Hundley Lauren, Spradley Shelley, Donelenko Scott
Clinical Pharmacy Specialist, Pain Management/Palliative Care, Orlando Veterans Affairs Medical Center at Lake Nona, Orlando, Florida.
Clinical Pharmacy Specialist, Pain Management/Palliative Care, Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida.
J Opioid Manag. 2018 Mar/Apr;14(2):89-101. doi: 10.5055/jom.2018.0436.
To assess the impact of tapering of chronic high dose opioid therapy in veterans prompted by the implementation of the Opioid Safety Initiative in 2013.
IRB and VA Office of Research and Development-approved retrospective, observational chart review.
North Florida/South Georgia Veterans Health System Patients: Veterans on high dose opioid therapy (≥300 mg of morphine equivalents per day) for chronic non-cancer pain as of 1/1/2012 with an opioid agreement discontinuation note documented in the medical record were included. Veterans treated for cancer pain or under palliative care were excluded.
Descriptive outcomes include rate of opioid discontinuation, average duration of tapering, and rate of relapse. Differences before and after discontinuation assessed include healthcare utilization, monitoring via urine drug screens and state prescription drug monitoring program (PDMP) queries, non-opioid analgesics, benzodiazepines, and non-pharmacologic modalities.
Forty-three patients were included. The mean duration of therapy was 7.8 years and 81.4 percent were on methadone prior to tapering. Opioids were tapered to discontinuation in 28 patients (65 percent) with long-term abstinence in 71 percent. The mean duration of tapering was 81 days and the median/mode was 30 days. Statistically significant differences after tapering include decreased PDMP queries, increased non-opioid analgesics, decreased benzodiazepine prescriptions, and increased use of mental health services (p < 0.05). There were zero adverse outcomes identified in those tapered and one death in the group who sought non-VA care for continuation.
This study suggests that moderate speed tapering in high-risk veterans on chronic high-dose opioid therapy can be achieved, but caution is warranted in ensuring adequate follow-up and monitoring. Clinical pharmacy services may improve tapering outcomes by providing more frequent follow-up, monitoring via state PDMP queries to identify patients who have relapsed, and dispensing naloxone for increased safety.
评估2013年实施的阿片类药物安全倡议促使退伍军人慢性高剂量阿片类药物治疗逐渐减量的影响。
经机构审查委员会（IRB）和退伍军人事务部（VA）研发办公室批准的回顾性观察图表审查。
北佛罗里达/南佐治亚退伍军人医疗系统 患者：纳入截至2012年1月1日因慢性非癌性疼痛接受高剂量阿片类药物治疗（每天≥300毫克吗啡当量）且病历中有阿片类药物协议终止记录的退伍军人。排除接受癌症疼痛治疗或处于姑息治疗的退伍军人。
描述性结果包括阿片类药物停药率、逐渐减量的平均持续时间和复发率。评估停药前后的差异包括医疗保健利用率、通过尿液药物筛查和州处方药监测计划（PDMP）查询进行的监测、非阿片类镇痛药、苯二氮䓬类药物和非药物治疗方式。
纳入43例患者。平均治疗持续时间为7.8年，81.4%的患者在逐渐减量前服用美沙酮。28例患者（65%）的阿片类药物逐渐减量至停药，71%的患者长期戒断。逐渐减量的平均持续时间为81天，中位数/众数为30天。逐渐减量后具有统计学意义的差异包括PDMP查询减少、非阿片类镇痛药增加、苯二氮䓬类药物处方减少以及心理健康服务使用增加（p<0.05）。逐渐减量的患者中未发现不良后果，而寻求非退伍军人事务部护理以继续治疗的患者中有1例死亡。
本研究表明，慢性高剂量阿片类药物治疗的高危退伍军人可以实现适度速度的逐渐减量，但在确保充分随访和监测方面需要谨慎。临床药学服务可通过提供更频繁的随访、通过州PDMP查询进行监测以识别复发患者以及分发纳洛酮以提高安全性来改善逐渐减量的结果。
