Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT.
Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD.
Am J Obstet Gynecol. 2022 Jul;227(1):68.e1-68.e24. doi: 10.1016/j.ajog.2022.02.030. Epub 2022 Mar 3.
Despite substantial reductions in the past decade, prescription opioids continue to cause widespread morbidity and mortality in the United States. Little is known regarding patterns and predictors of opioid use among women undergoing benign hysterectomy.
This study aimed to identify the incidence and predictors of new persistent opioid use after benign hysterectomy among opioid-naïve women from a set of demographic, operative, and opioid prescription characteristics of patients.
In this retrospective cohort study, we identified women undergoing benign hysterectomy from 2011 to 2016 using a validated national insurance claims database (IBM MarketScan Commercial Database). After excluding women with prevalent opioid use (from 365 to 31 days preoperatively), we identified patients who received a perioperative opioid prescription (30 days before to 14 days after hysterectomy) and evaluated them for new persistent opioid use, defined as at least 1 prescription from 15 to 90 days and at least 1 prescription from 91 to 365 days postoperatively. Multivariate logistic regression was used to examine demographic, clinical, operative, and opioid prescription-related factors associated with new persistent use. International Classification of Diseases, Ninth and Tenth Revisions, and Clinical Classification Software codes were used to identify hysterectomies, preoperative pain and psychiatric diagnoses, surgical indications, and surgical complications included as covariates.
We identified 114,260 women who underwent benign hysterectomy and were not prevalent opioid users, of which 93,906 (82.2%) received at least 1 perioperative opioid prescription. Of 93,906 women, 4334 (4.6%) developed new persistent opioid use. Logistic regression demonstrated that new persistent use odds is significantly increased by younger age (18-34 years; adjusted odds ratio, 1.97; 95% confidence interval, 1.69-2.30), southern geographic location (adjusted odds ratio, 2.03; 95% confidence interval, 1.79-2.27), preoperative psychiatric and pain disorders (anxiety: adjusted odds ratio, 1.20 [95% confidence interval, 1.09-1.33]; arthritis: adjusted odds ratio, 1.30 [95% confidence interval, 1.21-1.40]), >1 perioperative prescription (adjusted odds ratio, 1.53; 95% confidence interval, 1.24-1.88), mood disorder medication use (adjusted odds ratio, 1.51; 95% confidence interval, 1.40-1.64), tobacco smoking (adjusted odds ratio, 1.65; 95% confidence interval, 1.45-1.89), and surgical complications (adjusted odds ratio, 1.84; 95% confidence interval, 1.69-2.00). Although statistically nonsignificant, total morphine milligram equivalent of ≥300 in the first perioperative prescription increased persistent use likelihood by 9% (95% confidence interval, 1.01-1.17). Dispensing of a first perioperative prescription before the surgery, as opposed to after, increased new persistent use odds by 61% (95% confidence interval, 1.50-1.72). Each additional perioperative day covered by a prescription increased the likelihood of persistent use by 2% (95% confidence interval, 1.02-1.03). In contrast, minimally invasive hysterectomy (laparoscopic: adjusted odds ratio, 0.89 [95% confidence interval, 0.71-0.88]; vaginal: adjusted odds ratio, 0.82 [95% confidence interval, 0.72-0.93]) and a more recent surgery year (2016 vs reference 2011: adjusted odds ratio 0.58; 95% confidence interval, 0.51-0.65) significantly decreased its likelihood.
New persistent opioid use after hysterectomy was associated with several patient, operative, and opioid prescription-related factors. Considering these factors may be beneficial in counseling patients and shared decision-making about perioperative prescription to decrease the risk of persistent opioid use.
尽管在过去十年中大幅减少，但处方类阿片仍在美国造成广泛的发病率和死亡率。在美国，接受良性子宫切除术的女性中，阿片类药物的使用模式和预测因素知之甚少。
本研究旨在确定一组患者的人口统计学、手术和阿片类药物处方特征，从接受阿片类药物的女性中确定良性子宫切除术后新的持续性阿片类药物使用的发生率和预测因素。
在这项回顾性队列研究中，我们使用经过验证的全国保险索赔数据库（IBM MarketScan 商业数据库）确定了 2011 年至 2016 年期间接受良性子宫切除术的女性。在排除术前有阿片类药物使用的患者（从术前 365 天到 31 天）后，我们确定了接受围手术期阿片类药物处方的患者（从子宫切除术前 30 天到术后 14 天），并评估他们是否有新的持续性阿片类药物使用，定义为至少有 1 次术后 15 至 90 天和至少 1 次术后 91 至 365 天的处方。多变量逻辑回归用于检查与新的持续性使用相关的人口统计学、临床、手术和阿片类药物处方相关因素。国际疾病分类第 9 版和第 10 版修订版和临床分类软件代码用于识别子宫切除术、术前疼痛和精神科诊断、手术指征和手术并发症，作为协变量。
我们确定了 114260 名接受良性子宫切除术且未使用阿片类药物的女性，其中 93906 名（82.2%）接受了至少 1 次围手术期阿片类药物处方。在 93906 名女性中，有 4334 名（4.6%）出现了新的持续性阿片类药物使用。逻辑回归表明，新的持续性使用的可能性显著增加，年龄较小（18-34 岁；调整后的优势比，1.97；95%置信区间，1.69-2.30）、南部地理位置（调整后的优势比，2.03；95%置信区间，1.79-2.27）、术前精神和疼痛障碍（焦虑：调整后的优势比，1.20 [95%置信区间，1.09-1.33]；关节炎：调整后的优势比，1.30 [95%置信区间，1.21-1.40]）、>1 次围手术期处方（调整后的优势比，1.53；95%置信区间，1.24-1.88）、情绪障碍药物使用（调整后的优势比，1.51；95%置信区间，1.40-1.64）、吸烟（调整后的优势比，1.65；95%置信区间，1.45-1.89）和手术并发症（调整后的优势比，1.84；95%置信区间，1.69-2.00）。尽管统计学上无意义，但首次围手术期处方中吗啡毫克当量≥300 增加了持续性使用的可能性 9%（95%置信区间，1.01-1.17）。与术后相比，手术前开具首次围手术期处方增加了新的持续性使用的可能性 61%（95%置信区间，1.50-1.72）。每次处方覆盖的额外围手术期天数增加持续性使用的可能性增加 2%（95%置信区间，1.02-1.03）。相比之下，微创手术（腹腔镜：调整后的优势比，0.89 [95%置信区间，0.71-0.88]；阴道：调整后的优势比，0.82 [95%置信区间，0.72-0.93]）和较晚的手术年份（2016 年比参考 2011 年：调整后的优势比 0.58；95%置信区间，0.51-0.65）显著降低了其可能性。
子宫切除术后新的持续性阿片类药物使用与患者、手术和阿片类药物处方相关的多个因素有关。考虑这些因素可能有助于对围手术期处方进行咨询和共同决策，以降低持续性阿片类药物使用的风险。
