Mortality After Discontinuation of Primary Care-Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study
Mortality After Discontinuation of Primary Care-Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study
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DOI：
10.1007/s11606-019-05301-2
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发表时间：
2019-12-01
影响因子：
5.7
通讯作者：
Merrill, Joseph O.
中科院分区：
文献类型：
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作者：
James, Jocelyn R.;Scott, JoAnna M.;Merrill, Joseph O.
背景 尽管使用慢性阿片类药物治疗 (COT) 治疗疼痛的风险已知，但停止使用 COT 的风险在很大程度上尚不清楚。目的 与继续使用阿片类药物的患者相比，评估停止使用 COT 的患者的死亡率、处方阿片类药物使用情况和初级保健利用率。设计 对截至 2010 年 5 月登记在阿片类药物登记处的慢性疼痛患者进行回顾性队列研究。 参与者 慢性疼痛患者在华盛顿州西雅图城市安全网医院的初级保健诊所的阿片类药物登记处登记。主要成果和措施 从阿片类药物登记中终止是引起关注的问题。预先指定的主要结局包括死亡率、处方和初级保健利用数据以及停药原因。数据收集截至 2015 年 3 月。 主要结果 研究队列由 572 名患者组成，平均年龄为 54.9 +/- 10.1 岁。 344 名患者 (60.1%) 停止使用 COT； 254 名 (73.8%) 停药的患者随后在华盛顿州配了至少一份阿片类药物处方，187 名 (54.4%) 继续到诊所就诊。在研究期间，119名（20.8%）注册患者死亡，其中21名（3.7%）死于明确或可能的用药过量：17名（4.9%）停药患者死于用药过量，而4名（1.75%）保留患者死于用药过量。大多数患者至少有一个由医疗服务提供者发起的终止 COT 的原因。调整年龄和种族后，停药与死亡风险比相关，死亡风险比为 1.35（95% CI，0.92 至 1.98，p = 0.122），过量死亡风险比为 2.94（1.01-8.61，p = 0.049）。结论 在这组接受 COT 治疗慢性疼痛的患者中，死亡率很高。停止使用 COT 并不会降低死亡风险，反而会增加过量死亡的风险。这个高危人群可能需要改进的临床策略，包括多模式疼痛管理和阿片类药物使用障碍的治疗。
Background Despite known risks of using chronic opioid therapy (COT) for pain, the risks of discontinuation of COT are largely uncharacterized. Objective To evaluate mortality, prescription opioid use, and primary care utilization of patients discontinued from COT, compared with patients maintained on opioids. Design Retrospective cohort study of patients with chronic pain enrolled in an opioid registry as of May 2010. Participants Patients with chronic pain enrolled in the opioid registry of a primary care clinic at an urban safety-net hospital in Seattle, WA. Main Outcomes and Measures Discontinuation from the opioid registry was the exposure of interest. Pre-specified main outcomes included mortality, prescription and primary care utilization data, and reasons for discontinuation. Data was collected through March 2015. Key Results The study cohort comprised 572 patients with a mean age of 54.9 +/- 10.1 years. COT was discontinued in 344 patients (60.1%); 254 (73.8%) discontinued patients subsequently filled at least one opioid prescription in Washington State, and 187 (54.4%) continued to visit the clinic. During the study period, 119 (20.8%) registry patients died, and 21 (3.7%) died of definite or possible overdose: 17 (4.9%) discontinued patients died of overdose, whereas 4 (1.75%) retained patients died of overdose. Most patients had at least one provider-initiated reason for COT discontinuation. Discontinuation of COT was associated with a hazard ratio for death of 1.35 (95% CI, 0.92 to 1.98, p = 0.122) and for overdose death of 2.94 (1.01-8.61, p = 0.049), after adjusting for age and race. Conclusions In this cohort of patients prescribed COT for chronic pain, mortality was high. Discontinuation of COT did not reduce risk of death and was associated with increased risk of overdose death. Improved clinical strategies, including multimodal pain management and treatment of opioid use disorder, may be needed for this high-risk group.