Who gets high-dose opioid therapy for chronic non-cancer pain?
Who gets high-dose opioid therapy for chronic non-cancer pain?
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谁接受高剂量阿片类药物治疗慢性非癌性疼痛？
DOI：
10.1016/j.pain.2010.08.036
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发表时间：
2010
期刊：
影响因子：
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通讯作者：
M. Sullivan
中科院分区：
文献类型：
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作者：
M. Sullivan
Morasco等人在本期《疼痛》杂志上提供了一个有趣而重要的窗口，揭示了谁接受大剂量阿片类药物治疗慢性非癌性疼痛的奥秘。作者研究了在太平洋西北地区退伍军人管理局（VA）医院接受护理的退伍军人，他们在数值评定量表上的疼痛强度得分至少为4/10，并且接受了至少连续90天的阿片类药物治疗。由于大多数慢性阿片类药物的使用是间歇性的，本研究的重点是每天使用阿片类药物的少数患者[10]。作者将接受高剂量治疗（每天180毫克吗啡当量或更高）的患者与接受低剂量治疗和不接受阿片类药物治疗的患者进行了比较。正如对西北地区退伍军人的研究所预料的那样，样本主要是男性，白人，中年，超重，患有与退伍军人服务有关的残疾。由于其他研究表明女性更有可能接受慢性阿片类药物治疗，因此本研究中对男性的关注可能会限制其普遍性。作者发现，高剂量组的日剂量是传统剂量组的10倍（324毫克vs 32毫克）。这一惊人的观察结果与我们在商业保险人口中史无前例的阿片类药物使用浓度一致。事实上，2005年，5%的患者接受了为患有常见慢性非癌症疼痛的患者开出的70%的阿片类药物。没有其他药物显示出如此扭曲的剂量模式。像Morasco等人一样，我们发现这个群体的特点是多重疼痛主诉，以及精神健康和物质使用障碍。在不同的样本中，我们的研究发现，在这些相同的群体中，处方阿片类药物的使用率和剂量更高[2,3,6,16]。毫不奇怪，Morasco等人发现高剂量组更有可能接受长效阿片类药物和多种阿片类药物。他们也更有可能同时接受苯二氮卓类药物治疗。不幸的是，大剂量阿片类药物与镇静剂联合使用会增加过量bbb的风险。Morasco等人注意到，他们发现“没有统计学上可靠的大剂量阿片类药物使用预测因子，因为显著优势比都小于2.0。”这表明，慢性大剂量阿片类药物使用没有单一的原因，而是由各种类型的危险因素共同引起的。在人口统计学因素中，只有黑人种族与低剂量阿片类药物使用率显著相关。正如作者所指出的那样，这与其他医学专业的种族歧视发现以及少数民族人群中阿片类药物可用性下降的研究结果是一致的。正如多项研究表明的那样
Morasco et al.[11] in this issue of Pain provide an interesting and important window into the mystery of who receives high-dose opioid therapy for chronic non-cancer pain. The authors studied veterans receiving care in Veteran’s Administration (VA) hospitals in the Pacific Northwest who received a score of at least 4/10 in pain intensity on a numerical rating scale and who received at least 90 consecutive days of opioid therapy. Since most chronic opioid use is intermittent, this study focuses on the minority of patients that use opioids on a daily basis [15]. The authors compared those receiving high-dose therapy (180 mg morphine equivalent per day or greater) to those receiving lower doses and those receiving no opioids. As might be expected for a study of veterans in the Northwest, the sample was predominantly male, white, middle-aged, overweight and had a VA service-connected disability. Because other studies suggest that females are more likely to receive chronic opioid therapy, the focus on males in this study may limit its generalizability.The authors found that the high-dose group received daily doses ten-fold greater than the traditional dose group (324 mg vs 32 mg). This striking observation is consistent with our finding of an unprecedented concentration of opioid use in a commercially insured population [7]. Indeed, 5% of patients received 70% of the opioids prescribed to patients with common chronic non-cancer pain conditions in 2005. No other medication shows such skewed dosing patterns. Like Morasco et al., we found this group to be characterized by multiple pain complaints as well as mental health and substance use disorders. Across diverse samples, our research has found higher rates of prescription opioid use and higher doses in these same groups [2, 3, 6, 16]. Not surprisingly, Morasco et al. found that the high-dose group was more likely to receive longacting opioids and multiple opioid types. They were also more likely to receive concurrent benzodiazepine therapy. Unfortunately, use of high-dose opioids in combination with sedatives increases the risk of overdose [13]. Morasco et al.[11] note that they identified ‘‘no statistically robust predictors of high-dose opioid use, as the significant odds ratios were all less than 2.0.” This suggests that there is no single cause of high-dose chronic opioid use, but that it arises from a combination of risk factors of various types. Among demographic factors, only black race was significantly associated with lower rates of high-dose opioid use. As the authors point out, this is consistent with the findings of racial discrimination in other medical specialties and with studies that show decreased availability of opioids in minority populations. As multiple studies have shown