Rollins School of Public Health, Emory University, Atlanta, Georgia.
Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia.
JAMA Surg. 2018 Oct 1;153(10):948-954. doi: 10.1001/jamasurg.2018.2730.
Over the past 20 years, opioid misuse and opioid addiction have risen to epidemic proportions in the United States. One-third of adults receiving long-term opioid therapy report that their first opioid prescription came from a surgeon, indicating that postsurgical prescribing is an important point of intervention in the opioid epidemic. Such interventions differ from historical interventions on prescribing in that they must be closely monitored to ensure pain continues to be adequately controlled after surgical procedures. As evidence on nonopioid-based pain control grows, a key question is how to implement practice change in postsurgical discharge prescribing.
To examine interventions associated with changing opioid prescription practices on surgical discharge.
Studies published after 2000 that included interventions that aimed at postsurgical opiate stewardship and evaluated outcomes were included. PubMed and Embase were searched through March 2018 for relevant articles, with additional articles retrieved based on citations in articles retrieved in the initial search. Quality was assessed by 2 independent reviewers using the Quality Assessment Tool for Quantitative Studies, and quality scores were reconciled through discussion and mutual agreement.
Eight studies met inclusion criteria, of which 3 were preintervention and postintervention comparison studies, 3 were controlled clinical studies, 1 was a time-series study, and 1 compared postintervention results with a predetermined baseline. Interventions done at the organization level, including changes to electronic health records order sets and workflow, showed clear positive results. Additionally, 2 studies that centered on developing guidelines based on actual patient opioid use and disseminating these guidelines to clinicians reported reductions up to 53% in the quantity prescribed. No increases in emergency department visits or refill requests were reported in studies measuring these outcomes. However, 1 study focused on reducing the number of children who were prescribed codeine found via check-in telephone calls that 13 of 240 patients (5.4%) had inadequately controlled pain.
The studies reviewed provide evidence that clinician-mediated and organizational-level interventions are powerful tools in creating change in postsurgical opioid prescribing. This summary highlights paucity of high-quality studies that provide clear evidence on the most effective intervention at reducing postoperative opioid prescribing.
在过去的 20 年中，美国阿片类药物滥用和成瘾已达到流行的程度。接受长期阿片类药物治疗的成年人中有三分之一报告说，他们的第一份阿片类药物处方来自外科医生，这表明术后处方是阿片类药物流行中的一个重要干预点。这种干预与历史上的处方干预不同，因为它们必须密切监测，以确保手术后疼痛继续得到充分控制。随着非阿片类药物控制疼痛的证据不断增加，一个关键问题是如何在术后出院时实施实践改变。
研究与改变术后阿片类药物处方实践相关的干预措施。
纳入 2000 年后发表的、旨在进行术后阿片类药物管理并评估结果的干预措施相关研究。通过 PubMed 和 Embase 检索 2018 年 3 月前的相关文章，并根据在最初检索中检索到的文章的参考文献进一步检索文章。两名独立评审员使用定量研究质量评估工具评估质量，通过讨论和相互协议解决质量评分。
8 项研究符合纳入标准，其中 3 项为干预前后比较研究，3 项为对照临床试验，1 项为时间序列研究，1 项将干预后的结果与预定基线进行比较。以组织为基础的干预措施，包括电子病历医嘱集和工作流程的改变，显示出明确的积极结果。此外，2 项以实际患者阿片类药物使用为基础制定指南并向临床医生传播这些指南的研究报告称，处方量减少了 53%。在衡量这些结果的研究中，没有报告急诊就诊或药物续开请求增加的情况。然而，1 项研究侧重于减少被处方可待因的儿童数量，通过就诊时的电话检查发现，240 名患者中有 13 名（5.4%）疼痛控制不佳。
综述中的研究提供了证据，证明临床医生介导和组织层面的干预措施是改变术后阿片类药物处方的有力工具。这一总结突出表明，缺乏高质量的研究提供了明确的证据，说明最有效的干预措施可以减少术后阿片类药物的处方。
