Opioid Prescriptions for Chronic Pain and Overdose A Cohort Study
Opioid Prescriptions for Chronic Pain and Overdose A Cohort Study
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DOI：
10.7326/0003-4819-152-2-201001190-00006
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发表时间：
2010-01-19
影响因子：
39.2
通讯作者：
Von Korff, Michael
中科院分区：
文献类型：
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作者：
Dunn, Kate M.;Saunders, Kathleen W.;Von Korff, Michael
背景：在社区医疗实践中，针对慢性非癌性疼痛的长期阿片类药物治疗正变得越来越普遍。伴随着这种医疗实践的变化，致命性阿片类药物过量服用的比率有所上升。在接受医学处方的长期阿片类药物治疗的患者中，过量服用风险升高的程度尚不清楚。
目的：评估接受医学处方的长期阿片类药物治疗的患者中阿片类药物过量服用的比率及其与平均每日处方阿片类药物剂量的关联。
设计：使用考克斯比例风险模型，根据过量服用时所接受的平均每日阿片类药物剂量（吗啡当量）来评估过量服用风险。
环境：健康维护组织（HMO）。
患者：1997年至2005年间，9940名因慢性非癌性疼痛在90天内接受了3次或更多阿片类药物处方的患者。
测量：从自动化药房数据获取过去90天内的平均每日阿片类药物剂量。主要结局——非致命性和致命性过量服用——通过住院和门诊医疗的诊断代码以及死亡证明来确定，并通过病历审查进行确认。
结果：确定了51例与阿片类药物相关的过量服用病例，其中包括6例死亡。与接受每日1 - 20毫克阿片类药物（年过量服用率为0.2%）的患者相比，接受每日50 - 99毫克的患者过量服用风险增加了3.7倍（95%置信区间为1.5 - 9.5），年过量服用率为0.7%。接受每日100毫克或更多的患者过量服用风险增加了8.9倍（置信区间为4.0 - 19.7），年过量服用率为1.8%。
局限性：接受较高剂量方案的患者中过量服用风险增加可能是由于患者差异以及按照处方医生意图之外的方式使用阿片类药物所造成的混杂因素。研究队列中过量服用病例数量较少也是一个局限。
结论：接受较高剂量处方阿片类药物的患者过量服用风险增加，这强调了对这些患者进行密切监管的必要性。
Background: Long-term opioid therapy for chronic noncancer pain is becoming increasingly common in community practice. Concomitant with this change in practice, rates of fatal opioid overdose have increased. The extent to which overdose risks are elevated among patients receiving medically prescribed long-term opioid therapy is unknown.Objective: To estimate rates of opioid overdose and their association with an average prescribed daily opioid dose among patients receiving medically prescribed, long-term opioid therapy.Design: Cox proportional hazards models were used to estimate overdose risk as a function of average daily opioid dose (morphine equivalents) received at the time of overdose.Setting: HMO.Patients: 9940 persons who received 3 or more opioid prescriptions within 90 days for chronic noncancer pain between 1997 and 2005.Measurements: Average daily opioid dose over the previous 90 days from automated pharmacy data. Primary outcomes-nonfatal and fatal overdoses-were identified through diagnostic codes from inpatient and outpatient care and death certificates and were confirmed by medical record review.Results: 51 opioid-related overdoses were identified, including 6 deaths. Compared with patients receiving 1 to 20 mg/d of opioids (0.2% annual overdose rate), patients receiving 50 to 99 mg/d had a 3.7-fold increase in overdose risk (95% CI, 1.5 to 9.5) and a 0.7% annual overdose rate. Patients receiving 100 mg/d or more had an 8.9-fold increase in overdose risk (CI, 4.0 to 19.7) and a 1.8% annual overdose rate.Limitations: Increased overdose risk among patients receiving higher dose regimens may be due to confounding by patient differences and by use of opioids in ways not intended by prescribing physicians. The small number of overdoses in the study cohort is also a limitation.Conclusion: Patients receiving higher doses of prescribed opioids are at increased risk for overdose, which underscores the need for close supervision of these patients.