Chaudhary Muhammad Ali, Schoenfeld Andrew J, Harlow Alyssa F, Ranjit Anju, Scully Rebecca, Chowdhury Ritam, Sharma Meesha, Nitzschke Stephanie, Koehlmoos Tracey, Haider Adil H
Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
JAMA Surg. 2017 Oct 1;152(10):930-936. doi: 10.1001/jamasurg.2017.1685.
In the current health care environment with increased scrutiny and growing concern regarding opioid use and abuse, there has been a push toward greater regulation over prescriptions of opioids. Trauma patients represent a population that may be affected by this regulation, as the incidence of pain at hospital discharge is greater than 95%, and opioids are considered the first line of treatment for pain management. However, the use of opioid prescriptions in trauma patients at hospital discharge has not been explored.
To study the incidence and predictors of opioid prescription in trauma patients at discharge in a large national cohort.
DESIGN, SETTING, AND PARTICIPANTS: Analysis of adult (18-64 years), opioid-naive trauma patients who were beneficiaries of Military Health Insurance (military personnel and their dependents) treated at both military health care facilities and civilian trauma centers and hospitals between January 1, 2006, and December 31, 2013, was conducted. Patients with burns, foreign body injury, toxic effects, or late complications of trauma were excluded. Prior diagnosis of trauma within 1 year and in-hospital death were also grounds for exclusion. Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors were considered covariates. The Drug Enforcement Administration's list of scheduled narcotics was used to query opioid use. Unadjusted and adjusted logistic regression models were used to determine the predictors of opioid prescription. Data analysis was performed from June 7 to August 21, 2016.
Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors.
Prescription of opioid analgesics at discharge.
Among the 33 762 patients included in the study (26 997 [80.0%] men; mean [SD] age, 32.9 [13.3] years), 18 338 (54.3%) received an opioid prescription at discharge. In risk-adjusted models, older age (45-64 vs 18-24 years: odds ratio [OR], 1.28; 95% CI, 1.13-1.44), marriage (OR, 1.26; 95% CI, 1.20-1.34), and higher Injury Severity Score (≥9 vs <9: OR, 1.40; 95% CI, 1.32-1.48) were associated with a higher likelihood of opioid prescription at discharge. Male sex (OR, 0.76; 95% CI, 0.69-0.83) and anxiety (OR, 0.82; 95% CI, 0.73-0.93) were associated with a decreased likelihood of opioid prescription at discharge.
The incidence of opioid prescription at discharge (54.3%) closely matches the incidence of moderate to severe pain in trauma patients, indicating appropriate prescribing practices. We advocate that injury severity and level of pain-not arbitrary regulations-should inform the decision to prescribe opioids.
在当前医疗环境中，对阿片类药物使用和滥用的审查日益严格，人们也愈发担忧，因此对阿片类药物处方的监管力度不断加大。创伤患者可能会受到这一监管的影响，因为出院时疼痛发生率超过95%，而阿片类药物被视为疼痛管理的一线治疗药物。然而，尚未对创伤患者出院时阿片类药物处方的使用情况进行研究。
研究一个大型全国队列中创伤患者出院时阿片类药物处方的发生率及预测因素。
设计、地点和参与者：对2006年1月1日至2013年12月31日期间在军事医疗设施以及民用创伤中心和医院接受治疗的成年（18 - 64岁）、未使用过阿片类药物的创伤患者（军事人员及其家属，他们是军事医疗保险的受益者）进行分析。排除烧伤、异物损伤、中毒或创伤晚期并发症患者。1年内曾有创伤诊断及院内死亡患者也被排除。损伤机制和严重程度、合并症、精神健康障碍及人口统计学因素被视为协变量。使用美国缉毒局的管制麻醉药品清单查询阿片类药物使用情况。采用未调整及调整后的逻辑回归模型确定阿片类药物处方的预测因素。数据分析于2016年6月7日至8月21日进行。
损伤机制和严重程度、合并症、精神健康障碍及人口统计学因素。
出院时阿片类镇痛药物处方。
在纳入研究的33762例患者中（26997例[80.0%]为男性；平均[标准差]年龄32.9[13.3]岁），18338例（54.3%）出院时接受了阿片类药物处方。在风险调整模型中，年龄较大（45 - 64岁与18 - 24岁相比：比值比[OR]，1.28；95%置信区间[CI]，1.13 - 1.44）、已婚（OR，1.26；95%CI，1.20 - 1.34）以及较高的损伤严重度评分（≥9分与<9分相比：OR，1.40；95%CI，1.32 - 1.48）与出院时开具阿片类药物处方的可能性较高相关。男性（OR，0.76；95%CI，0.69 - 0.83）和焦虑（OR，0.82；95%CI，0.73 - 0.93）与出院时开具阿片类药物处方的可能性降低相关。
出院时阿片类药物处方的发生率（54.3%）与创伤患者中重度疼痛的发生率密切匹配，表明处方做法恰当。我们主张，开具阿片类药物的决定应以损伤严重程度和疼痛程度为依据，而非任意的规定。
