HEAL Initiative: Integrative Management of chronic Pain and OUD for Whole Recovery (IMPOWR): Research Centers

背景和意义：慢性疼痛是一种高患病率的问题，其全部激动剂阿片类药物是 通常是处方药。全激动剂阿片类药物的危害可能大于益处，在这种情况下，改用丁丙诺啡 是经常被推荐的。做出从完全激动剂转向丁丙诺啡的决定，患者和 提供者需要有关益处和危害的有效信息。FDA最近对这种药物的使用发出了警告 丁丙诺啡和牙科问题之间的关系 对照组315例。因此，在对艾滋病的相对风险的理解上存在很大差距。 全激动剂阿片类药物与丁丙诺啡之间的牙科问题 创新与影响：我们的研究将利用退伍军人老龄化队列研究(Vacs)的全VA样本。 包含约800万人，用于评估经粘膜丁丙诺啡与全阿片类药物的相对风险 使用严格的队列设计，根据假设进行调整的牙科问题激动剂与非阿片类药物治疗 混血儿。这项创新的工作将检查阿片类药物暴露的各种模式(完全激动剂与切换到 部分激动剂)，反映真实世界的临床比较，以告知与患者的风险讨论。 具体目标：1.确定发生的长期阿片激动剂(全部和部分)之间的联系 龋齿、龋齿、口腔感染和牙齿脱落(在此称为复合体 不良牙科结果：与没有长期服用阿片类激动剂的患者相比，调整了相关因素 社会人口学和临床因素。2.在长期接受阿片类激动剂事件的个人中， 检查模式之间的联系(继续服用全阿片激动剂与改用丁丙诺啡与停止) 阿片类药物收受和CADO。3.在有长期阿片类药物收受事件的个人中，不改用 检查较大的阿片类药物暴露(mg Medd x time=总mg Medd)与CADO之间的关系， 根据个别阿片类药物的免疫抑制特性进行分层。 方法：基于我们之前使用退伍军人事务部企业数据仓库(CDW)的方法，我们将确定 一大批接受长期阿片类药物治疗(LTOT)的退伍军人 2010-2019年，与缺乏LTOT接收的退伍军人1：2匹配，并随着时间的推移观察队列中的模式 阿片类药物的接受--包括全部和部分激动剂--和不良的牙科结果。对于主要结果(CADO)，a 考克斯比例风险模型将是我们评估阿片类药物接受模式的主要方法， 人口学和治疗特征与转归时间的关系。在接受治疗的患者子集中 完全激动剂类阿片类药物(即缺乏部分激动剂)，我们将检查总 阿片类药物暴露的数量、阿片类药物的免疫抑制特性和不良牙科后果。 下一步/实施：这项研究的结果将有助于与考虑 从全阿片类激动剂改用丁丙诺啡。

Background & Significance: Chronic pain is a high prevalence problem for which full agonist opioids are commonly prescribed. Harm of full agonist opioids may outweigh benefit in which case switch to buprenorphine is often recommended. To make decisions about switching from full agonists to buprenorphine, patients and providers need valid information about benefits and harms. The FDA recently issued a warning about the use of transmucosal buprenorphine and dental problems based on an accumulated case series of approximately 315 cases without control patients. Therefore, there is a significant gap in understanding of the relative risk of dental problems between full agonist opioids and buprenorphine Innovation & Impact: Our study will harness the “Full VA” sample of the Veterans Aging Cohort Study (VACS) containing ~8 million individuals to assess the relative risk of transmucosal buprenorphine vs. full opioid agonists vs. no opioid therapy for dental problems using a rigorous cohort design, adjusting for hypothesized confounders. This innovative work will examine various patterns of opioid exposure (full agonist vs. switch to partial agonist) that reflect real-world clinical comparisons to inform risk discussions with patients. Specific Aims: 1. To determine the association between incident long-term opioid agonist (full and partial) receipt and tooth decay, cavities, oral infections, and loss of teeth (here forward referred to as composite adverse dental outcome: CADO) compared to no long-term opioid agonist receipt, adjusting for relevant sociodemographic and clinical factors. 2. Among individuals with incident long-term full agonist opioid receipt, to examine the association between patterns (stay on full opioid agonists vs. switch to buprenorphine vs. stop) of opioid receipt and CADO. 3. Among individuals with incident long term opioid receipt who do not switch, to examine the association between greater opioid exposure (mg MEDD x time = total mg MEDD) and CADO, stratified by immunosuppressive properties of individual opioids. Methodology: Based on our previous methods using VA's Corporate Data Warehouse (CDW), we will identify a large retrospective cohort of all Veterans with incident long-term opioid therapy (LTOT) over the period of 2010-2019, matched 1:2 with Veterans who lack LTOT receipt and observe the cohort over time for patterns of opioid receipt—both full and partial agonist--and adverse dental outcomes. For the primary outcome (CADO), a Cox proportional hazards model will be our primary approach to assessing pattern of opioid receipt, demographic and treatment characteristics in relation to time to outcome. In the subset of patients who receive full agonist opioids exclusively (i.e. lack partial agonist receipt), we will examine the association between total quantity of opioid exposure, immunosuppressive properties of the opioids and adverse dental outcomes. Next Steps/Implementation: Results of this study will help inform risk discussions with patients considering a switch to buprenorphine from full opioid agonists.