Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA.
Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA.
Spine J. 2019 Apr;19(4):717-725. doi: 10.1016/j.spinee.2018.09.007. Epub 2018 Sep 14.
Prescription opioid abuse is a public health emergency. Opioid prescriptions for spine patients account for a large proportion of use. Some states have implemented statutory limits on prescribers, however it remains unclear whether such laws are effective.
This investigation compares opioid prescription patterns for patients undergoing lumbar spine surgery before and after the passage of statewide narcotic-limiting legislation in Rhode Island.
STUDY DESIGN/SETTING: Retrospective review of prospectively-collected medical and pharmacologic data.
Two patient cohorts (pre-law January 1, 2016-June 31, 2016 and post-law June 1, 2017-December 31, 2017) that included all patients undergoing selected lumbar spine surgeries (lumbar discectomy, lumbar decompression without fusion, and posterior lumbar fusion).
Demographic and surgical variables were collected from the patient's medical charts, and information on controlled substances was collected from the state prescription drug monitoring program database. Variables collected included the number of pills and total morphine milligram equivalents (MMEs) of the first prescription, number of prescriptions filled within 30 days of surgery, total MMEs filled in the 30-day postoperative period, and total MMEs filled from 30 to 90 days after surgery. For comparison of continuous variables, t test or Mann-Whitney U test were used as appropriate. Chi-squared analysis was utilized for comparison of categorical variables. Independent risk factors for prolonged postoperative opioid use were evaluated using logistic regression.
There were no significant differences between pre-law (n = 241) and post-law (n = 311) cohorts in terms of age, sex, preoperative opioid use, or preoperative anxiolytic use (p > .05). A greater than 50% decline was observed among all patients from the pre-law to the post-law period in terms of the number of pills (51.61 vs 23.60 pills, p < .001) and MMEs (525.56 vs 218.77 MMEs, p < .001) provided in the first postoperative opioid prescription. The mean total MMEs provided in the first 30 days decreased significantly (891.26 vs 628.63 MMEs, p < .001) despite an increase in the average number of opioid prescriptions filled (1.75 vs 2.04 prescriptions, p = .002) during this time. There was no significant difference in mean MMEs filled from 30 to 90 days. Upon subgroup analysis, there was a statistically significant decline in both the mean first prescription and total 30-day MMEs regardless of preoperative opioid status (all p < .05) or specific procedure performed (all p < .05). Preoperative opioid use was strongly associated with prolonged postoperative opioid requirements throughout the study period (OR 4.71, 95% CI 3.11-7.13, p < .001). There were no significant differences between cohorts in terms of emergency department (ED) visits or unplanned hospital readmissions at 30 and 90 days following surgery (all p > .05).
The institution of mandatory statewide opioid prescription limits has resulted in a significant reduction in initial and 30-day opioid prescriptions following lumbar spine surgery. Decreased opioid utilization was observed in all patients, regardless of preoperative opioid tolerance or procedure performed. No significant change in postoperative ED visits or unplanned hospital readmissions was seen following implementation of the legislation. This investigation provides preliminary evidence that narcotic limiting legislation may be effective in decreasing opioid prescriptions after lumbar spine surgery for both opioid-naïve and opioid-tolerant patients.
处方类阿片滥用是一项公共卫生紧急事件。脊柱患者的阿片类药物处方占使用量的很大比例。一些州已经对处方医生实施了法定限制，但尚不清楚这些法律是否有效。
本研究比较了罗得岛州通过全州范围内限制阿片类药物立法前后接受腰椎手术患者的阿片类药物处方模式。
研究设计/设置：前瞻性收集医疗和药理学数据的回顾性研究。
两个患者队列（法律实施前，即 2016 年 1 月 1 日至 2016 年 6 月 31 日和法律实施后，即 2017 年 6 月 1 日至 2017 年 12 月 31 日），包括所有接受选定腰椎手术（腰椎间盘切除术、腰椎减压术不融合和后路腰椎融合术）的患者。
从患者的病历中收集人口统计学和手术变量，并从州处方药物监测计划数据库中收集有关受控物质的信息。收集的变量包括第一份处方的药丸数量和总吗啡毫克当量（MME）、术后 30 天内填写的处方数量、术后 30 天内填写的总 MME 量以及术后 30 至 90 天内填写的总 MME 量。为了比较连续变量，使用 t 检验或曼-惠特尼 U 检验（适当时）。使用卡方分析比较分类变量。使用逻辑回归评估术后延长使用阿片类药物的独立危险因素。
在年龄、性别、术前阿片类药物使用或术前安定类药物使用方面，法律实施前队列（n=241）和法律实施后队列（n=311）之间没有显著差异（p>0.05）。与法律实施前相比，所有患者在术后第一个阿片类药物处方中提供的药丸数量（51.61 对 23.60 片，p<0.001）和 MME 量（525.56 对 218.77 MME，p<0.001）均有显著下降。尽管在此期间平均阿片类药物处方数量增加（1.75 对 2.04 张处方，p=0.002），但术后第一个 30 天内提供的平均总 MME 量显著减少（891.26 对 628.63 MME，p<0.001）。从 30 天到 90 天的平均 MME 量没有差异。在亚组分析中，无论术前阿片类药物状态（均 p<0.05）或特定手术方式（均 p<0.05）如何，第一份处方和 30 天内总 MME 的平均值均呈统计学显著下降。整个研究期间，术前阿片类药物使用与术后延长阿片类药物需求密切相关（比值比 4.71，95%置信区间 3.11-7.13，p<0.001）。两组在术后 30 天和 90 天的急诊室（ED）就诊或计划外医院再入院率方面没有显著差异（均 p>0.05）。
全州范围内强制性阿片类药物处方限制的实施导致腰椎手术后初始和 30 天阿片类药物处方显著减少。无论术前阿片类药物耐受或手术方式如何，所有患者的阿片类药物用量均有所减少。在实施立法后，术后 ED 就诊或计划外医院再入院率没有明显变化。本研究初步证明，在腰椎手术后，对于阿片类药物耐受和非耐受患者，限制阿片类药物的立法可能会有效减少阿片类药物的处方。
