Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York.
Department of Physical Medicine and Rehabilitation, New York-Presbyterian Columbia/Cornell, New York, New York.
Pain Med. 2020 Oct 1;21(10):2574-2582. doi: 10.1093/pm/pnz361.
Guidelines recommend that clinicians make decisions about opioid tapering for patients with chronic pain using a benefit-to-harm framework and engaging patients. Studies have not examined clinician documentation about opioid tapering using this framework.
Thematic and content analysis of clinician documentation about opioid tapering in patients' medical records in a large academic health system.
Medical records were reviewed for patients aged 18 or older, without cancer, who were prescribed stable doses of long-term opioid therapy between 10/2015 and 10/2016 then experienced an opioid taper (dose reduction ≥30%) between 10/2016 and 10/2017. Inductive thematic analysis of clinician documentation within six months of taper initiation was conducted to understand rationale for taper, and deductive content analysis was conducted to determine the frequencies of a priori elements of a benefit-to-harm framework.
Thematic analysis of 39 patients' records revealed 1) documented rationale for tapering prominently cited potential harms of continuing opioids, rather than observed harms or lack of benefits; 2) patient engagement was variable and disagreement with tapering was prominent. Content analysis found no patients' records with explicit mention of benefit-to-harm assessments. Benefits of continuing opioids were mentioned in 56% of patients' records, observed harms were mentioned in 28%, and potential harms were mentioned in 90%.
In this study, documentation of opioid tapering focused on potential harms of continuing opioids, indicated variable patient engagement, and lacked a complete benefit-to-harm framework. Future initiatives should develop standardized ways of incorporating a benefit-to-harm framework and patient engagement into clinician decisions and documentation about opioid tapering.
指南建议临床医生使用获益-风险框架并让患者参与，根据该框架对慢性疼痛患者的阿片类药物减量做出决策。然而，目前还没有研究检查过临床医生使用该框架对阿片类药物减量的记录。
对大型学术医疗系统中患者病历中关于阿片类药物减量的临床医生记录进行主题和内容分析。
对 2015 年 10 月至 2016 年 10 月期间服用稳定剂量长期阿片类药物治疗且在 2016 年 10 月至 2017 年 10 月期间经历阿片类药物减量（剂量减少≥30%）的年龄在 18 岁或以上且无癌症的患者的医疗记录进行回顾。在减量开始后 6 个月内对临床医生记录进行归纳主题分析，以了解减量的基本原理；并进行演绎内容分析，以确定获益-风险框架的预先确定要素的频率。
对 39 名患者记录的主题分析揭示：1）记录的减量理由主要提到继续使用阿片类药物的潜在危害，而不是观察到的危害或缺乏益处；2）患者参与度存在差异，且明显存在对减量的分歧。内容分析发现没有患者记录明确提到获益-风险评估。在 56%的患者记录中提到继续使用阿片类药物的益处，在 28%的患者记录中提到观察到的危害，在 90%的患者记录中提到潜在危害。
在这项研究中，阿片类药物减量的记录侧重于继续使用阿片类药物的潜在危害，表明患者参与度存在差异，且缺乏完整的获益-风险框架。未来的计划应制定标准化方法，将获益-风险框架和患者参与纳入临床医生对阿片类药物减量的决策和记录中。
