RESUMO
Vasopressins are evolutionarily conserved peptide hormones. Mammalian vasopressin functions systemically as an antidiuretic and regulator of blood and cardiac flow essential for adapting to terrestrial environments. Moreover, vasopressin acts centrally as a neurohormone involved in social and parental behavior and stress response. Vasopressin synthesis in several cell types, storage in intracellular vesicles, and release in response to physiological stimuli are highly regulated and mediated by three distinct G protein coupled receptors. Other receptors may bind or cross-bind vasopressin. Vasopressin is regulated spatially and temporally through transcriptional and post-transcriptional mechanisms, sex, tissue, and cell-specific receptor expression. Anomalies of vasopressin signaling have been observed in polycystic kidney disease, chronic heart failure, and neuropsychiatric conditions. Growing knowledge of the central biological roles of vasopressin has enabled pharmacological advances to treat these conditions by targeting defective systemic or central pathways utilizing specific agonists and antagonists.
RESUMO
CONTEXT: Oregon is experiencing an opioid overdose epidemic, similar to the United States as a whole. To address this crisis, the Oregon Health Authority (OHA) implemented a strategic Opioid Initiative, convening stakeholders and integrating public health and health care system activities across sectors. Recent data indicate progress: from 2015 to 2016, Oregon had the sharpest decline in prescription opioid overdose deaths of any state. PROGRAM: The Opioid Initiative, launched in 2015, focuses on integrating efforts to improve patient care and safety, and population health, by increasing access to nonopioid pain treatment, supporting medication-assisted treatment and naloxone access for people taking opioids, decreasing opioid prescribing, and using data to inform policies and interventions. IMPLEMENTATION: Four OHA projects highlight the integration: (1) a Medicaid Coordinated Care Organization Performance Improvement Project focused on decreasing risky opioid prescribing; (2) Health Evidence Review Commission guidelines that set coverage standards for opioid and nonopioid back pain treatments for Medicaid recipients; (3) statewide opioid prescribing guidelines; and (4) an opioid data dashboard. Each project involves a partnership between governmental public health, public and private health care systems, and external stakeholders. PROGRESS: From 2015 to 2017, the number of Oregonians on 90 or more Morphine Equivalent Doses (MEDs) decreased by 37%, from 11.1 per 1000 residents quarterly to 7.0 per 1000 residents quarterly. Prescription opioid overdose deaths decreased 20% from 4.5 per 100 000 in 2015 to 3.6 per 100 000 in 2016. Within the Medicaid population, the percentage of clients on 120 or more MEDs for 30 consecutive days decreased 27%, from 2.3% in December 2015 to 1.6% in September 2017. DISCUSSION: Oregon's integrated approach to address the opioid crisis spans public health and health care systems, engages key stakeholders, and uses data and evidence to inform policies. The progress to date is promising and may assist other states seeking to identify effective strategies to decrease opioid prescribing, misuse, and overdose.