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期刊来源：BMJ

原文链接：https://doi.org/10.1136/bmj-2023-076509

摘要内容如下：

客观

研究开处方者退出、长期阿片类药物治疗中断和临床结果之间的关系。

设计

准实验差异研究设置：美国医疗保险受益人的20%样本，2011-18。

参与者

接受长期阿片类药物治疗的人，其开处方者停止提供基于诊所的患者护理或退出工作，如退休或死亡（n=48079），以及开处方者未退出工作的人（n=48079）。

主要成果

停止长期阿片类药物治疗、药物过量、精神健康危机、入院或急诊就诊以及死亡。长期阿片类药物治疗被定义为连续四个季度每季度至少60天的阿片类药物，归因于多个阿片类药物处方者。差异分析用于比较接受长期阿片类药物治疗且开处方者离职的患者与接受长期阿片类药物治疗且在开处方者离职前后未失去开处方者的倾向匹配患者。

结果

从退出前一个季度到退出后一个季度，长期阿片类药物治疗的中断从每10000名处方退出患者中的132名增加到229名，而继续处方的患者中的中断从97名增加到100名（调整后差异为1.22个百分点，95%置信区间为1.02至1.42）。在提供者退出后的第一个季度，当停药率最高时，两组患者在自杀企图（调整后的差异为0.05个百分点（95%置信区间0.01至0.09））、阿片类药物或酒精戒断（0.14（0.01至0.27））和入院或急诊就诊（0.04次就诊（0.01至0.06））方面出现短暂但显著的升高。这些差异在一到两个季度后消失。未发现药物过量发生率有显著变化。在处方者退出后的所有四个季度中，精神健康危机（0.39个百分点（95%置信区间0.08至0.69））和阿片类药物或酒精戒断（0.31（0.01 4至0.58））的发生率有所增加，但药物过量（-0.12（-0.41至0.18））的发生率没有变化。

结论

处方医生的流失与长期阿片类药物治疗中断的发生率增加和不良后果（如自杀企图）的短暂增加有关，但与其他后果（如用药过量）无关。考虑到未观察到的混杂因素，长期停止阿片类药物治疗可能与暂时的不良健康影响有关。

英文原文如下：

Abstracts

OBJECTIVE  To examine the association between prescriber workforce exit, long term opioid treatment discontinuation, and clinical outcomes.

DESIGN  Quasi-experimental difference-in-differences study SETTING: 20% sample of US Medicare beneficiaries, 2011-18.

PARTICIPANTS  People receiving long term opioid treatment whose prescriber stopped providing office based patient care or exited the workforce, as in the case of retirement or death (n=48 079), and people whose prescriber did not exit the workforce (n=48 079).

MAIN OUTCOMES  Discontinuation from long term opioid treatment, drug overdose, mental health crises, admissions to hospital or emergency department visits, and death. Long term opioid treatment was defined as at least 60 days of opioids per quarter for four consecutive quarters, attributed to the plurality opioid prescriber. A difference-in-differences analysis was used to compare individuals who received long term opioid treatment and who had a prescriber leave the workforce to propensity-matched patients on long term opioid treatment who did not lose a prescriber, before and after prescriber exit.

RESULTS  Discontinuation of long term opioid treatment increased from 132 to 229 per 10 000 patients who had prescriber exit from the quarter before to the quarter after exit, compared with 97 to 100 for patients who had a continuation of prescriber (adjusted difference 1.22 percentage points, 95% confidence interval 1.02 to 1.42). In the first quarter after provider exit, when discontinuation rates were highest, a transient but significant elevation was noted between the two groups of patients in suicide attempts (adjusted difference 0.05 percentage points (95% confidence interval 0.01 to 0.09)), opioid or alcohol withdrawal (0.14 (0.01 to 0.27)), and admissions to hospital or emergency department visits (0.04 visits (0.01 to 0.06)). These differences receded after one to two quarters. No significant change in rates of overdose was noted. Across all four quarters after prescriber exit, an increase was reported in the rate of mental health crises (0.39 percentage points (95% confidence interval 0.08 to 0.69)) and opioid or alcohol withdrawal (0.31 (0.014 to 0.58)), but no change was seen for drug overdose (-0.12 (-0.41 to 0.18)).

CONCLUSIONS  The loss of a prescriber was associated with increased occurrences of discontinuation of long term opioid treatment and transient increases in adverse outcomes, such as suicide attempts, but not other outcomes, such as overdoses. Long term opioid treatment discontinuation may be associated with a temporary period of adverse health impacts after accounting for unobserved confounding.

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