Center on Implementing Evidence Based Practice, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana 46202, USA.
Pain Med. 2011 May;12(5):740-6. doi: 10.1111/j.1526-4637.2011.01099.x. Epub 2011 Apr 11.
To characterize long-term opioid prescribing and monitoring practices in primary care.
Retrospective medical record review.
Primary care clinics associated with a large Veterans Affairs (VA) medical center.
Adult patients who filled ≥6 prescriptions for opioid medications from the outpatient VA pharmacy between May 1, 2006 and April 30, 2007.
Indicators of potential opioid misuse, documentation of guideline-recommended opioid-monitoring processes.
Ninety-six patients (57%) received a long-acting opioid, 122 (72%) received a short-acting opioid, and 50 (30%) received two different opioids. Indicators of some form of potential opioid misuse were present in the medical records of 55 (33%) patients. Of the seven guideline-recommended opioid-monitoring practices we examined, the mean number documented within 6 months was 1.7 (standard deviation [SD] 1.5). Pain reassessment was the most frequently documented process (N = 105, 52%), and use of an opioid treatment agreement was the least frequent (N = 19, 11%). Patients with indicators of potential opioid misuse had more documented opioid-monitoring processes than those without potential misuse indicators (2.4 vs 1.3, P < 0.001). After adjustment, potential opioid misuse was positively associated with the number of documented guideline-recommended processes (mean = 1.0 additional process, 95% confidence interval [CI] 0.4, 1.5).
Guideline-recommended opioid management practices were infrequently documented overall but were documented more often for higher risk patients who had indicators of potential opioid misuse. The relationship between guideline-concordant opioid management and high-quality care has not been established, so our findings should not be interpreted as evidence of poor quality opioid management. Research is needed to determine optimal methods of monitoring opioid therapy in primary care.
描述初级保健中长期阿片类药物处方和监测的实践情况。
回顾性病历审查。
与大型退伍军人事务部（VA）医疗中心相关的初级保健诊所。
2006 年 5 月 1 日至 2007 年 4 月 30 日期间，从门诊 VA 药房领取≥6 份阿片类药物处方的成年患者。
潜在阿片类药物滥用的指标，指南推荐的阿片类药物监测过程的文件记录。
96 名患者（57%）接受了长效阿片类药物，122 名患者（72%）接受了短效阿片类药物，50 名患者（30%）接受了两种不同的阿片类药物。55 名（33%）患者的病历中存在某种形式的潜在阿片类药物滥用的指标。在我们检查的七种指南推荐的阿片类药物监测实践中，在 6 个月内记录的平均值为 1.7（标准差[SD] 1.5）。疼痛再评估是记录最频繁的过程（N=105，52%），而使用阿片类药物治疗协议的频率最低（N=19，11%）。有潜在阿片类药物滥用指标的患者比没有潜在滥用指标的患者记录的阿片类药物监测过程更多（2.4 与 1.3，P <0.001）。调整后，潜在阿片类药物滥用与记录的指南推荐流程数量呈正相关（平均增加 1.0 个流程，95%置信区间[CI]为 0.4，1.5）。
总体而言，指南推荐的阿片类药物管理实践很少被记录，但对于有潜在阿片类药物滥用指标的高风险患者，记录的实践更多。指南一致的阿片类药物管理与高质量护理之间的关系尚未建立，因此我们的发现不应被解释为阿片类药物管理质量差的证据。需要研究确定初级保健中监测阿片类药物治疗的最佳方法。
