How do contraindications to non-opioid analgesics and opioids affect the likelihood that patients with back pain diagnoses in the primary care setting receive an opioid prescription? An observational cross-sectional study.
How do contraindications to non-opioid analgesics and opioids affect the likelihood that patients with back pain diagnoses in the primary care setting receive an opioid prescription? An observational cross-sectional study.
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DOI：
10.1186/s12875-021-01386-z
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发表时间：
2021-02-20
影响因子：
2.9
通讯作者：
Nuckols TK
中科院分区：
文献类型：
--
作者：
Keller MS;Truong L;Mays AM;Needleman J;Heilemann MSV;Nuckols TK
考虑到阿片类药物的风险，临床医生面临着越来越大的压力，要求用非阿片类药物治疗疼痛。然而，非阿片类镇痛药如非甾体抗炎药（NSAID）也有其自身的风险：患有肾脏疾病或胃肠道疾病的患者可能会出现严重的不良事件。我们检查了背痛诊断和NSAID和阿片类药物禁忌症患者在初级保健中接受阿片类药物处方的可能性。我们确定了2012年至2017年的背痛门诊，并对每位患者每年的首次门诊进行了抽样（N = 24，543次就诊）。我们创建了反映NSAID禁忌症的指标（肾脏、肝脏、心脑血管和胃肠道疾病;同时或长期使用抗凝剂/抗血小板药物，长期使用皮质类固醇）和阿片类药物（抑郁、焦虑、物质使用（SUD）和双相情感障碍，以及并发苯二氮卓类药物），并估计了四个逻辑回归模型，其中一个模型包括所有患者就诊，而模型2-4针对先前的阿片样物质使用进行分层。我们估计了每种禁忌症的人群归因风险。在我们的所有患者访视模型中，患者在4%的访视中接受阿片类药物处方。接受阿片类药物治疗的预测概率（PP）为4%（无肾脏疾病）vs 7%（有肾脏疾病）;边际效应（ME）：3%; 95%CI：1-4%）。对于长期或合并抗凝/抗血小板处方，PP为4% vs. 6%（ME：2%; 95%CI：1-3%）。合并使用苯二氮卓类药物的PP为4% vs. 11%（ME：7%，95%CI：5-9%），SUD的PP为4% vs. 5%（ME：1%，95%CI：0-3%）。对于包括既往长期使用阿片类药物患者的模型，合并使用苯二氮卓类药物的PP为25% vs. 24%（ME：-1%; 95%CI：− 18-16%）。NSAID和阿片类药物禁忌症的人群归因风险（PAR）较小。对于肾脏疾病，PAR为0.16%（95%CI：0.08-0.23%），抗凝剂和抗血小板药物为0.44%（95%CI：0.30-0.58%），药物使用为0.13%（95%CI：0.03-0.22%），同时使用苯二氮卓类药物为0.20%（95%CI：0.13-0.26%）。诊断为肾脏疾病并同时使用抗凝剂/抗血小板药物的患者在初级保健访视时接受阿片类药物处方治疗腰痛的可能性更高，但这些情况不能解释大部分阿片类药物处方。
Given the risks of opioids, clinicians are under growing pressure to treat pain with non-opioid medications. Yet non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) have their own risks: patients with kidney disease or gastrointestinal diseases can experience serious adverse events. We examined the likelihood that patients with back pain diagnoses and contraindications to NSAIDs and opioids received an opioid prescription in primary care. We identified office visits for back pain from 2012 to 2017 and sampled the first office visit per patient per year (N = 24,543 visits). We created indicators reflecting contraindications for NSAIDs (kidney, liver, cardiovascular/cerebrovascular, and gastrointestinal diseases; concurrent or chronic use of anticoagulants/antiplatelets, chronic corticosteroid use) and opioids (depression, anxiety, substance use (SUD) and bipolar disorders, and concurrent benzodiazepines) and estimated four logistic regression models, with the one model including all patient visits and models 2–4 stratifying for previous opioid use. We estimated the population attributable risk for each contraindication. In our model with all patients-visits, patients received an opioid prescription at 4% of visits. The predicted probability (PP) of receiving an opioid was 4% without kidney disease vs. 7% with kidney disease; marginal effect (ME): 3%; 95%CI: 1–4%). For chronic or concurrent anticoagulant/antiplatelet prescriptions, the PPs were 4% vs. 6% (ME: 2%; 95%CI: 1–3%). For concurrent benzodiazepines, the PPs were 4% vs. 11% (ME: 7%, 95%CI: 5–9%) and for SUD, the PPs were 4% vs. 5% (ME: 1%, 95%CI: 0–3%). For the model including patients with previous long-term opioid use, the PPs for concurrent benzodiazepines were 25% vs. 24% (ME: -1%; 95%CI: − 18-16%). The population attributable risk (PAR) for NSAID and opioid contraindications was small. For kidney disease, the PAR was 0.16% (95%CI: 0.08–0.23%), 0.44% (95%CI: 0.30–0.58%) for anticoagulants and antiplatelets, 0.13% for substance use (95%CI: 0.03–0.22%) and 0.20% for concurrent benzodiazepine use (95%CI: 0.13–0.26%). Patients with diagnoses of kidney disease and concurrent use of anticoagulants/antiplatelet medications had a higher probability of receiving an opioid prescription at a primary care visit for low back pain, but these conditions do not explain a large proportion of the opioid prescriptions.
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影响因子：
5
作者：
Hernández-Díaz, S;Rodríguez, LAG
通讯作者：
Rodríguez, LAG
影响因子：
6
作者：
Boscarino, Joseph A.;Rukstalis, Margaret;Stewart, Walter F.
通讯作者：
Stewart, Walter F.
影响因子：
5.5
作者：
Jones, Christopher M.;McAninch, Jana K.
通讯作者：
McAninch, Jana K.
影响因子：
17.7
作者：
Compton, WM;Cottler, LB;Spitznagel, EL
通讯作者：
Spitznagel, EL
影响因子：
158.5
作者：
Ridker, PM;Goldhaber, SZ;Boross-Harmer, S
通讯作者：
Boross-Harmer, S