| 摘要: | 研究目的：利用全民健康保險資料庫，以回溯性世代研究法描述台灣慢性下背痛病人止痛藥物用藥型態，並分析與用藥選擇、用藥轉換時間長短與特殊處置有相關的因子。
研究方法：本研究利用國家衛生研究院提供之全民健康保險2005年百萬人承保抽樣歸人檔。納入2007到2011年間18到64歲的下背痛病人，定義慢性疼痛病人為第一次診斷後3到12月仍有兩次以上診斷（總共三次以上）。排除癌症、懷孕、脊椎相關感染、脊椎骨折及一年前有診斷出下背痛的病人。依照臨床療效與指引的定義將止痛藥物分成三個階層：(1) NSAIDs/acetaminophen (2) Tramadol (3)鴉片類止痛劑。
研究結果：78%的慢性下背痛病人在研究期間有使用止痛藥物，大多數的病人年齡為43到54歲、在骨科就診、被診斷為「其他背部疾患」。初次用藥選擇使用NSAIDs/acetaminophen者有98%其餘2%為tramadol與鴉片類止痛劑。大多數的病人短期（1到4週）使用鴉片類止痛劑，只有2%的人持續使用4個月。結果發現，和初次用藥選擇較高階層止痛劑有關的因素包括病患年齡較大、在骨科或神經外科就診或在較高醫院層級就醫、有消化道潰瘍或腎臟方面共病。和藥物升階轉換時間較長有關的因素包括有女性、年齡較大以及有做非藥物治療的處置。至於與X光檢查有關的因子有年齡較大、女性、在較高層級醫院就醫以及使用較後線的止痛藥物。約有33%有使用止痛藥物的病患有做非藥物治療處置（物理治療、復健、針灸、推拿等等），大部分使用升階藥物的病人都有做非藥物治療。
結論：在台灣，醫師開立後線止痛藥物相對較保守。不同科別醫師與不同醫療層級方面開立處方模式與處置習慣不同，病人年齡與性別也是和用藥型態不同有相關的因子，醫師在用藥上面也會因為病人的特殊共病而選擇不同階層藥物。Tramadol比其他鴉片類止痛劑更受歡迎，雖然其副作用少與療效良好使之成為方便的用藥，醫療人員還是須注意其成癮的風險。
Objective: Using the information of National Health Insurance Research Database in Taiwan to conduct a retrospective cohort study in chronic low back pain (CLBP) patients. The purpose of this study is 1) to describe the prescription pattern of analgesics, and 2) to identify factors associated with the analgesics use, length of analgesics stepwise approach and special procedures.
Method: Systemic sampling cohort database of 1,000,000 insurers from National Health Insurance Research Data (NHIRD). Individuals who were 18-64 years old and diagnosed with LBP were identified during the enrollment period, January 1 ,2007 to December 31, 2010. To define the patients with chronic LBP, the included patients should also have had at least two diagnoses between 3-12 month (the third to twelfth) from the initial diagnosis (3 or more diagnosis in total). Patients who have cancer, pregnant, spinal related infection, spinal fracture or previously diagnosed LBP were excluded. According to current guideline and clinical effect of the medication, we categorized analgesics into 3 groups: (1) NSAIDs/acetaminophen (2) Tramadol, and (3) Narcotics.
Results: This study found that 78% of chronic low back pain patients had used analgesics during the enrollment period. Patients in this study were mostly at 43-54 years old, visit orthopedics and diagnosed with “other and unspecified disorders of back.” Most of the initial choices for analgesics were NSAIDs/acetaminophen (98%), only 2% use tramadol and narcotics. Most of the patients used narcotics for short period (4-12 weeks), only 2% continuously use for 4 months. We found that factors that are related to the initial choice of higher level analgesics including higher age, people who visited orthopedic clinics and neurosurgery and visited the hospital that as higher level. Patients with comorbidity such as peptic ulcer disease, renal related disease tend to avoid using NSAIDs/acetaminophen. Factors that are related to longer time of analgesics stepping up approach are people who were female, older and had done nonpharmacological therapy. As for the factors that are related to X-ray procedure are older and female patients, who use higher level analgesics at the first visit, in higher hospital level. 33% patients who used analgesics had done nonpharmacological therapy (physical therapy, spinal manipulation, acupuncture, rehabilitation…), most of the patients who switched to higher level analgesics had done nonpharmacological therapy.
Conclusion: This study showed that the use of analgesics in CLBP patients is more conservative in Taiwan. More specialized physicians tend to have more active use on procedures and medications. Further pain management education on health care providers and on patients may improve the pain management. Compare to narcotics, tramadol is a more commonly used drug. Although it has less side effects and good effectiveness, health care providers should still be aware of its risks of addiction. |
