As-Sanie Sawsan, Till Sara R, Mowers Erika L, Lim Courtney S, Skinner Bethany D, Fritsch Laura, Tsodikov Alex, Dalton Vanessa K, Clauw Daniel J, Brummett Chad M
Departments of Obstetrics and Gynecology, Anesthesiology, and Internal Medicine, Institute for Healthcare Policy and Innovation, University of Michigan Medical School, the Department of Biostatistics, School of Public Health, University of Michigan, and the Department of Obstetrics and Gynecology, St Joseph Mercy Hospital, Ann Arbor, Michigan.
Obstet Gynecol. 2017 Dec;130(6):1261-1268. doi: 10.1097/AOG.0000000000002344.
To quantify physician prescribing patterns and patient opioid use in the 2 weeks after hysterectomy at an academic institution and to determine whether patient factors predict postsurgical opioid use and pain recovery.
We conducted a prospective quality initiative study by recruiting all English-speaking patients undergoing hysterectomy for benign, nonobstetric indications at a university hospital between August 2015 and December 2015, excluding those with major medical morbidities or substance abuse. Before hysterectomy, patients completed the Fibromyalgia Survey, a validated measure of centralized pain. After hysterectomy, opioid use (converted to oral morphine equivalents) and pain scores (0-10 numeric rating scale) were collected by a daily diary and a structured telephone interview 14 days after surgery. Primary outcomes were total opioid prescribed and consumed in the 2 weeks after hysterectomy. Secondary outcomes included daily opioid use and daily pain severity for 14 days after hysterectomy.
Of 103 eligible patients, 102 (99%) agreed to participate, including 44 (43.1%) laparoscopic, 42 (41.2%) vaginal, and 16 (15.7%) abdominal hysterectomies. Telephone surveys were completed on 89 (87%) participants; diaries were returned from 60 (59%) participants. Diary nonresponders had different baseline characteristics than nonresponders. Median amount of opioid prescribed was 200 oral morphine equivalents (interquartile range 150-250). Patients reported using approximately half of the opioids prescribed with a median excess of 110 morphine equivalents (interquartile range 40-150). The best fit model of total opioid consumption identified preoperative Fibromyalgia Survey Score, overall body pain, preoperative opioid use, prior endometriosis, abdominal hysterectomy (compared with laparoscopic), and uterine weight as significant predictors. Highest tertile of Fibromyalgia Survey Score was associated with greater daily opioid consumption (13.9 [95% CI 3.0-24.8] greater oral morphine equivalents at baseline, P=.02).
Gynecologists at a large academic medical center prescribe twice the amount of opioids than the average patient uses after hysterectomy. A personalized approach to prescribing opioids for postoperative pain should be considered.
量化某学术机构子宫切除术后2周内医生的处方模式及患者的阿片类药物使用情况，并确定患者因素是否可预测术后阿片类药物使用及疼痛恢复情况。
我们开展了一项前瞻性质量改进研究，纳入2015年8月至2015年12月期间在某大学医院因良性、非产科指征接受子宫切除术的所有讲英语的患者，排除有严重内科疾病或药物滥用的患者。子宫切除术前，患者完成纤维肌痛调查问卷，这是一种经过验证的集中性疼痛测量方法。子宫切除术后，通过每日日记及术后14天的结构化电话访谈收集阿片类药物使用情况（换算为口服吗啡当量）及疼痛评分（0 - 10数字评分量表）。主要结局为子宫切除术后2周内开具及使用的阿片类药物总量。次要结局包括子宫切除术后14天的每日阿片类药物使用情况及每日疼痛严重程度。
103名符合条件的患者中，102名（99%）同意参与，包括44名（43.1%）腹腔镜子宫切除术、42名（41.2%）阴道子宫切除术及16名（15.7%）腹部子宫切除术患者。89名（87%）参与者完成了电话调查；60名（59%）参与者返还了日记。日记未回复者与未回复电话调查者的基线特征不同。开具的阿片类药物中位数剂量为200口服吗啡当量（四分位间距150 - 250）。患者报告使用了所开具阿片类药物的约一半，中位数过量110吗啡当量（四分位间距40 - 150）。阿片类药物总消耗量的最佳拟合模型确定术前纤维肌痛调查问卷评分、全身疼痛、术前阿片类药物使用情况、既往子宫内膜异位症、腹部子宫切除术（与腹腔镜子宫切除术相比）及子宫重量为显著预测因素。纤维肌痛调查问卷评分最高三分位数与每日阿片类药物消耗量增加相关（基线时口服吗啡当量多13.9 [95% CI 3.0 - 24.8]，P = 0.02）。
某大型学术医学中心的妇科医生开具的阿片类药物量是子宫切除术后患者平均使用量的两倍。应考虑采用个性化方法开具术后疼痛的阿片类药物处方。
