A Detailed Exploration Into the Association of Prescribed Opioid Dosage and Overdose Deaths Among Patients With Chronic Pain
A Detailed Exploration Into the Association of Prescribed Opioid Dosage and Overdose Deaths Among Patients With Chronic Pain
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DOI：
10.1097/mlr.0000000000000505
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发表时间：
2016-05-01
期刊：
影响因子：
3
通讯作者：
Dowell, Deborah
中科院分区：
文献类型：
--
作者：
Bohnert, Amy S. B.;Logan, Joseph E.;Dowell, Deborah
背景资料：高阿片类药物剂量与过量有关，临床指南警告说，基于潜在的危害和缺乏高剂量获益的证据，剂量不要超过100吗啡当量mg（MEM）。然而，这100 MEM阈值选择有点任意.Objective：为了检查处方阿片类药物剂量的关联作为一个连续的措施与无意阿片类药物过量的风险，以确定在一个详细的水平与过量风险相关的剂量范围.在这项嵌套病例对照研究中，对照采用风险集抽样，病例（阿片类药物过量死亡者）和对照组是从退伍军人健康管理局的患者人群中确定的，这些患者被开了阿片类药物并被诊断为慢性疼痛。非故意致死性阿片类镇痛药过量从国家死亡指数记录和处方阿片类药物剂量从药房记录测量。病例组P < 0.001（平均值= 98.1 MEM，SD = 112.7;中位数= 60，四分位距，30-120）（平均值= 47.7 MEM，SD = 65.2;中位数= 25，四分位距，15-45）。在ROC分析中，剂量是阿片类药物过量死亡的适度良好“预测因子”，表明平均而言，过量病例的阿片类药物处方剂量高于对照组的71%。没有发现阿片类药物剂量的明确临界点，以区分过量病例和对照组。在最近的许多指南中，将推荐剂量阈值降低到100 MEM以下，将影响少数没有过量风险的患者，同时可能使许多有过量风险的患者受益因为吸毒过量
Background: High opioid dosage has been associated with overdose, and clinical guidelines have cautioned against escalating dosages above 100 morphine-equivalent mg (MEM) based on the potential harm and the absence of evidence of benefit from high dosages. However, this 100 MEM threshold was chosen somewhat arbitrarily.Objective: To examine the association of prescribed opioid dosage as a continuous measure in relation to risk of unintentional opioid overdose to identify the range of dosages associated with risk of overdose at a detailed level.Methods: In this nested case-control study with risk-set sampling of controls, cases (opioid overdose decedents) and controls were identified from a population of patients of the Veterans Health Administration who were prescribed opioids and who have a chronic pain diagnosis. Unintentional fatal opioid analgesic overdose was measured from National Death Index records and prescribed opioid dosage from pharmacy records.Results: The average prescribed opioid dosage was higher (P < 0.001) for cases (mean = 98.1 MEM, SD = 112.7; median = 60, interquartile range, 30-120), than controls (mean = 47.7 MEM, SD = 65.2; median = 25, interquartile range, 15-45). In a ROC analysis, dosage was a moderately good "predictor" of opioid overdose death, indicating that, on average, overdose cases had a prescribed opioid dosage higher than 71% of controls.Conclusions: A clear cut-point in opioid dosage to distinguish between overdose cases and controls was not found. However, lowering the recommended dosage threshold below the 100 MEM used in many recent guidelines would affect proportionately few patients not at risk for overdose while potentially benefitting many of those at risk for overdose.