Background

Severe headache, a hallmark of aneurysmal subarachnoid hemorrhage (aSAH), affects up to 90% of patients during hospitalization. Opioids remain the guideline recommended mainstay of acute therapy despite their significant side effects and potential for tolerance and addiction. We evaluated time trends in opioid prescriptions, hypothesizing a decline with increasing recognition of the opioid crisis.

Methods

We performed a retrospective review of patients with aSAH admitted to a single tertiary care center between 2012 and 2019 and included patients with Hunt-Hess-Grade ≤ 3 who were able to verbalize pain scores. Collected variables included mean and maximum daily headache scores, aneurysm treatment modality, and daily analgesic medication doses.

Results

Of 340 patients with aSAH, 114 (86 from 2012–2016 and 28 from 2017–2019) were included. Of the included patients, 86/114 (75.4%) were female. Patients in the 2012–2016 had a median age of 55 compared to 63 in the 2017–2019 group (P = 0.02). Otherwise, there was no significant difference in demographic data including time in hospital, treatment option utilized, or aneurysm characteristics. Maximal daily headache score ranged from 6 to 8 for 2012–2016 and 5 to 8 for 2017–2019 cohorts. Average oral morphine equivalents (in mg) administered during hospitalization were similar between groups (2012–2016: 251 ± 345 95% CI [178,323]; 2017–2019: 207 ± 237 95% CI [119,295]; P = 0.319). When prescribed, doses of opioids provided at discharge were less in the more recent group (2012–2016: 84.4 ± 78.9 95% CI [57.5, 111]; 2017–2019: 38.1 ± 20.2 95% CI [33.7, 42.5]; P = 0.004)

Conclusion

Despite recognition of important drawbacks of opioid use for headache control, and efforts to reduce opioid use during hospitalization, we found that utilization during hospitalization for SAH did not decrease over time. Maximal headache scores remained similar in the studied time periods, indicative of insufficient pain relief. This points out a pressing need to further investigate alternative opioid and narcotic sparing strategies for patients with SAH.

中文翻译：

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动脉瘤性蛛网膜下腔出血后阿片类药物和镇痛药的使用随时间的变化

背景

严重的头痛是动脉瘤性蛛网膜下腔出血 (aSAH) 的一个标志，在住院期间影响多达 90% 的患者。尽管阿片类药物具有显着的副作用和耐受性和成瘾性，但仍是指南推荐的急性治疗的主要支柱。我们评估了阿片类药物处方的时间趋势，假设随着人们对阿片类药物危机的认识增加，这种趋势会下降。

方法

我们对 2012 年至 2019 年间在一家三级医疗中心收治的 aSAH 患者进行了回顾性研究，其中包括 Hunt-Hess-Grade  ≤  3级且能够说出疼痛评分的患者。收集的变量包括平均和最大每日头痛评分、动脉瘤治疗方式和每日镇痛药物剂量。

结果

在 340 名 aSAH 患者中，纳入了 114 名（2012-2016 年为 86 名，2017-2019 年为 28 名）。在纳入的患者中，86/114 (75.4%) 为女性。2012-2016 年患者的中位年龄为 55 岁，而 2017-2019 年组为 63 岁（P  =  0.02）。否则，包括住院时间、使用的治疗方案或动脉瘤特征在内的人口统计学数据没有显着差异。2012-2016 年的最大每日头痛评分范围为 6 至 8，2017-2019 年的队列为 5 至 8。住院期间给药的平均口服吗啡当量（以 mg 为单位）在组间相似（2012-2016：251  ±  345 95% CI [178,323]；2017-2019：207  ±  237 95% CI [119,295]；P  = 0.319）。在开出处方时，较新组在出院时提供的阿片类药物剂量较少（2012-2016：84.4  ±  78.9 95% CI [57.5, 111]；2017-2019：38.1  ±  20.2 95% CI [33.7]；P  42.5）=  0.004)

结论

尽管认识到使用阿片类药物控制头痛的重要缺点，并努力减少住院期间阿片类药物的使用，但我们发现 SAH 住院期间的使用并没有随着时间的推移而减少。在研究的时间段内，最大头痛评分保持相似，表明疼痛缓解不足。这表明迫切需要进一步研究 SAH 患者的替代阿片类药物和麻醉剂备用策略。