新的护理途径成功减少了良性恶性泌尿科患者的阿片类药物使用率

In 2018, Pennsylvania providers wrote 49.9 opioid prescriptions for every 100 persons, slightly lower than the average U.S. rate of 51.4 prescriptions. Yet opioids still accounted for a record 2,866 fatalities (roughly 65% of all drug overdose deaths) statewide.

这se troubling trends inspired two urologists fromPenn State Health Milton S. Hershey Medical Center修订护理通路泌尿道的癌症tients, the other for symptomatic nephrolithiasis (kidney stone) patients—with encouraging results. The Milton S. Hershey Medical Center has decreased patient dependence on morphine milligram equivalents (MME) medications by 86% over the past 18 months.

杰伊·拉曼博士inspiration to change the pathways began when he reviewed a study of U.S. military veterans that explored risk factors for opioid misuse among cancer patients. The study followed 106,732 cancer survivors and found an overall incidence of persistent posttreatment opioid use of 8.3%. Opioid-naïve patients who received opioids during the diagnostic and treatment period reported a 6.2% rate of persistent post-treatment opioid use compared with 1.5% of those who did not receive a prescription. “It was eye-opening to see that, while doctors were curing their cancer, they were leaving them with a lifelong dependence in some cases,” Raman said.

Raman pulled together a Hershey Medical Center team—including urologic surgeons, nurse practitioners, nurses, neurologists, anesthesiologists and oncologists—to redefine the pathway for cancer patients. Simultaneously,Dr. Necole Streeperworked with a team to redefine the pathway for symptomatic nephrolithiasis patients. “Because kidney stones are often recurrent, we see some patients over many years,” Streeper said. “Many of these patients see different physicians during an acute episode and therefore run significant risk of being overprescribed opioids.”

To reduce that risk, Streeper’s team first conducted an Institutional Review Board-approved six-month retrospective review (May – October 2017), comparing data from the hospital’s electronic medical record (EMR) and the Pennsylvania Prescription Drug Monitoring Program (PDMP) database, which collects information on all controlled substances prescribed statewide.

“We found that, despite the integration of PDMP into our EMR, in 20% of cases, we prescribed opioids for kidney stone patients, not knowing they had received opioid prescriptions from other providers,” Streeper said. “This emphasized that there is still work to be done to reduce opioid overprescribing.”

新途径始于提供者和患者之间的坦率对话。提供者对患者当前药物进行彻底审查，并检查EMR和PDMP数据库，以帮助确定患者是否有先前的阿片类药物处方。然后，提供者设定了期望，让患者知道，尽管提供者将尽最大努力通过非阿片类药物来控制疼痛，但手术后或通过肾结石时，他们可能会感到不适。

Hershey Medical Center提供商现在使用一种强调非麻醉性止痛药的新算法，而不是像以前那样为所有患者提供麻醉性止痛药物。术后外科患者当然会接受对乙酰氨基酚，加巴喷丁，IV酮洛拉克和布洛芬。如果在李克特量表上疼痛持续超过5至7或8至10的疼痛水平，则开始使用较弱的阿片类药物（例如50 mg或100 mg的曲马多）。仅在绝对必要的情况下才能使用较强的阿片类药物，例如羟考酮，dilaudid或吗啡。

出院后，患者开处方对乙酰氨基酚，加巴喷丁和布洛芬。曲马多和羟考酮仅在术后订购时才提供少量（每粒10丸）的家庭使用。拉曼说：“除非我们知道他们正在适当地用非阿片类药物治疗，并且仍然有明显的突破性疼痛，否则我们不一定会为患者开药。”

Providers tracked the number of MMEs Hershey Medical Center patients were filling 30 days post-surgery to measure the new protocols’ efficacy. In the first month, the average patient was receiving more than 100 MMEs 30 days after surgery. At month 18, that number reduced to 14 MMEs at 30 days.

拉曼说：“数据清楚地表明，我们正处于阿片类药物流行中。”“我们鼓励从业者研究自己的实践，并考虑他们可以做出的改变以减少阿片类药物处方。即使是小的修改也会产生很大的不同。”

参考：

1. 美国国家药物滥用研究所 -https://www.drugabuse.gov/drug-topics/opioids/opioid-summaries-by-state/pennsylvania-opioid-involved-deaths-related-harms#:~:text=In%20Pennsylvania%2C%2065%25%20of%20drug,did%20not%20meet%20inclusion%20criteria.- 访问：2020年4月3日
2. 预测癌症幸存者中持续的阿片类药物使用，滥用和毒性 -https://academic.oup.com/jnci/article/112/7/720/5618684- 访问：2019年11月20日