Harvard Medical School, Boston, Massachusetts.
Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts.
J Bone Joint Surg Am. 2019 Jul 17;101(14):1286-1293. doi: 10.2106/JBJS.18.01022.
The extent of variation in analgesic prescribing following musculoskeletal injury among countries and cultural contexts is poorly understood. Such an understanding can inform both domestic prescribing and future policy. The aim of our survey study was to evaluate how opioid prescribing by orthopaedic residents varies by geographic context.
Orthopaedic residents in 3 countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the U.S.) responded to surveys utilizing vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for post-discharge analgesia. We standardized opioid prescriptions in the surveys by conversion to morphine milligram equivalents (MMEs). We then constructed multivariable regressions with generalized estimating equations to describe differences in opiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases.
U.S. residents prescribed significantly more total MMEs per case (mean [95% confidence interval] = 383 [331 to 435]) compared with residents from the Netherlands (229 [160 to 297]) and from Haiti (101 [52 to 150]) both overall (p < 0.0001) and for patients treated for injuries of the femur (452 [385 to 520], 315 [216 to 414], and 103 [37 to 169] in the U.S., the Netherlands, and Haiti, respectively), tibial plateau (459 [388 to 531], 280 [196 to 365], and 114 [46 to 183]), tibial shaft (440 [380 to 500], 294 [205 to 383], and 141 [44 to 239]), wrist (239 [194 to 284], 78 [36 to 119], and 63 [30 to 95]), and ankle (331 [270 to 393], 190 [100 to 280], and 85 [42 to 128]) (p = 0.0272). U.S. residents prescribed significantly more MMEs for patients <40 years old (432 [374 to 490]) than for those >70 years old (327 [270 to 384]) (p = 0.0019).
Our results demonstrate greater prescribing of postoperative opioids at discharge in the U.S. compared with 2 other countries, 1 low-income and 1 high-income. Our findings highlight the high U.S. reliance on opioid prescribing for postoperative pain control after orthopaedic trauma.
Our findings point toward a need for careful reassessment of current opioid prescribing habits in the U.S. and demand reflection on how we can maximize effectiveness in pain management protocols and reduce provider contributions to the ongoing opioid crisis.
在不同国家和文化背景下，肌肉骨骼损伤后阿片类药物的使用存在很大差异，这一点我们了解甚少。这种认识既能为国内的处方制定提供信息，也能为未来的政策提供参考。我们的调查研究旨在评估骨科住院医师在地域背景下的阿片类药物使用情况。
在三个国家（海地、荷兰和美国），骨科住院医师对基于案例的肌肉骨骼创伤场景的调查做出了回应，这些国家的住院医师是术后镇痛的主要处方医师。住院医师选择他们将为出院后的镇痛开出哪些药物。我们通过转换为吗啡毫克当量（MME）使调查中的阿片类药物处方标准化。然后，我们使用广义估计方程构建多变量回归，以描述按国家、住院医师的性别和培训年限、以及测试病例中的损伤部位和年龄划分的阿片类药物处方差异。
与荷兰（229 [160 至 297]）和海地（101 [52 至 150]）的住院医师相比，美国的住院医师开出的每例总 MME 量明显更多（平均值 [95%置信区间] = 383 [331 至 435]），无论是整体情况（p < 0.0001）还是股骨损伤患者（452 [385 至 520]、315 [216 至 414]和 103 [37 至 169]）、胫骨平台损伤患者（459 [388 至 531]、280 [196 至 365]和 114 [46 至 183]）、胫骨骨干损伤患者（440 [380 至 500]、294 [205 至 383]和 141 [44 至 239]）、腕部损伤患者（239 [194 至 284]、78 [36 至 119]和 63 [30 至 95]）和踝关节损伤患者（331 [270 至 393]、190 [100 至 280]和 85 [42 至 128]）（p = 0.0272）。与>70 岁的患者（327 [270 至 384]）相比，美国的住院医师为<40 岁的患者开出的 MME 明显更多（432 [374 至 490]）（p = 0.0019）。
与其他两个国家（1 个低收入国家和 1 个高收入国家）相比，我们的研究结果显示美国在术后出院时开出的阿片类药物更多。我们的研究结果强调了美国对阿片类药物在骨科创伤后疼痛控制中的高度依赖。
我们的发现表明，美国需要仔细重新评估当前的阿片类药物处方习惯，并需要反思如何在疼痛管理方案中最大限度地提高效果，同时减少提供者对持续阿片类药物危机的贡献。
