RTI International, United States of America.
RTI International, United States of America.
J Subst Abuse Treat. 2019 Aug;103:58-63. doi: 10.1016/j.jsat.2019.05.001. Epub 2019 May 5.
Between 2012 and 2017, the United States dramatically reduced opioid prescribing rates. While this may be appropriate given the opioid epidemic, there has been little research to guide the clinical practice of discontinuing patients from opioid medications and opioid death rates have continued to increase.
To determine the relationship between time to opioid discontinuation and the risk of an opioid-related emergency department visit or hospitalization among high dose opioid users.
We applied Cox proportional hazard models to 2013-2017 Medicaid claims data to research this relationship.
Medicaid beneficiaries in Vermont who filled prescription opioids at high daily doses (at least 120 morphine milligram equivalents) for 90 or more consecutive days and who subsequently discontinued opioid prescriptions (n = 494).
The outcome was an opioid-related adverse event defined as an emergency department visit or hospitalization with a primary or secondary diagnosis of opioid poisoning or substance use disorder.
The median length of time to discontinuation was 1 day indicating that half of patients had no dose reduction prior to discontinuation. 86% of patients discontinued within 21 days (considered rapid tapering in recent clinical guidelines). 49% of members had an opioid-related hospitalization or emergency department visit. After controlling for sociodemographic and clinical factors, each additional week of discontinuation time was associated with a 7% reduction in the probability of having opioid related adverse event (p < 0.01). Although 60% of members had a diagnosed substance use disorder prior to tapering, <1% of beneficiaries were transitioned onto an opioid use disorder medication.
Faster rates of opioid tapering were associated with a greater probability of adverse events and many patients discontinued opioids suddenly, with no dose reduction. Additional clinical guidance, research, and interventions are needed to ensure that patients' opioid prescriptions are discontinued safely.
2012 年至 2017 年期间，美国大幅降低了阿片类药物的处方率。虽然考虑到阿片类药物流行，这可能是合适的，但几乎没有研究来指导临床实践，即停止给患者开阿片类药物，而阿片类药物的死亡率仍在继续上升。
确定停止使用阿片类药物的时间与高剂量阿片类药物使用者发生阿片类药物相关急诊就诊或住院的风险之间的关系。
我们应用 Cox 比例风险模型来研究 2013-2017 年医疗补助数据中这种关系。
佛蒙特州医疗补助受益人的处方药中含有高剂量（至少 120 毫克吗啡等效物）阿片类药物，连续服用 90 天或以上，随后停止使用阿片类药物处方（n=494）。
研究结果是阿片类药物相关不良事件，定义为急诊就诊或住院治疗，其主要或次要诊断为阿片类药物中毒或物质使用障碍。
停止使用的中位时间为 1 天，表明一半的患者在停止使用之前没有减少剂量。86%的患者在 21 天内（在最近的临床指南中被认为是快速减量）停止使用。49%的成员有阿片类药物相关的住院或急诊就诊。在控制社会人口统计学和临床因素后，每多一周停药时间，发生阿片类药物相关不良事件的概率就会降低 7%（p<0.01）。尽管 60%的成员在减量前被诊断患有物质使用障碍，但不到 1%的受益患者被转用阿片类药物使用障碍药物。
更快的阿片类药物减量速度与不良事件的发生概率更高相关，许多患者突然停止使用阿片类药物，没有减少剂量。需要更多的临床指导、研究和干预措施，以确保患者的阿片类药物处方安全停药。
