Alam Ishrat Z, DiPrete Bethany L, Pence Brian W, Planey Arrianna Marie, Marshall Stephen W, Fulcher Naoko, Ranapurwala Shabbar I
Gillings School of Global Public Health, Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States.
Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States.
Pain Med. 2025 Feb 1;26(2):63-69. doi: 10.1093/pm/pnae119.
Rapid opioid reduction or discontinuation among patients on high-dose long-term opioid therapy (HD-LTOT) is associated with increased risk of heroin use, overdose, opioid use disorder, and mental health crises. We examined the association of residential segregation and health care access with rapid opioid reduction or discontinuation among patients on HD-LTOT and examined effect measure modification of individual-level characteristics.
Using 2006-2018 North Carolina private insurance claims data, we conducted a retrospective cohort study of patients who were 18-64 years of age and on HD-LTOT (≥90 morphine milligram equivalents for 81 of 90 consecutive days), with 1-year follow-up. The outcome was rapid opioid reduction or discontinuation (versus maintenance, increase, or gradual reduction/discontinuation). Individual-level characteristics included age, sex, and clinical diagnoses (post-traumatic stress disorder [PTSD], depression, anxiety, and substance use disorder). Neighborhood-level characteristics included health care access (measured as geographic distance to health care facilities) and residential segregation (operationalized with the Index of Concentration at the Extremes). We conducted bivariate linear regression to estimate 1-year risk differences and 95% confidence intervals.
Of 13 375 patients on HD-LTOT, 48.6% experienced rapid opioid reduction or discontinuation during 1-year follow-up. Female patients and those diagnosed with PTSD who lived in areas of least racial and economic privilege had higher risks of rapid opioid reduction or discontinuation than did those living in areas with the most racial and economic privilege.
Health care providers need to address potential biases toward patients living in underserved and marginalized communities, as well as intersectionality with mental health stigma, by prioritizing training and education in delivering unbiased care during opioid tapering.
在接受高剂量长期阿片类药物治疗（HD-LTOT）的患者中，快速减少或停用阿片类药物与使用海洛因、过量用药、阿片类药物使用障碍及心理健康危机风险增加相关。我们研究了居住隔离和医疗保健可及性与HD-LTOT患者快速减少或停用阿片类药物之间的关联，并研究了个体水平特征的效应测量修正。
利用2006 - 2018年北卡罗来纳州的私人保险索赔数据，我们对年龄在18 - 64岁且接受HD-LTOT（连续90天中有81天≥90毫克吗啡当量）的患者进行了一项回顾性队列研究，并进行了1年的随访。结局为快速减少或停用阿片类药物（相对于维持、增加或逐渐减少/停用）。个体水平特征包括年龄、性别和临床诊断（创伤后应激障碍[PTSD]、抑郁症、焦虑症和物质使用障碍）。社区水平特征包括医疗保健可及性（以到医疗保健设施的地理距离衡量）和居住隔离（用极端集中度指数衡量）。我们进行了双变量线性回归以估计1年风险差异和95%置信区间。
在13375名接受HD-LTOT的患者中，48.6%在1年随访期间经历了快速减少或停用阿片类药物。居住在种族和经济特权最少地区的女性患者及被诊断为PTSD的患者，与居住在种族和经济特权最多地区的患者相比，快速减少或停用阿片类药物的风险更高。
医疗保健提供者需要通过在阿片类药物减量期间优先开展提供无偏见护理的培训和教育，来解决对生活在服务不足和边缘化社区患者的潜在偏见，以及与心理健康污名的交叉性问题。
