加拿大麦吉尔大学Julio F Fiore Jr团队研究了术后出院开具与不开具阿片类镇痛药物对患者预后的影响。这一研究成果发表在2022年6月18日出版的《柳叶刀》杂志上。

术后过量的阿片类药物处方导致了目前的阿片类药物危机；然而，在手术出院时开阿片类药物的价值仍不确定。该研究旨在评估与无阿片类镇痛处方相比，出院后开具阿片类药物对自我报告的疼痛强度和不良事件的影响程度。

在这项系统回顾和荟萃分析中，研究组在MEDLINE、Embase、Cochrane图书馆、Scopus、AMED、Biosis和CINAHL数据库中检索从1990年1月1日至2021年7月8日的相关文献，纳入多剂量随机对照试验，比较15岁及以上患者接受阿片类镇痛与无阿片类镇痛的影响，这些患者在接受手术后根据死亡率和发病率来定义生理和手术严重度评分（轻微、中度、严重和严重并发症），术后患者均出院。

研究组筛选了文章，提取了数据，并评估了偏倚风险（Cochrane的随机试验偏倚风险工具）。主要结局是出院后第1天的自我报告疼痛强度（标准化为0-10 cm视觉模拟量表）和长达30天的呕吐。还评估了其他时间点的疼痛强度、疼痛干扰、其他不良事件、不满意风险和医疗保健再使用情况。使用推荐分级、评估、发展和评估评分系统进行随机效应荟萃分析和评估证据的确定性。

该研究共包括47项试验（6607名患者）。30项（64%）试验涉及选择性小手术（63%为牙科手术），17项（36%）试验涉及中度手术（47%为骨科手术，29%为普外科手术）。与无阿片类镇痛相比，阿片类药物处方在出院后第一天（加权平均差0.01cm；中度确定性）或其他术后时间点（中度至极低确定性）没有减轻疼痛。阿片类药物处方与呕吐风险增加（相对风险4.50；高度确定）及其他不良事件相关，包括恶心、便秘、头晕和嗜睡（高度至中度确定性）。阿片类药物不影响其他结果。

这项荟萃分析的结果表明，在手术出院时开阿片类药物并不能降低疼痛强度，但会增加不良事件。证据依赖于侧重于轻度和中度选择性手术的试验，这表明临床医生可以考虑在这些手术环境下不开具阿片类镇痛药。数据主要来自低质量的试验，没有一个涉及到有严重和严重并发症手术的患者。鉴于这些局限性，迫切需要提高这一领域的研究质量和范围。

附：英文原文

Title: Opioid versus opioid-free analgesia after surgical discharge: a systematic review and meta-analysis of randomised trials

Author: Julio F Fiore, Charbel El-Kefraoui, Marc-Aurele Chay, Philip Nguyen-Powanda, Uyen Do, Ghadeer Olleik, Fateme Rajabiyazdi, Araz Kouyoumdjian, Alexa Derksen, Tara Landry, Alexandre Amar-Zifkin, Amy Bergeron, Agnihotram V Ramanakumar, Marc Martel, Lawrence Lee, Gabriele Baldini, Liane S Feldman

Issue&Volume: 2022/06/18

Abstract:

Background

Excessive opioid prescribing after surgery has contributed to the current opioid crisis; however, the value of prescribing opioids at surgical discharge remains uncertain. We aimed to estimate the extent to which opioid prescribing after discharge affects self-reported pain intensity and adverse events in comparison with an opioid-free analgesic regimen.

Methods

In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, Scopus, AMED, Biosis, and CINAHL from Jan 1, 1990, until July 8, 2021. We included multidose randomised controlled trials comparing opioid versus opioid-free analgesia in patients aged 15 years or older, discharged after undergoing a surgical procedure according to the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity definition (minor, moderate, major, and major complex). We screened articles, extracted data, and assessed risk of bias (Cochrane's risk-of-bias tool for randomised trials) in duplicate. The primary outcomes of interest were self-reported pain intensity on day 1 after discharge (standardised to 0–10 cm visual analogue scale) and vomiting up to 30 days. Pain intensity at further timepoints, pain interference, other adverse events, risk of dissatisfaction, and health-care reutilisation were also assessed. We did random-effects meta-analyses and appraised evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluations scoring system. The review was registered with PROSPERO (ID CRD42020153050).

Findings

47 trials (n=6607 patients) were included. 30 (64%) trials involved elective minor procedures (63% dental procedures) and 17 (36%) trials involved procedures of moderate extent (47% orthopaedic and 29% general surgery procedures). Compared with opioid-free analgesia, opioid prescribing did not reduce pain on the first day after discharge (weighted mean difference 0·01cm, 95% CI –0·26 to 0·27; moderate certainty) or at other postoperative timepoints (moderate-to-very-low certainty). Opioid prescribing was associated with increased risk of vomiting (relative risk 4·50, 95% CI 1·93 to 10·51; high certainty) and other adverse events, including nausea, constipation, dizziness, and drowsiness (high-to-moderate certainty). Opioids did not affect other outcomes.

Interpretation

Findings from this meta-analysis support that opioid prescribing at surgical discharge does not reduce pain intensity but does increase adverse events. Evidence relied on trials focused on elective surgeries of minor and moderate extent, suggesting that clinicians can consider prescribing opioid-free analgesia in these surgical settings. Data were largely derived from low-quality trials, and none involved patients having major or major-complex procedures. Given these limitations, there is a great need to advance the quality and scope of research in this field.

DOI: 10.1016/S0140-6736(22)00582-7

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00582-7/fulltext