a Addiction Recovery Treatment Services, Department of Mental Health, San Francisco Veterans Affairs Health Care System , San Francisco , California , USA.
b Department of Psychiatry , University of California, San Francisco School of Medicine , San Francisco , California , USA.
Subst Abus. 2018;39(4):441-448. doi: 10.1080/08897077.2018.1455163. Epub 2018 Apr 26.
Co-prescribing opioids and benzodiazepines increases overdose risk. A paucity of literature exists evaluating strategies to improve safety of co-prescribing. This study evaluated an electronic intervention to improve safety for patients co-prescribed chronic opioids for pain and benzodiazepines at 3 and 6 months.
A prospective cohort study was conducted from December 2015 through May 2016 at San Francisco Veterans Affairs Health Care System. A clinical dashboard identified 145 eligible patients prescribed chronic opioids and benzodiazepines. Individualized taper and safety recommendations were communicated to prescribers via electronic medical record progress note and encrypted e-mail at baseline. Primary outcome was number of patients co-prescribed chronic opioids and benzodiazepines. Secondary outcomes included daily dose of opioids and benzodiazepines and number prescribed ≥100 mg morphine equivalent daily dose. Safety outcomes included number with opioid overdose education and naloxone distribution, annual urine drug screening, annual prescription drug monitoring program review, and signed opioid informed consent. Linear mixed models and generalized estimating equations were used to examine within-group change in outcomes between baseline and 3 and 6 months.
Among the 145 patients, mean (standard deviation) age was 62 (11) years and 91.7% (133/145) were male. Number co-prescribed significantly decreased from 145/145 (100%) at baseline to 93/139 (67%) at 6-month follow-up (odds ratio [OR] = 0.53, 95% confidence interval [CI]: 0.34-0.81, P = .003). Mean opioid and benzodiazepine doses significantly decreased from 84.61 to 65.63 mg (95% CI: 8.32-27.86, P < .001) and from 16.10 to 13.45 mg (95% CI: 1.6-3.9, P < .001), respectively, from baseline to 6-month follow-up. Patients prescribed ≥100 mg morphine equivalent daily dose significantly decreased from 39/145 (26.8%) at baseline to 26/139 (18.7%) at end of study (OR = 0.59, 95% CI: 0.44-0.78, P < .001), and patients with opioid overdose education and naloxone distribution significantly increased from 3/145 (2.1%) at baseline to 46/139 (33.1%; OR = 23.4, 95% CI: 7.61-71.99, P < .001) by the end of study. Number of patients with annual urine drug screening tended to increase from 123/145 (84.8%) at baseline to 132/145 (91.4%) by the end of study (OR = 1.89, 95% CI: 0.95-3.76, P = .07), and there were no significant changes across time in numbers of patients with annual prescription drug monitoring program review or signed opioid informed consent.
Electronic interventions may provide an effective strategy to improve safety for patients co-prescribed chronic opioids for pain and benzodiazepines.
同时开具阿片类药物和苯二氮䓬类药物会增加用药过量的风险。目前，关于改善共同开具这两种药物的安全性的策略的文献很少。本研究评估了一种电子干预措施，以改善 3 个月和 6 个月时同时开具慢性阿片类药物治疗疼痛和苯二氮䓬类药物的患者的安全性。
这是一项从 2015 年 12 月至 2016 年 5 月在旧金山退伍军人事务医疗保健系统进行的前瞻性队列研究。临床仪表板确定了 145 名符合条件的同时开具慢性阿片类药物和苯二氮䓬类药物的患者。基线时，通过电子病历进展记录和加密电子邮件向医生提供个体化的减量和安全建议。主要结局是同时开具慢性阿片类药物和苯二氮䓬类药物的患者人数。次要结局包括阿片类药物和苯二氮䓬类药物的日剂量和规定的每日 100 毫克等效吗啡剂量。安全性结局包括接受阿片类药物用药过量教育和纳洛酮分发、年度尿液药物筛查、年度处方药物监测计划审查以及签署阿片类药物知情同意书的人数。线性混合模型和广义估计方程用于检查基线和 3 个月和 6 个月时组内结局的变化。
在 145 名患者中，平均（标准差）年龄为 62（11）岁，91.7%（133/145）为男性。从基线时的 145/145（100%）到 6 个月随访时的 93/139（67%），同时开具的人数显著减少（比值比[OR] = 0.53，95%置信区间[CI]：0.34-0.81，P =.003）。阿片类药物和苯二氮䓬类药物的平均剂量分别从 84.61 降至 65.63mg（95%CI：8.32-27.86，P <.001）和从 16.10 降至 13.45mg（95%CI：1.6-3.9，P <.001），从基线到 6 个月随访。规定每日 100 毫克等效吗啡剂量的患者人数从基线时的 39/145（26.8%）显著减少到研究结束时的 26/139（18.7%）（OR = 0.59，95%CI：0.44-0.78，P <.001），接受阿片类药物用药过量教育和纳洛酮分发的患者人数从基线时的 3/145（2.1%）显著增加到研究结束时的 46/139（33.1%）（OR = 23.4，95%CI：7.61-71.99，P <.001）。年度尿液药物筛查的患者人数也呈上升趋势，从基线时的 123/145（84.8%）增加到研究结束时的 132/145（91.4%）（OR = 1.89，95%CI：0.95-3.76，P =.07），但年度处方药物监测计划审查和签署阿片类药物知情同意书的患者人数在各时间点均无显著变化。
电子干预措施可能是改善同时开具慢性阿片类药物治疗疼痛和苯二氮䓬类药物的患者安全性的有效策略。
