Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon; Department of Health Management and Policy, School of Public Health, OHSU-Portland State University, Portland, Oregon.
Department of Occupational Health, VA Long Beach Healthcare System, Long Beach, California; Department of Occupational Medicine, UC Irvine School of Medicine, Irvine, California; Department of Environmental and Occupational Health, School of Public Health, University of California, Irvine, Irvine, California.
Am J Prev Med. 2022 Sep;63(3):454-465. doi: 10.1016/j.amepre.2022.04.021. Epub 2022 Jun 22.
The opioid epidemic has resulted in significant morbidity and mortality in the U.S. Health systems, policymakers, payers, and public health have enacted numerous strategies to reduce the harms of opioids, including opioid use disorder (OUD). Much of this implementation has occurred before the development of OUD‒related comparative effectiveness evidence, which would enable an understanding of the benefits and harms of different approaches. This article from the American College of Preventive Medicine (ACPM) uses a prevention framework to identify the current approaches and make recommendations for addressing the opioid epidemic, encompassing strategies across a primordial, primary, secondary, and tertiary prevention approach. Key primordial prevention strategies include addressing social determinants of health and reducing adverse childhood events. Key primary prevention strategies include supporting the implementation of evidence-based prescribing guidelines, expanding school-based prevention programs, and improving access to behavioral health supports. Key secondary prevention strategies include expanding access to evidence-based medications for opioid use disorder, especially for high-risk populations, including pregnant women, hospitalized patients, and people transitioning out of carceral settings. Key tertiary prevention strategies include the expansion of harm reduction services, including expanding naloxone availability and syringe exchange programs. The ACPM Opioid Workgroup also identifies opportunities for de-implementation, in which historical and current practices may be ineffective or causing harm. De-implementation strategies include reducing inappropriate opioid prescribing; avoiding mandatory one-size-fits-all policies; eliminating barriers to medications for OUD, debunking the myth of detoxification as a primary solo treatment for opioid use disorder; and destigmatizing care practices and policies to better treat people with OUD.
阿片类药物泛滥已导致美国大量民众患病和死亡。卫生系统、政策制定者、医保支付方和公共卫生部门已采取多项策略，以减少阿片类药物危害，包括阿片类使用障碍（OUD）。其中许多措施都是在制定 OUD 相关的疗效比较证据之前实施的，该证据可以帮助了解不同方法的获益和危害。美国预防医学学院（ACPM）的这篇文章采用预防框架，确定了当前的方法，并就解决阿片类药物泛滥问题提出建议，涵盖了从初级预防到三级预防的各种策略。主要的初级预防策略包括解决健康的社会决定因素和减少不利的儿童事件。主要的初级预防策略包括支持实施循证处方指南、扩大学校预防计划，以及改善获得行为健康支持的机会。主要的二级预防策略包括扩大获得循证 OUD 治疗药物的机会，特别是针对高危人群，包括孕妇、住院患者和从监禁环境过渡的人群。主要的三级预防策略包括扩大减少伤害服务，包括扩大纳洛酮的可及性和注射器交换计划。ACPM 阿片类工作组还确定了消除不必要的实施策略的机会，其中包括历史和当前实践可能无效或造成危害的策略。消除不必要的实施策略包括减少不合理的阿片类药物处方；避免一刀切的强制性政策；消除 OUD 治疗药物的障碍，揭穿解毒作为 OUD 主要单一治疗方法的神话；以及消除对治疗 OUD 患者的护理实践和政策的污名化，以更好地治疗这些患者。
