Examining the Consequences of Reductions in Opioid Prescribing on Patients, Clinical Care, and Community Health

我们建议使用定性方法来检查减少阿片类药物处方的后果， 慢性非癌症疼痛（CNCP）对患者，临床护理提供和社区健康的影响。八千多万 美国人报告称，CNCP被定义为持续时间超过三个月的非恶性疼痛， 生命的终结过去二十年来，CNCP阿片类药物处方的增加与以下因素有关： 阿片类药物相关的发病率和死亡率急剧增加。作为回应，疾病控制中心 美国疼痛协会和美国医学协会制定了 建议通过鼓励临床医生（1）咨询全州范围内的处方， 开阿片类药物处方时的药物监测程序;（2）不启动CNCP的阿片类药物治疗;和（3）监测， 减少和/或停用阿片类药物。这些建议正在执行中 在全国范围内，有证据表明类阿片处方总数随之减少。然而， 现有数据记录了减少类阿片处方的长期后果，无论是积极的还是消极的。 拟议的研究建立在我们之前的R 01（DA 034625），临床和社区疼痛管理的基础上 （PMCC），研究了有物质使用史的疼痛患者的CNCP管理 安全网临床环境中的护理。有CNCP诊断的医疗补助保险患者比他们的 接受阿片类药物处方的CNCP私人保险同行。有药物史的患者 使用者更有可能被诊断为CNCP，被处方阿片类药物，并过渡到慢性阿片类药物 与没有药物使用史的患者相比，这项研究将采用社会生态模型 （SA 1）审查减少阿片类药物的后果， 根据CNCP患者的经历开处方;（SA 2）检查阿片类药物减少的后果 在初级保健安全网环境中，对患者-临床医生关系和临床护理提供进行处方;（SA 3） 从社区的角度研究阿片类药物处方减少的后果 持份者拟议的纵向研究将在四个安全网诊所和病人的 家庭/社区环境在两个不同的旧金山弗朗西斯科湾区县。我们将进行定性分析 对30名初级保健临床医生和60名有CNCP病史的CNCP患者进行了招募和随访 药物使用，临床医生和匹配的患者之间的临床观察（SA1&2）。我们将 从理论上对60名CNCP患者中的30名进行抽样，并在患者的家庭环境中进行民族志研究， 访谈40名社区利益相关者（SA1&3）。多学科研究小组，由一名医学专家组成， 人类学家，研究阿片类药物滥用和安全网实践的医生调查员， 护士/临床疼痛政策专家将综合数据，以提高我们对 减少阿片类药物处方的后果，以提出临床和政策建议。

We propose to use qualitative methods to examine the consequences of reductions in opioid prescribing for chronic non-cancer pain (CNCP) on patients, clinical care delivery, and community health. Over 80 million Americans report CNCP, defined as non-malignant pain that lasts longer than three months, not associated with end of life. Escalations in opioid prescribing for CNCP over the past two decades have been associated with dramatic increases in opioid-associated morbidity and mortality. In response, the Centers for Disease Control and Prevention, the American Pain Society, and the American Medical Association developed recommendations to limit reliance on opioids, by encouraging clinicians to (1) consult statewide prescription drug monitoring programs when prescribing opioids; (2) not initiate opioid therapy for CNCP; and (3) monitor, taper, and/or discontinue opioids in CNCP patients. These recommendations are being implemented nationwide and evidence suggests a concomitant decrease in the total number of opioid prescriptions. Yet, little data exist documenting the long term consequences, positive or negative, of reductions in opioid prescribing. The proposed study builds on our previous R01 (DA034625), Pain Management in the Clinic and Community (PMCC), that examined the management of CNCP in patients with a history of substance use who received pain care in safety net clinical settings. Medicaid insured patients with a CNCP diagnosis are more likely than their privately insured counterparts with CNCP to receive opioid prescriptions. Patients with a history of substance use are more likely to receive a diagnosis of CNCP, to be prescribed opioids, and to transition to chronic opioid therapy than patients without substance use histories. The proposed study will use the social-ecological model of health to address the following specific aims: (SA1) To examine the consequences of reductions in opioid prescribing on patients' experiences of CNCP; (SA2) To examine the consequences of reductions in opioid prescribing on patient-clinician relationships and clinical care delivery in primary care safety net settings; (SA3) To examine the consequences of reductions in opioid prescribing from the perspectives of community stakeholders. The proposed longitudinal study will take place in four safety-net clinics and patients' home/community environments in two diverse San Francisco Bay Area Counties. We will conduct qualitative enrollment and follow-up interviews with 30 primary care clinicians and 60 of their CNCP patients with a history of substance use, and clinical observations between clinicians and matched patients (SA1&2). We will theoretically sample 30 of the 60 CNCP patients and conduct ethnography in patients' home environments, and interview 40 community stakeholders (SA1&3). The multidisciplinary research team, consisting of a medical anthropologist, a physician investigator who studies opioid misuse and practices in the safety net, and a nurse/clinical pain policy expert will synthesize the data with the goal of improving our understanding of the consequences of opioid prescription reductions to make clinical and policy recommendations.