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2.
Pain Med ; 2020 Mar 18.
Artigo em Inglês | MEDLINE | ID: mdl-32186722

RESUMO

OBJECTIVE: To examine the relationship between body mass index (BMI) and pain intensity among veterans with musculoskeletal disorder diagnoses (MSDs; nontraumatic joint disorder; osteoarthritis; low back, back, and neck pain). SETTING: Administrative and electronic health record data from the Veterans Health Administration (VHA). SUBJECTS: A national cohort of US military veterans with MSDs in VHA care during 2001-2012 (N = 1,759,338). METHODS: These cross-sectional data were analyzed using hurdle negative binomial models of pain intensity as a function of BMI, adjusted for comorbidities and demographics. RESULTS: The sample had a mean age of 59.4, 95% were male, 77% were white/Non-Hispanic, 79% were overweight or obese, and 42% reported no pain at index MSD diagnosis. Overall, there was a J-shaped relationship between BMI and pain (nadir = 27 kg/m2), with the severely obese (BMI ≥ 40 kg/m2) being most likely to report any pain (OR vs normal weight = 1.23, 95% confidence interval = 1.21-1.26). The association between BMI and pain varied by MSD, with a stronger relationship in the osteoarthritis group and a less pronounced relationship in the back and low back pain groups. CONCLUSIONS: There was a high prevalence of overweight/obesity among veterans with MSD. High levels of BMI (>27 kg/m2) were associated with increased odds of pain, most markedly among veterans with osteoarthritis.

3.
Prev Med ; 134: 106036, 2020 Feb 22.
Artigo em Inglês | MEDLINE | ID: mdl-32097753

RESUMO

Reports indicate that long-term opioid therapy is associated with cardiovascular disease (CVD). Using VA electronic health record data, we measured the impact of opioid use on the incidence of modifiable CVD risk factors. We included Veterans whose encounter was between October 2001 to November 2014. We identified Veterans without CVD risk factors during our baseline period, defined as the date of first primary care visit plus 365 days. The main exposure was opioid prescriptions (yes/no, long-term (i.e. ≥90 days) vs no opioid, and long-term vs short-term (i.e. <90 days)), which was time-updated yearly from the end of the baseline period to February 2015. The main outcome measures were incident CVD risk factors (hypertension, dyslipidemia, diabetes, obesity, and current smoking). After excluding prevalent CVD risk factors, we identified 308,015 Veterans. During the first year of observation, 12,725 (4.1%) Veterans were prescribed opioids, including 2028 (0.6%) with long-term exposure. Compared to patients without opioid use, Veterans with opioid use were more likely to have CVD risk factors. Those with long-term exposure were at higher risk of having hypertension (adjusted average hazards ratio [HR] 1.45, 99% confidence interval [CI] 1.33-1.59), dyslipidemia (HR 1.45, 99% CI 1.35-156), diabetes (HR 1.30, 99% CI 1.07-1.57), current smoking status (HR 1.34, 99% CI 1.24-1.46), and obesity (HR 1.22, 99% CI 1.12-1.32). Compared to short-term exposure, long-term had higher risk of current smoking status (HR 1.12, 99% CI 1.01-1.24). These findings suggest potential benefit to screening and surveillance of CVD risk factors for patients prescribed opioids, especially long-term opioid therapy.

4.
Pain Med ; 2020 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-31909803

RESUMO

BACKGROUND: Cannabis is increasingly available and used for medical and recreational purposes, but few studies have assessed provider knowledge, attitudes, and practice regarding cannabis. METHODS: We administered a 47-item electronic survey to assess nationwide Veterans Health Administration (VHA) clinician knowledge, beliefs, attitudes, and practice regarding patients' use of cannabis. RESULTS: We received 249 completed surveys from 39 states and the District of Columbia. Fifty-five percent of respondents were female, 74% were white, and the mean age was 50 years. There were knowledge gaps among a substantial minority of respondents in specific areas: terminology, psychoactive effects of cannabis components, VHA policy, and evidence regarding benefits and harms of cannabis. Most respondents were likely or very likely to plan to taper opioids if urine drug testing was positive for tetra-hydro cannabinol (THC; 73%). A significantly greater proportion of respondents from states in which cannabis is illegal for any purpose (odds ratio [OR] = 4.9, 95% confidence interval [CI] = 2.0-10.8) or is recreationally illegal (OR = 5.0, 95% CI = 2.4-10.8) reported being likely or very likely to taper opioids as compared with respondents from states in which cannabis is legal for medical and recreational purposes. CONCLUSIONS: Among the sample, we found knowledge gaps, areas of discomfort discussing key aspects of cannabis use with their patients, and variation in practice regarding opioids in patients also using THC. These results suggest a need for more widespread clinician education about cannabis, as well as an opportunity to develop more robust guidance and evidence regarding management of patients using prescription opioids and cannabis concomitantly.

5.
J Pain Symptom Manage ; 59(1): 49-57, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31476361

RESUMO

CONTEXT: Signature informed consent (SIC) is a part of a Veterans Health Administration ethics initiative for patient education and shared decision making with long-term opioid therapy (LTOT). Historically, patients with cancer-related pain receiving LTOT are exempt from this process. OBJECTIVES: Our objective is to understand patients' and providers' perspectives on using SIC for LTOT in patients with cancer-related pain. METHODS: Semistructured interviews with 20 opioid prescribers and 20 patients who were prescribed opioids at two large academically affiliated Veterans Health Administration Medical Centers. We used a combination of deductive and inductive approaches in content analysis to produce emergent themes. RESULTS: Potential advantages of SIC are that it can clarify and help patients comprehend LTOT risks and benefits, provide clear upfront boundaries and expectations, and involve the patient in shared decision making. Potential disadvantages of SIC include time delay to treatment, discouragement from recommended opioid use, and impaired trust in the patient-provider relationship. Providers and patients have misconceptions about the definition of SIC. Providers and patients question if SIC for LTOT is really informed consent. Providers and patients advocate for strategies to improve comprehension of SIC content. Providers had divergent perspectives on exemptions from SIC. Oncologists want SIC for LTOT to be tailored for patients with cancer. CONCLUSION: Provider and patient interviews highlight various aspects about the advantages and disadvantages of requiring SIC for LTOT in cancer-related pain. Tailoring SIC for LTOT to be specific to cancer-related concerns and to have an appropriate literacy level are important considerations.

6.
Pain Med ; 21(2): 247-254, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-31393585

RESUMO

BACKGROUND: Marijuana use is common among patients on long-term opioid therapy (LTOT) for chronic pain, but there is a lack of evidence to guide clinicians' response. OBJECTIVE: To generate expert consensus about responding to marijuana use among patients on LTOT. DESIGN: Analysis from an online Delphi study. SETTING/SUBJECTS: Clinician experts in pain and opioid management across the United States. METHODS: Participants generated management strategies in response to marijuana use without distinction between medical and nonmedical use, then rated the importance of each management strategy from 1 (not at all important) to 9 (extremely important). A priori rules for consensus were established, and disagreement was explored using cases. Thematic analysis of free-text responses examined factors that influenced participants' decision-making. RESULTS: Of 42 participants, 64% were internal medicine physicians. There was consensus that it is not important to taper opioids as an initial response to marijuana use. There was disagreement about the importance of tapering opioids if there is a pattern of repeated marijuana use without clinical suspicion for a cannabis use disorder (CUD) and consensus that tapering is of uncertain importance if there is suspicion for CUD. Three themes influenced experts' perceptions of the importance of tapering: 1) benefits and harms of marijuana for the individual patient, 2) a spectrum of belief about the overall riskiness of marijuana use, and 3) variable state laws or practice policies. CONCLUSIONS: Experts disagree and are uncertain about the importance of opioid tapering for patients with marijuana use. Experts were influenced by patient factors, provider beliefs, and marijuana policy, highlighting the need for further research.

7.
Addict Sci Clin Pract ; 14(1): 42, 2019 12 02.
Artigo em Inglês | MEDLINE | ID: mdl-31787111

RESUMO

Cannabis use has become increasingly common in the U.S. in recent years, with legalization for medical and recreational purposes expanding to more states. With this increase in use and access, providers should be prepared to have more conversations with patients about use. This review provides an overview of cannabis terminology, pharmacology, benefits, harms, and risk mitigation strategies to help providers engage in these discussions with their patients. Current evidence for the medical use of cannabis, cannabis-related diagnoses including cannabis use disorder (CUD) and withdrawal syndromes, and the co-use of opioids and cannabis are discussed. It is crucial that providers have the tools and information they need to deliver consistent, evidence-based assessment, treatment, prevention and harm-reduction, and we offer practical guidance in these areas.

8.
J Addict Med ; 2019 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-31855919

RESUMO

OBJECTIVE: Long-term opioid therapy (LTOT) is commonly prescribed for chronic pain, despite risks such as opioid use disorder (OUD) and overdose. Caring for patients on LTOT can be difficult, given lack of evidence about assessment of challenging behaviors among patients on LTOT. To develop this evidence, a critical first step is to systematically identify the common and challenging behaviors that primary care providers encounter among patients on LTOT, and also to highlight to diverse range of behaviors encountered. METHOD: We conducted a Delphi study in 42 chronic pain experts to determine consensus on how to address the top common and challenging behaviors. This paper reports on the first round of the study, which elicited a range of behaviors. We conducted thematic analysis of the behaviors and also used the Diagnostic and Statistical Manual (DSM)-5 criteria for OUD as a priori codes. RESULTS: In all, 124 unique behaviors were identified by participants and coded into 4 thematic categories: concerning behaviors that map onto DSM-5 criteria for OUD, and those that do not which were: behaviors that suggest deception, signs of diversion, and nonadherence to treatment plan. Those behaviors that fell outside of OUD criteria we identified as "gray zone" behaviors. CONCLUSIONS: While some of these challenging behaviors fall under the criteria for an OUD, many fall outside of this framework, making diagnosis and treatment difficult, and consensus on how to deal with these "gray zone" behaviors is vital. Future research should explore how these "gray zone" behaviors can best be assessed and managed in a primary care setting.

9.
Drug Alcohol Depend ; 205: 107671, 2019 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-31706248

RESUMO

OBJECTIVES: To examine trends in polysubstance detection associated with drug-related overdose deaths in Connecticut. METHODS: We used 2012-2018 data provided by Connecticut's Office of the Chief Medical Examiner (OCME) on accidental overdose deaths. We estimated annual trends, standardizing the number of deaths per 100,000 Connecticut residents each year. We then conducted stratified analyses by polysubstance use status. We also examined the numbers of deaths involving fentanyl in a separate analysis. We obtained data in April 2019, and statistical analyses were performed from April to September 2019. RESULTS: The rate of overdose deaths in Connecticut increased from 9.9 per 100,000 residents in 2012 to 28.5 per 100,000 residents in 2018-a 221 % increase-with the majority occurring among persons aged 35-64 (65.3 %), men (73.9 %), and non-Hispanic whites (78.5 %). Among deaths involving fentanyl, the overall deaths escalated from 5.2 deaths per 100,000 residents in 2015 to 21.3 deaths per 100,000 residents in 2018, and more than 50% of these fentanyl-related deaths involved polysubstance use. CONCLUSIONS: Connecticut experienced a more-than doubling of opioid-involved overdose deaths, largely driven by fentanyl and polysubstance use. The role of polysubstance use should be considered in efforts toward reducing opioid-related overdose incidents.

11.
AIDS Behav ; 23(12): 3340-3349, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31317364

RESUMO

A better understanding of predisposition to transition to high-dose, long-term opioid therapy after initial opioid receipt could facilitate efforts to prevent opioid use disorder (OUD). We extracted data on 69,268 patients in the Veterans Aging Cohort Study who received any opioid prescription between 1998 and 2015. Using latent growth mixture modelling, we identified four distinguishable dose trajectories: low (53%), moderate (29%), escalating (13%), and rapidly escalating (5%). Compared to low dose trajectory, those in the rapidly escalating dose trajectory were proportionately more European-American (59% rapidly escalating vs. 38% low); had a higher prevalence of HIV (31% vs. 29%) and hepatitis C (18% vs. 12%); and during follow-up, had a higher incidence of OUD diagnoses (13% vs. 3%); were hospitalised more often [18.1/100 person-years (PYs) vs. 12.5/100 PY]; and had higher all-cause mortality (4.7/100 PY vs. 1.8/100 PY, all p < 0.0001). These measures can potentially be used in future prevention research, including genetic discovery.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Infecções por HIV/epidemiologia , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Veteranos , Adulto , Afro-Americanos , Dor Crônica/epidemiologia , Estudos de Coortes , Grupo com Ancestrais do Continente Europeu , Feminino , Hepatite C/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Mortalidade , Prevalência
14.
Nat Commun ; 10(1): 2275, 2019 05 17.
Artigo em Inglês | MEDLINE | ID: mdl-31101824

RESUMO

The original version of this Article omitted the following from the Acknowledgements: 'Supported by the Mental Illness Research, Education and Clinical Center of the Veterans Integrated Service Network 4 of the Department of Veterans Affairs.' This has now been corrected in both the PDF and HTML versions of the Article.

15.
Nat Commun ; 10(1): 1499, 2019 04 02.
Artigo em Inglês | MEDLINE | ID: mdl-30940813

RESUMO

Alcohol consumption level and alcohol use disorder (AUD) diagnosis are moderately heritable traits. We conduct genome-wide association studies of these traits using longitudinal Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) scores and AUD diagnoses in a multi-ancestry Million Veteran Program sample (N = 274,424). We identify 18 genome-wide significant loci: 5 associated with both traits, 8 associated with AUDIT-C only, and 5 associated with AUD diagnosis only. Polygenic Risk Scores (PRS) for both traits are associated with alcohol-related disorders in two independent samples. Although a significant genetic correlation reflects the overlap between the traits, genetic correlations for 188 non-alcohol-related traits differ significantly for the two traits, as do the phenotypes associated with the traits' PRS. Cell type group partitioning heritability enrichment analyses also differentiate the two traits. We conclude that, although heavy drinking is a key risk factor for AUD, it is not a sufficient cause of the disorder.


Assuntos
Consumo de Bebidas Alcoólicas/genética , Alcoolismo/genética , Estudo de Associação Genômica Ampla , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Herança Multifatorial , Fenótipo , Polimorfismo de Nucleotídeo Único , Adulto Jovem
16.
J Acquir Immune Defic Syndr ; 81(2): 231-237, 2019 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-30865181

RESUMO

BACKGROUND: People living with HIV (PLWH) commonly report marijuana use for chronic pain, although there is limited empirical evidence to support its use. There is hope that marijuana may reduce prescription opioid use. Our objective was to investigate whether marijuana use among PLWH who have chronic pain is associated with changes in pain severity and prescribed opioid use (prescribed opioid initiation and discontinuation). METHODS: Participants completed self-report measures of chronic pain and marijuana use at an index visit and were followed up for 1 year in the Center for AIDS Research Network of Integrated Clinical Systems (CNICS). Self-reported marijuana use was the exposure variable. Outcome variables were changes in pain and initiation or discontinuation of opioids during the study period. The relationship between exposure and outcomes was assessed using generalized linear models for pain and multivariable binary logistic regression models for opioid initiation/discontinuation. RESULTS: Of 433 PLWH and chronic pain, 28% reported marijuana use in the past 3 months. Median pain severity at the index visit was 6.3/10 (interquartile range 4.7-8.0). Neither increases nor decreases in marijuana use were associated with changes in pain severity, and marijuana use was not associated with either lower odds of opioid initiation or higher odds of opioid discontinuation. CONCLUSIONS: We did not find evidence that marijuana use in PLWH is associated with improved pain outcomes or reduced opioid prescribing. This suggests that caution is warranted when counseling PLWH about potential benefits of recreational or medical marijuana.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Infecções por HIV/complicações , Uso da Maconha , Maconha Medicinal/uso terapêutico , Medicamentos sob Prescrição/uso terapêutico , Dor Crônica/etiologia , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Fumar Maconha , Pessoa de Meia-Idade , Análise Multivariada , Transtornos Relacionados ao Uso de Opioides , Estudos Prospectivos , Autorrelato , Inquéritos e Questionários , Resultado do Tratamento , Estados Unidos
17.
JAMA Intern Med ; 179(3): 297-304, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30615036

RESUMO

Importance: Some opioids are known immunosuppressants; however, the association of prescribed opioids with clinically relevant immune-related outcomes is understudied, especially among people living with HIV. Objective: To assess the association of prescribed opioids with community-acquired pneumonia (CAP) by opioid properties and HIV status. Design, Setting, and Participants: This nested case-control study used data from patients in the Veterans Aging Cohort Study (VACS) from January 1, 2000, through December 31, 2012. Participants in VACS included patients living with and without HIV who received care in Veterans Health Administration (VA) medical centers across the United States. Patients with CAP requiring hospitalization (n = 4246) were matched 1:5 with control individuals without CAP (n = 21 146) by age, sex, race/ethnicity, length of observation, and HIV status. Data were analyzed from March 15, 2017, through August 8, 2018. Exposures: Prescribed opioid exposure during the 12 months before the index date was characterized by a composite variable based on timing (none, past, or current); low (<20 mg), medium (20-50 mg), or high (>50 mg) median morphine equivalent daily dose; and opioid immunosuppressive properties (yes vs unknown or no). Main Outcome and Measure: CAP requiring hospitalization based on VA and Centers for Medicare & Medicaid data. Results: Among the 25 392 VACS participants (98.9% male; mean [SD] age, 55 [10] years), current medium doses of opioids with unknown or no immunosuppressive properties (adjusted odds ratio [AOR], 1.35; 95% CI, 1.13-1.62) and immunosuppressive properties (AOR, 2.07; 95% CI, 1.50-2.86) and current high doses of opioids with unknown or no immunosuppressive properties (AOR, 2.07; 95% CI, 1.50-2.86) and immunosuppressive properties (AOR, 3.18; 95% CI, 2.44-4.14) were associated with the greatest CAP risk compared with no prescribed opioids or any past prescribed opioid with no immunosuppressive (AOR, 1.24; 95% CI, 1.09-1.40) and immunosuppressive properties (AOR, 1.42; 95% CI, 1.21-1.67), especially with current receipt of immunosuppressive opioids. In stratified analyses, CAP risk was consistently greater among people living with HIV with current prescribed opioids, especially when prescribed immunosuppressive opioids (eg, AORs for current immunosuppressive opioids with medium dose, 1.76 [95% CI, 1.20-2.57] vs 2.33 [95% CI, 1.60-3.40]). Conclusions and Relevance: Prescribed opioids, especially higher-dose and immunosuppressive opioids, are associated with increased CAP risk among persons with and without HIV.


Assuntos
Analgésicos Opioides/efeitos adversos , Infecções Comunitárias Adquiridas/etiologia , Infecções por HIV/complicações , Pneumonia/etiologia , Analgésicos Opioides/administração & dosagem , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , Veteranos
18.
Pain Med ; 20(3): 528-542, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-29800338

RESUMO

OBJECTIVE: High proportions of post-9/11 veterans have musculoskeletal disorders (MSDs), but engaging them in care early in their course of illness has been challenging. The service connection application is an ideal point of contact for referring veterans to early interventions for their conditions. DESIGN: Among MSD claimants who reported risky substance use, we pilot-tested a counseling intervention targeting pain and risky substance use called Screening Brief Intervention and Referral to Treatment-Pain Module (SBIRT-PM). Veterans were randomly assigned in a 2:1:1 ratio to SBIRT-PM, Pain Module counseling only, or treatment as usual (TAU). METHODS: Participants assigned to either counseling arm were offered a single meeting with a study therapist with two follow-up telephone calls as needed. Participants completed outcome assessments at four and 12 weeks after randomization. RESULTS: Of 257 veterans evaluated, 101 reported risky substance use and were randomized. Counseling was attended by 75% of veterans offered it and was well received. VA pain-related services were used by 51% of participants in either of the pain-focused conditions but only by 27% in TAU (P < 0.04). Starting with average pain severity ratings of 5.1/10 at baseline, only minimal changes in mean pain severity were noted regardless of condition. Self-reported risky substance use was significantly lower over time in the SBIRT-PM condition relative to the two other conditions (P < 0.02). At week 12, proportions of veterans reporting risky substance use were 0.39, 0.69, and 0.71 for the SBIRT-PM, Pain Module counseling, and TAU conditions, respectively. CONCLUSIONS: SBIRT-PM shows promise as a way to engage veterans in pain treatment and reduce substance use.


Assuntos
Aconselhamento/métodos , Doenças Musculoesqueléticas/psicologia , Manejo da Dor/métodos , Transtornos Relacionados ao Uso de Substâncias/psicologia , Adulto , Feminino , Humanos , Masculino , Doenças Musculoesqueléticas/complicações , Dor/etiologia , Dor/psicologia , Projetos Piloto , Estados Unidos , Veteranos
19.
Addict Biol ; 24(5): 1056-1065, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30284751

RESUMO

A validated, scalable approach to characterizing (phenotyping) smoking status is needed to facilitate genetic discovery. Using established DNA methylation sites from blood samples as a criterion standard for smoking behavior, we compare three candidate electronic medical record (EMR) smoking metrics based on longitudinal EMR text notes. With data from the Veterans Aging Cohort Study (VACS), we employed a validated algorithm to translate each smoking-related text note into current, past or never categories. We compared three alternative summary characterizations of smoking: most recent, modal and trajectories using descriptive statistics and Spearman's correlation coefficients. Logistic regression and area under the curve analyses were used to compare the associations of these phenotypes with the DNA methylation sites, cg05575921 and cg03636183, which are known to have strong associations with current smoking. DNA methylation data were available from the VACS Biomarker Cohort (VACS-BC), a sub-study of VACS. We also considered whether the associations differed by the certainty of trajectory group assignment (<0.80/≥0.80). Among 140 152 VACS participants, EMR summary smoking phenotypes varied in frequency by the metric chosen: current from 33 to 53 percent; past from 16 to 24 percent and never from 24 to 33 percent. The association between the EMR smoking pairs was highest for modal and trajectories (rho = 0.89). Among 728 individuals in the VACS-BC, both DNA methylation sites were associated with all three EMR summary metrics (p < 0.001), but the strongest association with both methylation sites was observed for trajectories (p < 0.001). Longitudinal EMR smoking data support using a summary phenotype, the validity of which is enhanced when data are integrated into statistical trajectories.

20.
Implement Sci ; 13(1): 145, 2018 11 29.
Artigo em Inglês | MEDLINE | ID: mdl-30486877

RESUMO

BACKGROUND: Dissemination of evidence-based practices that can reduce morbidity and mortality is important to combat the growing opioid overdose crisis in the USA. Research and expert consensus support reducing high-dose opioid therapy, avoiding risky opioid-benzodiazepine combination therapy, and promoting multi-modal, collaborative models of pain care. Collaborative care interventions that support primary care providers have been effective in medication tapering. We developed a patient-centered Primary Care-Integrated Pain Support (PIPS) collaborative care clinical program based on effective components of previous collaborative care interventions. Implementation facilitation, a multi-faceted and dynamic strategy involving the provision of interactive problem-solving and support during implementation of a new program, is used to support key organizational staff throughout PIPS implementation. The primary aim of this study is to evaluate the effectiveness of the implementation facilitation strategy for implementing and sustaining PIPS in the Veterans Health Administration (VHA). The secondary aim is to examine the effect of the program on key patient-level clinical outcomes-transitioning to safer regimens and enhancing access to complementary and integrative health treatments. The tertiary aim is to determine the categorical costs and ultimate budget impact of PIPS implementation. METHODS: This multi-site study employs an interrupted time series, hybrid type III design to evaluate the effectiveness of implementation facilitation for a collaborative care clinical program-PIPS-in primary care clinics in three geographically diverse VHA health care systems (sites). Participants include pharmacists and allied staff involved in the delivery of clinical pain management services as well as patients. Eligible patients are prescribed either an outpatient opioid prescription greater than or equal to 90 mg morphine equivalent daily dose or a combination opioid-benzodiazepine regimen. They must also have an upcoming appointment in primary care. The Consolidated Framework for Implementation Research will guide the mixed methods work across the formative evaluation phases and informs the selection of activities included in implementation facilitation. The RE-AIM framework will be used to assess Reach, Effectiveness, Adoption, Implementation, and Maintenance of PIPS. DISCUSSION: This implementation study will provide important insight into the effectiveness of implementation facilitation to enhance uptake of a collaborative care program in primary care, which targets unsafe opioid prescribing practices.


Assuntos
Analgésicos Opioides/administração & dosagem , Comportamento Cooperativo , Ciência da Implementação , Manejo da Dor/métodos , Atenção Primária à Saúde/métodos , Analgésicos Opioides/efeitos adversos , Prática Clínica Baseada em Evidências , Humanos , Capacitação em Serviço , Análise de Séries Temporais Interrompida , Padrões de Prática Médica , Avaliação de Programas e Projetos de Saúde , Projetos de Pesquisa , Estados Unidos , United States Department of Veterans Affairs , Engajamento no Trabalho
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