The OUD Cascade of Care and Critical Outcomes: Longitudinal Linkage with Opioid Use

护理和关键结局的OUD级联：与药物使用的纵向联系 美国过量死亡人数的急剧增加迫切需要改善获得 阿片类药物使用障碍（OUD）与药物（MOUD）的循证护理，根据OUD 护理级联框架。级联模型强调治疗过程中的关键阶段或过渡， OUD患者，以降低不良结局的风险：关键，成功的MOUD启动和长期 潴留然而，迄今为止，它对同时使用阿片类药物持不可知论态度。在芬太尼价格上涨的时代 鉴于非法药物供应的普遍性，公共卫生框架需要根据环境条件进行调整， 可能影响临床结果。我们的研究方法来自阿片类药物使用的概念化， 反应，和不良后果，作为演变沿着轨迹，在不同的时间框架，强调 需要针对患者目标定制的伤害减少方法，因为它们随着时间的推移而演变。我们假设 在当地药物供应中更多地接触芬太尼将阻碍成功的治疗参与，我们 我还预计丁丙诺啡治疗的持续时间更长，以防止过量的风险，即使在患者中， 间歇性使用阿片类药物然而，在护理中使用阿片类药物的患者可能会经历 治疗中止后风险降低减弱。 迫切需要对治疗途径和结果进行纵向分析，包括 毒理学结果和治疗保留的交叉作用和预后意义，及其 与治疗期间和治疗后过量风险的关系。因为目前的证据表明， 由于缺乏持续的护理，特别是在个别患者或亚群体水平上，目前几乎没有 经验证据，指导临床医生和卫生系统如何最好地定制服务提供， 在患者层面估计不良事件的风险。我们的建议旨在填补这些关键的知识空白。 我们将链接来自多州丁丙诺啡供应商的95，000人的EHR记录-全国最大的丁丙诺啡供应商 最大的OBOT提供商-与医疗补助索赔和国家死亡指数（NDI）数据，以创建一个新的，独特的， 2014年至2022年在十几个州建立的综合数据库，以在摄入前、基线时观察患者， 而在照顾多年，占死亡率在芬太尼的冲击。医疗补助现在是 MOUD的最大付款人。我们的发现将对临床护理、政策、系统设计， 质量测量开发和医疗保健管理。我们的目标是建立一个经验主义的 为患者风险（例如，不良结局，包括用药过量）的临床评价提供信息的证据基础 个人层面。针对不断变化的阿片类药物流行病的规模和严重性，临床和政策至关重要 战略是通过仔细考虑对大量的经验数据进行严格的分析而制定的， 跨越州界的人口。

The OUD Cascade of Care and Critical Outcomes: Longitudinal Linkage with Drug Use Dramatic increases in overdose deaths in the US have created an urgent need to improve access to and retention in evidence-based care for opioid use disorder (OUD) with medication (MOUD), under the OUD Cascade of Care framework. The Cascade model emphasizes key stages or transitions during the treatment of individuals with OUD to reduce risks of adverse outcomes: critically, successful MOUD initiation and long-term retention. However, it has thus far been agnostic towards concurrent opioid use. In the era of rising fentanyl prevalence in the illicit drug supply, public health frameworks need to adjust for environmental conditions that may impact clinical outcomes. Our research approach draws from a conceptualization of opioid use, treatment response, and adverse outcomes as evolving along trajectories, over varying timeframes emphasizing the need for harm reduction approaches tailored to patient goals as they evolve over time. While we hypothesize that greater exposure to fentanyl in the local drug supply will impede successful treatment engagement, we also expect longer durations of buprenorphine treatment to protect against overdose risk, even among patients with intermittent opioid use while in care. However, patients with opioid use in care will likely experience attenuated risk reductions following treatment discontinuation. There is a critical need for longitudinal analyses of treatment pathways and outcomes, including the intersecting roles and prognostic significance of toxicology results and treatment retention, and their relationship to overdose risk during and following treatment. Because current evidence concerning optimal durations of care, especially at the individual patient or sub-population level, is lacking, there is currently little empirical evidence to guide clinicians and health systems regarding how to best tailor service provision and estimate risks of adverse events at the patient level. Our proposal seeks to fill these critical gaps in knowledge. We will link EHR records for 95,000 individuals from a multi-state buprenorphine provider-- the nation’s largest OBOT provider-- with Medicaid claims and National Death Index (NDI) data to create a new, unique, integrated database spanning 2014-2022 in a dozen states to observe patients before intake, at baseline, and while in care over multiple years, accounting for mortality during the onslaught of fentanyl. Medicaid is now the largest payer for MOUD. Our findings will have broad implications for clinical care, policy, systems design, quality measurement development, and healthcare administration. Our goal is to establish an empirical evidence base to inform clinical evaluations of patient risks (e.g. adverse outcomes including overdose) at the individual level. Against the scale and gravity of the evolving opioid epidemic, it is vital that clinical and policy strategies are informed by careful consideration of rigorous analyses of empirical data with large, usual-care populations across state lines.