Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital, Adelaide, Australia.
Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.
Anaesth Intensive Care. 2022 Mar;50(1-2):29-43. doi: 10.1177/0310057X211018211. Epub 2021 Aug 4.
Prescription opioid use has risen steeply for over two decades, driven primarily by advocacy for better management of chronic non-cancer pain, but also by poor opioid stewardship in the management of acute pain. Inappropriate prescribing, among other things, contributed to the opioid 'epidemic' and striking increases in patient harm. It has also seen a greater proportion of opioid-tolerant patients presenting to acute care hospitals. Effective and safe management of acute pain in opioid-tolerant patients can be challenging, with higher risks of opioid-induced ventilatory impairment and persistent post-discharge opioid use compared with opioid-naive patients. There are also increased risks of some less well known adverse postoperative outcomes including infection, earlier revision rates after major joint arthroplasty and spinal fusion, longer hospital stays, higher re-admission rates and increased healthcare costs. Increasingly, opioid-free/opioid-sparing techniques have been advocated as ways to reduce patient harm. However, good evidence for these remains lacking and opioids will continue to play an important role in the management of acute pain in many patients.Better opioid stewardship with consideration of preoperative opioid weaning in some patients, assessment of patient function rather than relying on pain scores alone to assess adequacy of analgesia, prescription of immediate release opioids only and evidence-based use of analgesic adjuvants are important. Post-discharge opioid prescribing should be contingent on an assessment of patient risk, with short-term only use of opioids. In partnership with pharmacists, nursing staff, other medical specialists, general practitioners and patients, anaesthetists remain ideally positioned to be involved in opioid stewardship in the acute care setting.
处方类阿片药物的使用在过去二十多年里急剧上升，主要是由于倡导更好地管理慢性非癌痛，但也由于急性疼痛管理中阿片类药物的管理不善。除其他外，不适当的处方是阿片类药物“流行”和患者伤害显著增加的原因之一。这也导致更多的阿片类药物耐受患者出现在急性护理医院。在阿片类药物耐受患者中有效和安全地管理急性疼痛可能具有挑战性，与阿片类药物未耐受患者相比，阿片类药物诱导的通气障碍和持续出院后阿片类药物使用的风险更高。还有一些不太知名的不良术后结局的风险增加，包括感染、大关节置换术和脊柱融合术后更早的翻修率、住院时间延长、再入院率增加和医疗保健费用增加。越来越多的无阿片类药物/减少阿片类药物的技术被提倡作为减少患者伤害的方法。然而，这些方法的良好证据仍然缺乏，阿片类药物将继续在许多患者的急性疼痛管理中发挥重要作用。更好的阿片类药物管理，考虑在某些患者中进行术前阿片类药物戒断，评估患者的功能，而不仅仅依赖于疼痛评分来评估镇痛的充分性，仅开具即释阿片类药物，并基于证据使用镇痛佐剂，这很重要。出院后的阿片类药物处方应根据患者风险评估，仅短期使用阿片类药物。与药剂师、护理人员、其他医学专家、全科医生和患者合作，麻醉师仍然是参与急性护理环境中的阿片类药物管理的理想人选。
