Long-Term Opioid Therapy: Screen to Evaluate and Treat (Opioid-SET)

长期阿片类药物治疗：筛查、评估和治疗 (Apioid-SET)

• 批准号: 10700087
• 负责人: Jessica Yelena Breland
• 金额: --
• 依托单位: VETERANS ADMIN PALO ALTO HEALTH CARE SYS
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-09-01 至 2025-02-28
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10700087
• 关键词: Activities of Daily Living; Acute; Address; Adherence; Behavior; Caring; Clinic; Clinical; Clinical Practice Guideline; Dangerousness; Data; Decision Making; Diagnosis; Doctor of Philosophy; Electronic Health Record; Emergency department visit; Feeling suicidal; Focus Groups; Goals; Guidelines; Harm Reduction; Healthcare; Healthcare Systems; Heroin; Hospitalization; Link; Measures; Mental Health; Mental Health Services; Methods; Modeling; Monitor; Opioid; Overdose; Pain Clinics; Pain management; Patient Care; Patient Monitoring; Patient-Centered Care; Patient-Focused Outcomes; Patients; Physicians; Policies; Practice Guidelines; Prevalence; Primary Care; Program Evaluation; Provider; Recommendation; Research; Resources; Risk; Screening procedure; Self Direction; Site; Subgroup; Substance Use Disorder; Surveys; Telephone; Testing; Veterans; Veterans Health Administration; Violence; Withdrawal Symptom; Work; alternative treatment; caregiving; cognitive interview; comorbidity; coping; cost; data warehouse; field study; follow-up; health care settings; improved; innovation; instrument; integrated care; medication-assisted treatment; non-opioid analgesic; operation; opioid mortality; opioid tapering; opioid therapy; opioid use disorder; overdose death; pain catastrophizing; patient oriented; patient subsets; prescription opioid; programs; response; side effect; substance use; suicidal; suicide rate; systematic review; text searching; therapy development; tool

Background: Despite high numbers of VHA patients (>300,000) receiving long-term opioid therapy (LTOT), evidence of its harms is growing (e.g., inadequate pain control, side effects, overdoses). Although VA/DoD Guidelines recommend frequent, multi-component monitoring of LTOT patients, monitoring is under-utilized because it does not fit with primary care’s workflow. In addition, rates of opioid discontinuation are increasing, even though discontinuation is often harmful (e.g., more use of street heroin, worsening mental health). Further, for patients for whom both continued LTOT and tapering for discontinuation are determined to be potentially harmful, a clinical practice guideline (CPG) is not available, leaving them “guideline-orphaned.” Significance: With increasing opioid overdose deaths and complications of LTOT due to comorbidities, policy emphases have shifted to reducing opioid prescribing, and monitoring and discontinuing opioids among LTOT patients. This project will help providers maintain high-quality patient care while responding to policy shifts. It addresses the VHA’s and HSR&D’s goal of offering patient-centered care by giving providers an integrated instrument to reduce harms due to LTOT continuation and discontinuation, which are widespread and severe among Veterans. Innovation: This project has the potential to change LTOT practices by giving primary care and other providers new, easy-to-use screening tools that will facilitate adherence to recommended guidelines on monitoring of LTOT patients, and discontinuation of LTOT when it is harmful. The integrated instrument may be incorporated into CPRS to facilitate its use in VA health care clinics. The project will also change practice by providing new, provisional guidelines for a challenging group of LTOT patients for whom CPGs do not exist. The work to be accomplished is complementary to VHA initiatives by contributing to components of best practices for balancing pain management and opioid prescribing, “S.T.O.P. P.A.I.N,” i.e., Stepped care model; Treatment alternatives; Ongoing monitoring of usage; and Practice guidelines. Specific Aims are to develop an integrated instrument with two screening tools, the first to indicate if LTOT is harmful to continue (yes or no; Aim 1), and the second to indicate if tapering to discontinue opioids is harmful to initiate (yes or no; Aim 2). Positive screens will indicate that providers should undertake additional, more comprehensive monitoring and examination to determine the harm of continued LTOT or tapering to discontinuation, respectively. Aim 3: Inform subsequent CPGs by determining preliminary treatment approaches for “guideline-orphaned” LTOT patients. Methods to develop the tools will involve (1) comprehensive literature searches to yield an initial item bank for each screening tool; (2) qualitative item analyses using focus groups with patients and providers, cognitive interviewing with patients, expert review, and item revision to yield small item banks for each screening tool for field testing; and (3) field testing to yield the final bank of items for each screening tool, which will include (a) linking patients’ (n=500 for each tool) telephone survey responses to their electronic health record data from the Corporate Data Warehouse, and (b) reliability testing (n=30 patients). Methods to work toward the CPG will follow the same methods used to develop the VA/DoD CPG for the Management of Substance Use Disorders, which consist of (1) conducting a systematic review, (2) obtaining input from the expert reviewers, and (3) drafting and submitting a preliminary guideline about the management of “orphaned” LTOT patients to our operations partners on this project. Next steps/Implementation: The next step in this research program will be a multi-site project to examine the extent to which use of the screening tools and potential CPG, resulting from this proposed study, is associated with improved patient outcomes (e.g., fewer overdoses), and health care system utilization and costs (e.g., fewer emergency department visits and hospitalizations for opioid-related acute crises). Next steps also include partnering on quality improvement projects to implement the screening tools and CPG in VA primary care and pain clinics.

背景：尽管有大量的VHA患者（> 300,000）接受长期阿片类药物疗法（LTOT），但 危害的证据正在增长（例如，疼痛控制不足，副作用，过量服用）。尽管VA/DOD 准则经常建议对LTOT患者进行多组分监测，监测未充分利用 因为它不符合初级保健的工作流程。此外，阿片类药物停工率正在增加， 即使停产通常是有害的（例如，更多地使用街道海洛因，使心理健康恶化）。 此外，对于继续LTOT的患者和终止逐渐减少的患者被确定为 潜在有害的是，临床实践指南（CPG）不可用，使其“指导方向”。 意义：随着阿片类药物过量死亡的增加和由于合并症而引起的LTOT并发症，政策 重点已转移到减少阿片类药物的处方，并监视和停用LTOT之间的阿片类药物 患者。该项目将帮助提供者在响应政策转变的同时维持高质量的患者护理。它 解决VHA和HSR＆D的目标，即通过为提供者提供综合的目的提供以患者为中心的护理 减少因LTOT延续和停用而造成危害的工具，这些损害是宽度且严重的 在退伍军人中。创新：该项目有可能通过提供初级保健来改变LTOT实践 以及其他提供商的新型，易于使用的筛选工具，将有助于遵守推荐准则 在监测LTOT患者时，并在有害时停用了LTOT。综合仪器可以 被纳入CPR，以促进其在VA医疗保健诊所的使用。该项目还将通过 为不存在CPG的LTOT患者提供新的临时指南。 VHA计划的完成是通过最佳组成部分来完成的 平衡疼痛管理和阿片类药物处方的实践，“ S.T.O.P. P.A.I.N”，即阶梯护理模型； 治疗替代方案；持续监控使用情况；和练习指南。具体目的是开发 与两个筛选工具集成了仪器，第一个指示LTOT是否有害继续（是或否； AIM 1），第二个指示逐渐终止阿片类药物的逐渐启动（是或否; AIM 2）是否有害的。 正面屏幕将表明提供者应进行其他更全面的监控，并 检查分别确定持续的LTOT或逐渐减少的危害。目标3： 通过确定“指南孔” LTOT的初步治疗方法，告知随后的CPG 患者。开发工具的方法将涉及（1）全面的文献搜索以产生初始项目 为每个筛选工具进行库存； （2）使用焦点小组与患者和提供者进行定性项目分析， 对患者的认知访谈，专家审查和项目修订，以产生每个项目库 用于现场测试的筛选工具； （3）现场测试，以产生每个筛选工具的最终物品库， 将包括（a）链接患者（每个工具的n = 500）电话调查回复其电子健康 记录公司数据仓库的数据，以及（b）可靠性测试（n = 30名患者）。工作方法 朝向CPG将遵循与开发VA/DOD CPG进行管理相同的方法 物质使用障碍，包括（1）进行系统审查，（2）从 专家审阅者，以及（3）起草和提交有关“孤儿”管理的初步指南 LTOT患者是我们的运营合作伙伴。下一步/实现：此的下一步 研究计划将是一个多站点项目，旨在检查筛选工具的使用程度和 这项拟议的研究引起的潜在CpG与改善患者结局有关（例如，较少 服用过量），以及医疗保健系统的利用和成本（例如，急诊室访问较少， 阿片类药物有关的急性犯罪的住院）。下一步还包括合作质量改进 在VA初级保健和疼痛诊所中实施筛查工具和CPG的项目。