From the Department of Surgery (C.A.T., S.F.P., M.D.R.-Z., M.D.Z.), Surgical Outcomes Program, The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (K.T.H., E.B.H.), and Department of Anesthesiology (H.M.G.), Mayo Clinic, Rochester, Minnesota.
J Trauma Acute Care Surg. 2018 Jul;85(1):62-70. doi: 10.1097/TA.0000000000001834.
BACKGROUND: Postoperative prescribing following acute care surgery must be optimized to limit excess opioids in circulation as misuse and diversion are frequently preceded by a prescription for acute pain. This study aimed to identify patient characteristics associated with higher opioid prescribing following laparoscopic cholecystectomy (LC). METHODS: Among patients aged 18 years or older who underwent LC at a single institution in 2014 to 2016, opioids prescribed at discharge were converted to oral morphine equivalents (OME) and compared with developing state guidelines (maximum, 200 OME). Preoperative opioid use was defined as any opioid prescription 1 month to 3 months before LC or a prescription unrelated to gallbladder disease less than 1 month before LC. Univariate and multivariable methods determined characteristics associated with top quartile opioid prescriptions among opioid-naive patients. RESULTS: Of 1,606 LC patients, 34% had emergent procedures, and 14% were preoperative opioid users. Nonemergent LC patients were more likely to use opioids preoperatively (16% vs. 11%, p = 0.006), but median OME did not differ by preoperative opioid use (225 vs. 219, p = 0.40). Among 1,376 opioid-naive patients, 96% received opioids at discharge. Median OME was 225 (interquartile range, 150-300), and 52% were prescribed greater than 200 OME. Top quartile prescriptions (≥300 OME) were associated with gallstone pancreatitis diagnosis, younger age, higher pain scores, and longer length of stay (all p < 0.05). While median OME did not differ by emergent status (median, 225; interquartile range, 150-300 for both, p = 0.15), emergent had more top quartile prescriptions (32% vs. 25%, p = 0.005). After adjusting for diagnosis, age, and sex, emergent status showed evidence of being associated with top quartile prescription (odds ratio, 1.3; 95% confidence interval, 1.0-1.8). Thirty-day refill rate was 5%. CONCLUSION: Over half of opioid-naive patients undergoing LC were prescribed opioids exceeding draft state guidelines. Variation in prescribing patterns was not fully explained by patient factors. Acute care surgeons have an opportunity to optimize prescribing practices with the ultimate goal of reducing opioid misuse. LEVEL OF EVIDENCE: Therapeutic study, level IV; Epidemiologic study, level III.
背景：急性手术后的术后处方必须优化，以限制循环中的过量阿片类药物，因为滥用和转移通常是在急性疼痛的处方之前发生的。本研究旨在确定与腹腔镜胆囊切除术（LC）后开具更高阿片类药物处方相关的患者特征。
方法：在 2014 年至 2016 年期间在一家机构接受 LC 的年龄在 18 岁或以上的患者中，将出院时开具的阿片类药物转换为口服吗啡当量（OME），并与制定的州指南进行比较（最大剂量为 200 OME）。术前阿片类药物使用是指在 LC 前 1 个月至 3 个月内开具的任何阿片类药物处方，或在 LC 前不到 1 个月内开具的与胆囊疾病无关的处方。单变量和多变量方法确定了在阿片类药物无使用史的患者中开具阿片类药物处方的前四分位数的特征。
结果：在 1606 例 LC 患者中，34%为紧急手术，14%为术前阿片类药物使用者。非紧急 LC 患者更有可能在术前使用阿片类药物（16%对 11%，p=0.006），但术前阿片类药物使用与 OME 中位数无差异（225 对 219，p=0.40）。在 1376 例阿片类药物无使用史的患者中，96%的患者在出院时开具了阿片类药物。OME 中位数为 225（四分位距 150-300），52%的患者处方大于 200 OME。前四分位数的处方（≥300 OME）与胆石性胰腺炎的诊断、年龄较小、疼痛评分较高和住院时间较长有关（均 p<0.05）。虽然紧急状态下的 OME 中位数没有差异（中位数 225；四分位距 150-300，两者均为 p=0.15），但紧急状态下开具的前四分位数处方更多（32%对 25%，p=0.005）。调整诊断、年龄和性别后，紧急状态显示与开具前四分位数处方有关（优势比 1.3；95%置信区间 1.0-1.8）。30 天的续药率为 5%。
结论：超过一半的接受 LC 的阿片类药物无使用史患者被开具了超过州草案指南规定的阿片类药物处方。处方模式的变化不能完全用患者因素来解释。急性护理外科医生有机会优化处方实践，最终目标是减少阿片类药物的滥用。
证据水平：治疗性研究，IV 级；流行病学研究，III 级。
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