Opioid Treatment of Pain in People with Cancer: Intended and unintended consequences of state policies addressing opioid prescribing

摘要 慢性癌症相关疼痛非常普遍，国际指南长期以来一直支持使用 阿片类药物治疗与活动性疾病相关的中到重度疼痛。这种共识的力量是 对患有晚期疾病和预期寿命有限的患者最有效。对于经历了 长期缓解，或稳定或惰性疾病，不需要持续的抗癌治疗(“长期- 生存“一词)，有一个新的共识，即阿片类药物治疗应以类似的 对于慢性非癌性疼痛患者的治疗方式。关于以下方面的最佳实践越来越含糊不清 接受积极抗癌治疗的患者意向治愈。在阿片类药物流行之后，国家 为了减少不安全的阿片类药物处方，政策激增。近期突出的政策包括 国家对处方药参与处方药监测计划(PDMP)的规定和州 对治疗急性疼痛的阿片类药物处方的持续时间和/或剂量的立法限制。这些政策的内容各不相同 对癌症患者亚群的预期适用性，以及关于临床的模棱两可 最佳做法，可能在不经意间影响了阿片类药物的使用和不同群体的相关结果 癌症患者的亚群。我们建议进行一项研究，以评估有意和无意的后果。 关于阿片类药物处方和与疼痛和阿片类药物相关的不良健康事件的两种国家政策 在晚期癌症患者、长期存活者和接受活动癌症的患者中 治疗。为了帮助阐明应对政策变化的潜在机制，我们还将探讨 使用创新模式，在每个亚群中分配阿片类药物和临床遭遇的轨迹 采矿方法。我们将使用SEER-Medicare关联数据库和一个大型国家商业保险 数据库来实现研究目的。调查结果将为建立共识、指导方针和干预提供信息 发展，以及提供者、保健组织和政策制定者的政策和做法变化 优化癌症患者的阿片类药物处方和疼痛管理。

ABSTRACT Chronic cancer-related pain is highly prevalent and international guidelines have long supported the use of opioid therapy for moderate to severe pain related to active disease. The strength of such consensus is strongest for patients experiencing advanced disease and limited life expectancy. For patients experiencing long-term remission, or, stable or indolent disease without the need for ongoing anti-cancer treatment (“long- term survivorship”), there is emerging consensus that opioid therapies should be addressed in a similar manner as for patients with chronic non-cancer pain. There is mounting ambiguity regarding best practices for patients receiving active anti-cancer treatment intended for cure. In the wake of the opioid epidemic, state policies have proliferated in an effort to reduce unsafe opioid prescribing. Prominent recent policies include state mandates for prescriber participation in the Prescription Drug Monitoring Programs (PDMPs) and state legislative limits on duration and/or dosage of opioid prescriptions for acute pain. These policies vary in their intended applicability to subpopulations of cancer patients, and, coupled with the ambiguity regarding clinical best practices, may have inadvertently impacted opioid use and related outcomes among the different subpopulations of people with cancer. We propose a study to evaluate intended and unintended consequences of the two types of state policies for opioid prescriptions and pain- and opioid-related adverse health events among cancer patients with advanced disease, long-term survivors, and patients receiving active cancer treatment. To help elucidate mechanisms underlying changes in response to policies, we will also explore the trajectories of opioids dispensed and clinical encounters within each subpopulation, using an innovative pattern mining approach. We will use the SEER-Medicare linked database and a large national commercial insurance database to achieve study aims. Findings will inform consensus-building, guideline and intervention development, and policy and practice changes by providers, health care organizations, and policymakers in optimizing opioid prescribing and pain management for cancer patients.