Chronic Pain Management and Patient-Centered Outcomes Following Discontinuation of Long-Term Opioid Therapy

停止长期阿片类药物治疗后的慢性疼痛管理和以患者为中心的结果

• 批准号: 10051321
• 负责人: Travis Ian Lovejoy
• 金额: --
• 依托单位: PORTLAND VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-11-01 至 2023-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10051321
• 关键词: Accounting; Acute; Address; Administrator; Attention; Caring; Centers for Disease Control and Prevention (U.S.); Characteristics; Clinical; Communities; Community Networks; Data; Data Analyses; Dose; Electronic Health Record; Enrollment; Ethnic Origin; Feeling suicidal; Female; Gender; Goals; Guidelines; Heroin; Hospitals; Intervention; Interview; Mental Health; Methodology; Methods; Modality; Opioid; Outcome; Pain; Pain Clinics; Pain intensity; Pain interference; Pain management; Patient Monitoring; Patient-Centered Care; Patient-Focused Outcomes; Patients; Pharmacy facility; Population; Primary Health Care; Process; Prospective cohort study; Qualitative Methods; Quality of life; Race; Reporting; Resources; Safety; Sampling; Secondary pain; Severities; Structure; Suicide attempt; Surveys; Symptoms; Telephone; Testing; Time; Veterans; Volition; base; chronic pain management; chronic pain patient; cohort; design; empowered; ethnic minority population; evidence base; experience; follow-up; health care service utilization; health disparity; non-cancer chronic pain; non-opioid analgesic; operation; opioid epidemic; opioid therapy; overdose death; pain outcome; pain patient; prescription opioid; racial and ethnic; risk mitigation; substance use; systematic review; trend

Nearly 900,000 Veterans were dispensed opioid medication at the prescribing peak in 2012, with rates of opioid prescribing in VA subsequently declining year-over-year to fewer than 700,000 Veterans dispensed opioid medication in 2016. These downward trends are likely to continue with more widespread implementation of the VA Opioid Safety Initiative, additional efforts at local VA hospitals to enhance opioid risk mitigation and safe opioid prescribing practices, and recently released CDC and VA/DoD opioid prescribing guidelines that discourage long-term opioid therapy for chronic non-cancer pain. Despite steady rates of opioid discontinuation in VA, little is known about consequences—both positive and negative—of opioid discontinuation. The objectives of this study are to characterize patients’ experiences with the opioid discontinuation process, identify ways patients subsequently manage their pain through the use of VA and non-VA resources, and examine patient-centered outcomes such as quality of life, pain, substance use, and mental health symptom severity following opioid discontinuation. This prospective cohort study will enroll 1,144 VA patients randomly selected from the population of VA patients prescribed long-term opioid therapy. All patients will complete 5 mailed or online survey assessments at baseline, 6-, 12-, 18-, and 24-month follow-up that assess quality of life, pain, substance use, and mental health symptoms. Additional clinical and pharmacy data will be extracted from patients’ VA electronic health record. We will monitor patients in the cohort for reductions in opioid dose and complete opioid discontinuation. Patients who discontinue opioid therapy will complete an additional survey to assess acute patient outcomes following opioid discontinuation. A subset of 40 patients who discontinue opioid therapy will participate in semi-structured interviews over the telephone immediately following discontinuation, as well as 6- and 12 months post-discontinuation. Interviews will ascertain patients’ experiences with the opioid discontinuation process, pain treatment approaches utilized within and external to VA, and patient outcomes following discontinuation. This study has three specific aims: (1) compare acute (immediate), intermediate (6-month), and long-term (12-month) quality of life and pain outcomes between patients who discontinue versus those who remain on long-term opioid therapy (LTOT), (2) test the moderating effect of gender and race/ethnicity on changes in quality of life and pain outcomes between patients who discontinue versus those who remain on LTOT, and (3) use qualitative methods to augment quantitative findings on patient quality of life and pain outcomes, identify patient experiences with the opioid discontinuation process, and characterize the impact of discontinuation on patient-clinician relationships. The integration of results from quantitative and qualitative data analyses will characterize patient experiences with, and outcomes following, opioid discontinuation. This study is both timely and highly relevant to current national VA priority goals of (1) Pain and Use of Opioids and (2) Care in Community Networks. Specifically, this study will provide VA operations administrators, hospital executives, and clinicians with information that characterizes opioid discontinuation from patients’ perspectives. These perspectives can inform best practices for discontinuing opioid therapy, when clinically indicated, while simultaneously mitigating negative consequences of discontinuation and engaging and empowering patients to manage chronic pain with evidence-based non- opioid treatment modalities available within VA and in the community.

在2012年的处方峰值处，将近90万退伍军人被分配给阿片类药物 弗吉尼亚州的阿片类药物处方随后同比下降到不到70万退伍军人 2016年阿片类药物。这些下降趋势可能会继续进行更广泛的实施 在VA阿片类药物安全计划中，当地VA医院的额外努力以增强阿片类药物的风险降低和 安全的阿片类药物处方实践，最近发布了CDC和VA/DOD阿片类药物处方指南 劝阻长期阿片类药物治疗慢性非癌症疼痛。尽管停止阿片类药物的速度稳定 在弗吉尼亚州，对阿片类药物停用的后果（无论是积极和负面）知之甚少。这 这项研究的目标是表征患者在阿片类药物停用过程中的经历， 确定患者随后通过使用VA和非VA资源来管理疼痛的方法，以及 检查以患者为中心的结果，例如生活质量，疼痛，吸毒和心理健康症状 阿片类药物停用后的严重程度。这项前瞻性队列研究将随机招募1,144名VA患者 从VA患者人群中选出的长期阿片类药物治疗。所有患者将完成5 邮寄或在线调查评估在基线，6，12-，18和24个月的随访中，评估质量 生命，疼痛，吸毒和心理健康症状。将提取其他临床和药房数据 来自患者的VA电子健康记录。我们将监测队列中的患者减少阿片类药物剂量 并完成阿片类药物中断。停止阿片类药物疗法的患者将完成额外的 在阿片类药物中止后评估急性患者预后的调查。 40名患者的子集 停止阿片类药物疗法将立即通过电话参加半结构化访谈 终止后的6个月和12个月之后。访谈将确定患者 通过阿片类药物停用过程，在内部和外部使用的疼痛治疗方法 VA和停产后的患者结果。这项研究具有三个特定的目的：（1）比较急性 （立即），中级（6个月）和长期（12个月）的生活质量和痛苦结果 停止进行长期阿片类药物治疗（LTOT）的患者，（2）测试调节 性别和种族/种族的影响对患者生活质量和疼痛结果的变化的影响 停用与保留在LTOT上的人，以及（3）使用定性方法来增强定量 关于患者生活质量和疼痛结果的发现，确定终止阿片类药物的患者体验 过程，并表征停用对患者 - 痛苦关系的影响。整合 定量和定性数据分析的结果将表征患者的经历和结果 以下，阿片类药物中断。这项研究既及时又与当前国家VA优先事项高度相关 （1）阿片类药物疼痛和使用的目标以及（2）社区网络中的护理。具体而言，这项研究将提供 VA运营管理员，医院高管和临床医生，并提供有关阿片类药物特征的信息 从患者的角度终止。这些观点可以为中止的最佳实践提供信息 阿片类药物疗法在临床表明时，同时减轻了 中止和引人入胜，并使患者通过基于证据的非 - VA和社区内可用的阿片类药物治疗方式。