癌患者的发病率相当。在一项对接受治疗的患者的症状调查中， 血液透析、骨和关节疼痛是最常见的（约50%）和最麻烦的 症状报告。此外，疼痛与较低的健康相关生活质量和较高的 抑郁情绪的可能性，缩短透析疗程，急诊科（艾德）就诊， 住院和死亡率。最近使用Medicare Part D处方数据的研究发现， 透析患者在1年的过程中接受了至少一次阿片类药物的处方。 不幸的是，阿片类药物的这种广泛使用不是良性的;接受阿片类药物的患者的死亡率更高。 因精神状态改变、福尔斯和骨折而住院或遭遇艾德的风险，以及全因死亡率。 尽管在透析人群中广泛使用阿片类镇痛药， 它们在治疗常见慢性疼痛方面的疗效有限，大多数接受长期 长期阿片类药物治疗继续经历严重疼痛和功能限制。此外，虽然 在一般慢性疼痛人群中的研究已经确定了成功的干预措施来控制疼痛， 改善功能状态，很少有研究解决了透析人群中的这一紧迫问题。 因为接受维持性血液透析的患者受到独特的治疗组合的阻碍， 负担、共病状况和心理社会挑战，在非透析患者中可能有效的策略 在透析人群中可能无法提供获益。此外，鉴于其多样性和复杂性， 接受维持性血液透析的慢性疼痛患者面临的挑战，个性化护理 方法在这一人群中可能特别重要。 同时解决美国血液透析中慢性疼痛和阿片类药物使用相关问题 我们建议评估量身定制的，以患者为中心的干预措施，以管理疼痛和减少阿片类药物 使用.具体来说，我们建议将患者以1：2：2的比例随机分配到三组中的一组， 1个月研究期：1）疼痛护理管理（PCM），包括协作阿片类药物逐渐减量支持，非阿片类药物 药物管理和护理协调，对比2）PCM加在线疼痛自我管理 结合认知行为训练并在透析期间提供的PSM计划，与 3)通过药物审查和教育进行控制。我们还建议评估提供的有效性 丁丙诺啡我们将随机分配两个积极治疗组的参与者， 丁丙诺啡轮换与不选择丁丙诺啡的持续标准阿片类药物减量支持。

PROJECT SUMMARY/ABSTRACT The opioid epidemic has not spared the hemodialysis population. Rates of chronic pain and opioid use are higher among patients treated with hemodialysis than in the general Medicare population and are comparable to rates for individuals with liver cancer. In a survey of symptoms among patients receiving hemodialysis, bone and joint pain was among the most prevalent (approximately 50%) and most bothersome symptoms reported. In addition, pain was associated with lower health-related quality of life and higher likelihood of depressive affect, abbreviated dialysis sessions, emergency department (ED) encounters, hospitalizations, and mortality. Recent studies using Medicare Part D prescription data found that over 60% of dialysis patients received at least one prescription for an opioid medication over the course of 1 year. Unfortunately, this widespread use of opioid medications is not benign; patients receiving opioids are at higher risk of hospitalization or ED encounters for altered mental status, falls, and fractures, and all-cause mortality. Despite the pervasive use of opioid analgesics in the dialysis population and the substantial risks they engender, their efficacy is limited in treating common chronic pain conditions, and most patients receiving long- term opioid therapy continue to experience severe pain and functional limitations. Furthermore, although studies in the general chronic pain population have identified successful interventions to manage pain and improve functional status, few studies have addressed this pressing problem in the dialysis population. Because patients receiving maintenance hemodialysis are encumbered by a unique combination of treatment burden, comorbid conditions, and psychosocial challenges, strategies that may be effective in non-dialysis populations may not provide benefit in the dialysis population. Further, given the diversity and complexity of challenges faced by patients with chronic pain receiving maintenance hemodialysis, individualized care approaches are likely to be especially important in this population. To simultaneously address problems related to chronic pain and opioid use in the U.S. hemodialysis population, we propose to evaluate tailored, patient-centered interventions to manage pain and reduce opioid use. Specifically, we propose to randomly assign patients in a 1:2:2 fashion to one of three groups over a 12- month study period: 1) pain care management (PCM), including collaborative opioid taper support, non-opioid medication management, and care coordination, versus 2) PCM plus an on-line pain self-management program (PSM) that incorporates cognitive behavioral training and is delivered during dialysis sessions, versus 3) control with medication review and education. We also propose to evaluate the effectiveness of offering buprenorphine. We will randomly assign participants in both active treatment arms to being offered buprenorphine rotation versus continued standard opioid taper support without the option of buprenorphine.