Kidner Cindy L, Mayer Tom G, Gatchel Robert J
PRIDE Research Foundation, 5701 Maple Avenue #100, Dallas, TX 75235, USA.
J Bone Joint Surg Am. 2009 Apr;91(4):919-27. doi: 10.2106/JBJS.H.00286.
Opioids are frequently used for the postoperative treatment of chronic disabling occupational musculoskeletal disorders. In many such cases, long-term opioid use persists because of patient requests for ongoing pain relief. Little is known about the relationship between chronic opioid use and functional recovery in these patients.
A total of 1226 patients with a chronic disabling occupational musculoskeletal disorder were consecutively admitted into an interdisciplinary functional restoration program. They were divided into two groups: 630 patients who reported no opioid use at the time of admission (No group) and 596 patients who reported some opioid use at the time of admission (Yes group). The 516 patients for whom daily opioid doses could be determined were further divided into four subgroups: Low (<30 mg, n=267), Medium (31 to 60 mg, n=112), High (61 to 120 mg, n=78), and Very High (>120 mg, n=59). During the initial weeks of treatment, patients consented to be weaned from all opioid medications. In addition, the patients were assessed before and after rehabilitation with regard to self-reported measures of pain, function, and depression and were analyzed for change. One year after the termination of treatment, socioeconomic outcomes were assessed to measure work and financial status, healthcare utilization, and recurrent injury-associated pain.
A higher post-injury opioid dose was associated with a greater risk of program noncompletion, which was anticipated because of the requirement that patients taper opioids. High opioid use was significantly related to important socioeconomic outcomes, such as lower rates of return to work and work retention as well as higher healthcare utilization (p<or=0.05 for all). Moreover, at one year after treatment, the group reporting the highest opioid use was 11.6 times as likely to be receiving Social Security Disability Income/Supplemental Security Income as compared with the group reporting no opioid use at the time of admission into the program.
Chronic opioid use beginning after a work-related injury is a predictor of less successful outcomes for patients whose final treatment intervention is an interdisciplinary functional restoration program. Higher dose levels are associated with progressively greater indemnity and medical costs for ongoing disability. Physicians involved in the treatment of chronic disabling occupational musculoskeletal disorders should be aware of problems associated with permitting long-term opioid use in patients with a disabling occupational disorder.
阿片类药物常用于慢性致残性职业性肌肉骨骼疾病的术后治疗。在许多此类病例中，由于患者要求持续缓解疼痛，长期使用阿片类药物的情况持续存在。对于这些患者中慢性阿片类药物使用与功能恢复之间的关系，人们了解甚少。
共有1226例慢性致残性职业性肌肉骨骼疾病患者连续纳入一个跨学科功能恢复项目。他们被分为两组：630例入院时报告未使用阿片类药物的患者（无用药组）和596例入院时报告使用过一些阿片类药物的患者（有用药组）。可确定每日阿片类药物剂量的516例患者进一步分为四个亚组：低剂量组（<30毫克，n = 267）、中剂量组（31至60毫克，n = 112）、高剂量组（61至120毫克，n = 78）和非常高剂量组（>120毫克，n = 59）。在治疗的最初几周，患者同意逐渐停用所有阿片类药物。此外，在康复前后对患者进行自我报告的疼痛、功能和抑郁测量评估，并分析变化情况。治疗结束一年后，评估社会经济结果以衡量工作和财务状况、医疗保健利用情况以及与复发性损伤相关的疼痛。
受伤后阿片类药物剂量越高，项目未完成的风险越大，这是因为要求患者逐渐减少阿片类药物用量，所以这是可以预料的。高剂量使用阿片类药物与重要的社会经济结果显著相关，如较低的重返工作率和工作保留率以及较高的医疗保健利用率（所有p≤0.05）。此外，在治疗一年后，报告阿片类药物使用量最高的组接受社会保障残疾收入/补充保障收入的可能性是项目入院时报告未使用阿片类药物组的11.6倍。
与工作相关的损伤后开始慢性使用阿片类药物是最终治疗干预为跨学科功能恢复项目的患者预后较差的一个预测因素。更高的剂量水平与持续残疾的赔偿和医疗费用的逐步增加相关。参与治疗慢性致残性职业性肌肉骨骼疾病的医生应意识到允许患有致残性职业疾病的患者长期使用阿片类药物所带来的问题。
