Ladha Karim S, Patorno Elisabetta, Liu Jun, Bateman Brian T
From the Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (K.S.L., B.T.B.); Department of Anesthesia, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada (K.S.L.; and) Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (E.P., J.L., B.T.B.).
Anesthesiology. 2016 Feb;124(2):396-403. doi: 10.1097/ALN.0000000000000952.
Opioids play a crucial role in providing analgesia throughout the perioperative period; however, patients may become persistent users of these medications months after surgery. Epidurals have been posited to prevent the development of persistent pain, but there are little data on the effect of epidurals on persistent opioid use.
This study was conducted using a claims database of a large, nationwide commercial health insurer. Opioid-naive patients who underwent open abdominal surgery from January 2004 to December 2013 were included in the study. Propensity scores for epidural placement were calculated accounting for demographic characteristics, resource utilization, and comorbid conditions (including medical, psychiatric, and pain conditions). Time-to-event analysis was used with the primary outcome defined as 30 days without filling an opioid prescription after discharge. In addition, total morphine equivalents dispensed within 90 days of discharge were also calculated for each patient.
A total of 6,432 patients were included in the final propensity score-matched cohort. The Cox proportional hazards ratio was 0.96 (95% CI, 0.91 to 1.01; P = 0.0910) for the relation between epidural placement and time till a 30-day gap without filling an opioid prescription. There was no difference in the total morphine equivalents dispensed within 90 days of discharge between the groups (P = 0.7670).
Epidural placement was not protective against persistent opioid use in a large cohort of opioid-naive patients undergoing abdominal surgery. This finding does not detract from the other potential benefits of epidural placement. More research is needed to understand the mechanism of persistent opioid use after surgery and its prevention.
阿片类药物在围手术期镇痛中起着至关重要的作用；然而，患者在术后数月可能会持续使用这些药物。硬膜外麻醉被认为可以预防持续性疼痛的发生，但关于硬膜外麻醉对持续性阿片类药物使用影响的数据很少。
本研究使用了一家大型全国性商业健康保险公司的理赔数据库。纳入了2004年1月至2013年12月期间接受开腹手术且未使用过阿片类药物的患者。计算硬膜外麻醉置入的倾向评分时考虑了人口统计学特征、资源利用情况和合并症（包括内科、精神科和疼痛方面的疾病）。采用事件发生时间分析，主要结局定义为出院后30天内未开具阿片类药物处方。此外，还计算了每位患者出院后90天内发放的吗啡总当量。
最终倾向评分匹配队列中共有6432例患者。硬膜外麻醉置入与直至出现30天未开具阿片类药物处方间隔时间之间的Cox比例风险比为0.96（95%CI，0.91至1.01；P = 0.0910）。两组出院后90天内发放的吗啡总当量无差异（P = 0.7670）。
在一大群接受腹部手术且未使用过阿片类药物的患者中，硬膜外麻醉置入并不能预防持续性阿片类药物使用。这一发现并不影响硬膜外麻醉置入的其他潜在益处。需要更多研究来了解术后持续性阿片类药物使用的机制及其预防措施。
