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阿片肽用于非癌性慢性疼痛的核心推荐

已有 2038 次阅读 2017-5-15 07:40 |个人分类:临床指南和病例解析|系统分类:观点评述

阿片肽用于非癌性慢性疼痛的核心推荐

Abstract

Recommendation 1: When considering therapy for patients with chronic noncancer pain, we recommend optimization of nonopioid pharmacotherapy and nonpharmacologic therapy, rather than a trial of opioids (strong recommendation) (www.magicapp.org/goto/guideline/8nyb0E/rec/ LqqP6L).
Recommendation 2: For patients with chronic noncancer pain, without current or past substance use disorder and without other active psychiatric disorders, who have persistent problematic pain despite optimized nonopioid therapy, we suggest adding a trial of opioids rather than continued therapy without opioids (weak recommendation) (www.magicapp.org/goto/guideline/8nyb0E/ rec/j91boj).
• By a trial of opioids, we mean initiation, titration and monitoring of response, with discontinuation of opioids if important improvement in pain or function is not achieved. The studies that identified substance use disorder as a risk factor for adverse outcomes characterized the conditions as alcohol abuse and dependence, and narcotic abuse and dependence, and sometimes referred to International Classification of Diseases, 9th revision (ICD-9) diagnoses. The mental illnesses identified in studies as risk factors for adverse outcomes were generally anxiety and depression, including ICD-9 definitions, as well as “psychiatric diagnosis,” “mood disorder” and post-traumatic stress disorder.
Recommendation 3: For patients with chronic noncancer pain with an active substance use disorder, we recommend against the use of opioids (strong recommendation) (www.magicapp.org/goto/guideline/8nyb0E/rec/jxZ7Dn).
• Clinicians should facilitate treatment of the underlying substance use disorders, if not yet addressed. The studies that identified substance use disorder as a risk factor for adverse outcomes characterized the conditions as alcohol abuse and dependence, narcotic abuse and dependence, and sometimes referred to ICD-9 diagnoses.
Recommendation 4: For patients with chronic noncancer pain with an active psychiatric disorder whose nonopioid therapy has been optimized, and who have persistent problematic pain, we suggest stabilizing the psychiatric disorder before a trial of opioids is considered (weak recommendation) (www.magicapp.org/goto/guideline/8nyb0E/rec/jzPK1n).
Recommendation 5: For patients with chronic noncancer pain with a history of substance use disorder, whose nonopioid therapy has been optimized, and who have persistent problematic pain, we suggest continuing nonopioid therapy rather than a trial of opioids (weak recommendation) (www.magicapp.org/goto/guideline/8nyb0E/rec/j79BGn).
• The studies that identified a history of substance use disorder as a risk factor for adverse outcomes characterized the conditions as alcohol abuse and dependence, and narcotic abuse and dependence, and sometimes referred to ICD-9 diagnoses.
Recommendation 6: For patients with chronic noncancer pain who are beginning opioid therapy, we recommend restricting the prescribed dose to less than 90 mg morphine equivalents daily, rather than having no upper limit or a higher limit on dosing (strong recommendation) (www.magicapp.org/goto/guideline/8nyb0E/ rec/jmJ0VL).
• Some patients may gain important benefit at a dose of more than 90 mg morphine equivalents daily. Referral to a colleague for a second opinion regarding the possibility of increasing the dose to more than 90 mg morphine equivalents daily may therefore be warranted in some individuals.
Recommendation 7: For patients with chronic noncancer pain who are beginning opioid therapy, we suggest restricting the prescribed dose to less than 50 mg morphine equivalents daily (weak recommendation) (www.magicapp.org/goto/guideline/8nyb0E/rec/noAgMj).
• The weak recommendation to restrict the prescribed dose to less than 50 mg morphine equivalents daily acknowledges that there are likely to be some patients who would be ready to accept the increased risks associated with a dose higher than 50 mg in order to potentially achieve improved pain control.
Recommendation 8: For patients with chronic noncancer pain who are currently using opioids, and have persistent problematic pain and/or problematic adverse effects, we suggest rotation to other opioids rather than keeping the opioid the same (weak recommendation) (www. magicapp.org/goto/guideline/8nyb0E/rec/ nJM4bL).
• Rotation in such patients may be done in parallel with, and as a way of facilitating, dose reduction.
Recommendation 9: For patients with chronic noncancer pain who are currently using 90 mg morphine equivalents of opioids per day or more, we suggest tapering opioids to the lowest effective dose, potentially including discontinuation, rather than making no change in opioid therapy (weak recommendation) (www.magicapp.org/goto/guideline/8nyb0E/rec/L4BypE).
• Some patients may have a substantial increase in pain or decrease in function that persists for more than one month after a small dose reduction; tapering may be paused or potentially abandoned in such patients.
Recommendation 10: For patients with chronic noncancer pain who are using opioids and experiencing serious challenges in tapering, we recommend a formal multidisciplinary program (strong recommendation) (www.magicapp.org/goto/guideline/8nyb0E/rec/ERX6WL).
• In recognition of the cost of formal multidisciplinary opioid reduction programs and their current limited availability/capacity, an alternative is a coordinated multidisciplinary collaboration that includes several health professionals whom physicians can access according to their availability (possibilities include, but are not limited to, a primary care physician, a nurse, a pharmacist, a physical therapist, a chiropractor, a kinesiologist, an occupational therapist, an addiction medicine specialist, a psychiatrist and a psychologist).