Vickie and Jack Farber Institute for Neuroscience at Jefferson, Philadelphia, Pennsylvania.
Department of Neurosurgery, St. Luke's University Health Network, Bethlehem, Pennsylvania.
Pain Med. 2018 Apr 1;19(4):699-707. doi: 10.1093/pm/pnx262.
Observational study using insurance claims.
To quantify opioid usage leading up to spinal cord stimulation (SCS) and the potential impact on outcomes of SCS.
SCS is an interventional therapy that often follows opioid usage in the care continuum for chronic pain.
This study identified SCS patients using the Truven Health MarketScan databases from January 2010 to December 2014. The index event was the first occurrence of a permanent SCS implant. Indicators of opioid usage at implant were daily morphine equivalent dose (MED), number of unique pain drug classes, and diagnosis code for opioid abuse. System explant was used as a measure of ineffective SCS therapy. Multivariate logistic regression was used to analyze the effect of pre-implant medications on explants.
A total of 5,476 patients (56 ± 14 years; 60% female) were included. SCS system removal occurred in 390 patients (7.1%) in the year after implant. Number of drug classes (odds ratio [OR] = 1.11, P = 0.007) and MED level (5-90 vs < 5 mg/d: OR = 1.32, P = 0.043; ≥90 vs < 5 mg/d: OR = 1.57, P = 0.005) were independently predictive of system explant. Over the year before implant, MED increased in 54% (stayed the same in 21%, decreased in 25%) of patients who continued with SCS and increased in 53% (stayed the same in 20%, decreased in 27%) of explant patients (P = 0.772). Over the year after implant, significantly more patients with continued SCS had an MED decrease (47%) or stayed the same (23%) than before (P < 0.001).
Chronic pain patients receive escalating opioid dosage prior to SCS implant, and high-dose opioid usage is associated with an increased risk of explant. Neuromodulation can stabilize or decrease opioid usage. Earlier consideration of SCS before escalated opioid usage has the potential to improve outcomes in complex chronic pain.
使用保险索赔进行观察性研究。
量化脊髓刺激（SCS）前阿片类药物的使用情况及其对 SCS 结果的潜在影响。
SCS 是一种介入性治疗，常用于慢性疼痛护理连续体中的阿片类药物使用之后。
本研究使用 Truven Health MarketScan 数据库从 2010 年 1 月至 2014 年 12 月确定 SCS 患者。索引事件为首次发生永久性 SCS 植入。植入时阿片类药物使用的指标为每日吗啡等效剂量（MED）、独特的疼痛药物种类数量和阿片类药物滥用的诊断代码。系统取出被用作 SCS 治疗无效的衡量标准。多变量逻辑回归用于分析植入前药物对取出的影响。
共纳入 5476 名患者（56±14 岁；60%为女性）。植入后一年内，有 390 名患者（7.1%）取出 SCS 系统。药物种类数量（比值比[OR] = 1.11，P=0.007）和 MED 水平（5-90 与 <5mg/d：OR=1.32，P=0.043；≥90 与 <5mg/d：OR=1.57，P=0.005）与系统取出独立相关。在植入前一年，54%（继续使用 SCS 的患者中有 21%保持不变，25%下降）患者的 MED 增加，53%（取出患者中有 20%保持不变，27%下降）患者的 MED 增加（P=0.772）。在植入后一年，继续使用 SCS 的患者中 MED 下降（47%）或保持不变（23%）的患者比例明显高于之前（P<0.001）。
慢性疼痛患者在接受 SCS 植入前接受阿片类药物剂量逐渐增加，高剂量阿片类药物使用与取出风险增加相关。神经调节可以稳定或减少阿片类药物的使用。在阿片类药物使用逐渐增加之前更早地考虑 SCS 有可能改善复杂慢性疼痛的结局。
