Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia.
Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.
JAMA Cardiol. 2020 Aug 1;5(8):889-896. doi: 10.1001/jamacardio.2020.1445.
The overuse of opioids for acute pain management has led to an epidemic of persistent opioid use.
To determine the proportion of opioid-naive patients who develop persistent opioid use after cardiac surgery and investigate the association between the initial amount of opioids prescribed at discharge and the likelihood of developing new persistent opioid use.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used data from a national administrative claims database from January 1, 2004, to December 31, 2016 and included 35 817 patients who underwent coronary artery bypass grafting (CABG) (25 673 [71.7%]) and heart valve (10 144 [28.3%]) procedures. All patients were opioid-naive within 180 days before the index procedure and filled an opioid prescription within 14 days after surgery.
Opioid medications after cardiac surgery.
The proportion of opioid-naive patients who developed new persistent opioid use within 90 to 180 days after surgery was determined. Oral morphine equivalents (OMEs) were calculated for the first opioid prescription filled after discharge. A multivariable logistic regression with cubic splines was used to analyze the association among the OMEs at discharge and likelihood of developing persistent opioid use.
Of the 25 673 patients who underwent CABG, the mean (SD) age for those without (n = 23 064) vs with (n = 2609) persistent opioid use was 62.9 (9.8) years vs 61.6 (9.7) years, respectively, and the number who were men were 18 758 (81.3%) vs 1998 (76.6%). Of the 10 144 patients who underwent heart valve surgery, the mean (SD) age for those without (n = 9343) vs with (n = 821) persistent opioid use was 63.2 (12.4) years vs 61.2 (12.5) years, respectively, and the number who were men were 6378 (68.3%) vs 511 (62.2%). Persistent opioid use is a substantial concern after cardiac surgery and occurred in 2609 patients undergoing CABG (10.2%) and 821 valve surgery patients (8.1%; P = .001). The likelihood for developing persistent opioid use was decreased among heart valve surgery recipients (odds ratio [OR], 0.78; P < .001) and increased for patients who were women; younger; with preoperative congestive heart failure, chronic lung disease, diabetes, kidney failure, chronic pain, and alcoholism; and those taking preoperative benzodiazepines and muscle relaxants (women: OR, 1.15 [95% CI, 1.03-1.26]; younger age: OR, 1.02 [95% CI, 1.01-1.02]; congestive heart failure: OR, 1.17 [95% CI, 1.06-1.30]; chronic lung disease: OR, 1.32 [95% CI, 1.19-1.45]; diabetes: OR, 1.27 [95% CI, 1.15-1.40]; kidney failure: OR, 1.17 [95% CI, 1.00-1.37]; chronic pain: OR, 2.71 [95% CI, 2.10-3.56]; alcoholism: OR, 1.56 [95% CI, 1.23-2.00]; benzodiazepines: OR, 1.71 [95% CI, 1.52-1.91]; muscle relaxants: OR, 1.74 [95% CI, 1.51-2.02]; all P < .001). Furthermore, we found that when patients were prescribed more than approximately 300 mg of OMEs at discharge, they had a significantly increased risk of new persistent opioid use than with lower opioid prescriptions.
Opioids are used extensively after cardiothoracic surgery and nearly 1 of 10 patients will continue to use opioids over 90 days after surgery. Furthermore, higher OMEs prescribed at discharge were significantly associated with developing persistent use. Centers must adopt protocols to increase patient education and limit opioid prescriptions after discharge.
重要性：阿片类药物在急性疼痛管理中的过度使用导致了持续性阿片类药物使用的流行。
目的：确定心脏手术后初次使用阿片类药物的患者中持续性阿片类药物使用的比例，并探讨出院时开的阿片类药物初始剂量与新发生持续性阿片类药物使用的可能性之间的关系。
设计、设置和参与者：本回顾性队列研究使用了来自全国行政索赔数据库的数据，时间范围为 2004 年 1 月 1 日至 2016 年 12 月 31 日，纳入了 35817 名接受冠状动脉旁路移植术（CABG）（25673 [71.7%]）和心脏瓣膜手术（10144 [28.3%]）的患者。所有患者在手术前 180 天内都没有使用过阿片类药物，并且在手术后 14 天内都开了阿片类药物处方。
暴露：心脏手术后的阿片类药物。
主要结果和措施：确定了手术后 90 至 180 天内新发生持续性阿片类药物使用的无阿片类药物使用史患者的比例。计算了出院后首次开的阿片类药物处方的奥施康定等效剂量（OMEs）。使用带有三次样条的多变量逻辑回归分析了出院时 OMEs 与发生持续性阿片类药物使用的可能性之间的关系。
结果：在 25673 名接受 CABG 的患者中，无持续性阿片类药物使用史的患者（n=23064）与有持续性阿片类药物使用史的患者（n=2609）的平均（SD）年龄分别为 62.9（9.8）岁和 61.6（9.7）岁，男性患者分别为 18758（81.3%）和 1998（76.6%）。在 10144 名接受心脏瓣膜手术的患者中，无持续性阿片类药物使用史的患者（n=9343）与有持续性阿片类药物使用史的患者（n=821）的平均（SD）年龄分别为 63.2（12.4）岁和 61.2（12.5）岁，男性患者分别为 6378（68.3%）和 511（62.2%）。心脏手术后持续性阿片类药物使用是一个严重的问题，在接受 CABG 的患者中有 2609 例（10.2%）和接受瓣膜手术的患者中有 821 例（8.1%）发生了这种情况（P<.001）。瓣膜手术患者发生持续性阿片类药物使用的可能性较低（比值比[OR]，0.78；P<.001），而女性、年龄较小、术前充血性心力衰竭、慢性肺部疾病、糖尿病、肾衰竭、慢性疼痛和酗酒的患者以及术前服用苯二氮䓬类药物和肌肉松弛剂的患者发生持续性阿片类药物使用的可能性较高（女性：OR，1.15[95%CI，1.03-1.26]；年龄较小：OR，1.02[95%CI，1.01-1.02]；充血性心力衰竭：OR，1.17[95%CI，1.06-1.30]；慢性肺部疾病：OR，1.32[95%CI，1.19-1.45]；糖尿病：OR，1.27[95%CI，1.15-1.40]；肾衰竭：OR，1.17[95%CI，1.00-1.37]；慢性疼痛：OR，2.71[95%CI，2.10-3.56]；酗酒：OR，1.56[95%CI，1.23-2.00]；苯二氮䓬类药物：OR，1.71[95%CI，1.52-1.91]；肌肉松弛剂：OR，1.74[95%CI，1.51-2.02]；所有 P<.001）。此外，我们发现当患者出院时开的阿片类药物处方超过大约 300 毫克奥施康定时，他们发生新的持续性阿片类药物使用的风险显著增加。
结论和相关性：阿片类药物在心胸手术后广泛使用，近 1/10 的患者在手术后 90 天以上将继续使用阿片类药物。此外，出院时开的奥施康定等效剂量较高与持续性使用显著相关。各中心必须制定方案，增加患者教育并限制出院后的阿片类药物处方。
