Assessing the Unintended Consequences of Restrictive Opioid Pain Reliever Policies

阿片类止痛药(OPR)过量在美国已经达到流行的程度。在……里面 为了应对这场公共卫生危机，地方、州和国家都做出了努力，减少不适当的 阿片类药物处方。最近OPR死亡率在2012-3年度的小幅下降表明，这些努力可能已经 很有效。然而，最近海洛因使用、海洛因使用障碍和海洛因使用前所未有的增加 此外，还出现了过量服用的情况。有人建议，遏制不适当的OPR处方的努力 正在产生增加海洛因使用及其不良事件的意想不到的后果。成本低、覆盖面广 可得性是从OPR转向海洛因使用的常见原因。要有效地管理 海洛因引发的风险、卫生系统、保险计划和医疗提供者需要了解， OPR处方做法如何以及对谁影响这些风险。 科罗拉多州的几项政策旨在遏制阿片类药物的处方。2014年8月，科罗拉多州 医疗补助计划将每月短效阿片类药物的数量限制在120片。2016年2月，医疗补助计划限制了 每日平均覆盖吗啡当量剂量(MED)至300MED。科罗拉多州凯撒永久酒店(Kaiser Permanente Colorado) 遵循医疗补助在阿片类药物政策上的领导。这些政策旨在鼓励医疗服务提供者逐渐减少患者 减少大剂量阿片类药物治疗，从而降低口服避孕药过量的风险。然而，到目前为止，这些措施的影响 关于医生处方行为、OPR过量、海洛因使用和海洛因过量的政策尚不清楚。 这个项目的总体目标是进行一项大型的纵向队列研究，以检查OPR的影响 2012-2017年海洛因使用和海洛因过量的政策和处方做法。该研究将包括 来自大型管理医疗组织(科罗拉多州Kaiser Permanente)和科罗拉多州医疗补助的患者 程序。这些系统总共覆盖了科罗拉多州约200万人，占 该州的人口。暴露和结果，以及协变量将通过将患者水平的数据从 药房记录、诊断、毒理学发现、卫生保健利用和州生命记录。曝光量 结果将通过病历审查进行验证。分析将以线性和 非线性混合效应回归模型，使用倾向性分数来解释混杂。结果是 这些分析将对OPR在州和国家层面制定政策产生影响。

Overdoses from opioid pain relievers (OPR) have reached epidemic proportions in the United States. In response to this public health crisis, there have been local, state and national efforts to reduce inappropriate opioid prescribing. Recent small reductions in OPR deaths rates in 2012-3 suggest that these efforts may have been effective. However, unprecedented recent increases in heroin use, heroin use disorders, and heroin overdoses have also been observed. It has been suggested that efforts to curb inappropriate OPR prescribing are having the unintended consequence of increasing heroin use and its adverse events. Low cost and wide availability are common reasons provided for the switch from OPR to heroin use. To effectively manage the risk of heroin initiation, health systems, insurance plans, and medical providers need to understand whether, how, and for whom these risks are affected by OPR prescribing practices. Several policies in Colorado have been directed at curbing opioid prescribing. In August of 2014, Colorado Medicaid limited monthly quantities of short-acting opioid pills to 120. In February 2016, Medicaid limited the average daily covered morphine equivalent dose (MED) to 300 MED. Kaiser Permanente Colorado (KPCO) follows Medicaid's lead on opioid policy. These policies were intended to encourage providers to taper patients from high-dose opioid therapy, thus reducing the risk of OPR overdose. To date, however, the effect of these policies on physician prescribing behavior, OPR overdose, heroin use, and heroin overdose is not known. The overall goal of this project is to conduct a large, longitudinal cohort study to examine the impact of OPR policies and prescribing practices on heroin use and heroin overdose from 2012 to 2017. The study will include patients from a large managed care organization (Kaiser Permanente Colorado) and Colorado's Medicaid program. Together these systems cover approximately 2 million people in Colorado, representing 40% of the state's population. Exposures and outcomes, and covariates will be measured by linking patient-level data from pharmacy records, diagnoses, toxicology findings, health care utilization, and state vital records. Exposures and outcomes will be validated with medical record review. Analyses will be conducted with linear and nonlinear mixed effects regression models, with propensity scores to account for confounding. The results of these analyses will have implications for OPR prescribing policies at the state and national level.