一项针对接受阿片类药物治疗的慢性非癌性疼痛患者且伴有高负担精神疾病共病的初级保健多学科疾病管理项目。
A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity.
作者信息
Chelminski Paul R, Ives Timothy J, Felix Katherine M, Prakken Steven D, Miller Thomas M, Perhac J Stephen, Malone Robert M, Bryant Mary E, DeWalt Darren A, Pignone Michael P
机构信息
Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA.
出版信息
BMC Health Serv Res. 2005 Jan 13;5(1):3. doi: 10.1186/1472-6963-5-3.
BACKGROUND
Chronic non-cancer pain is a common problem that is often accompanied by psychiatric comorbidity and disability. The effectiveness of a multi-disciplinary pain management program was tested in a 3 month before and after trial.
METHODS
Providers in an academic general medicine clinic referred patients with chronic non-cancer pain for participation in a program that combined the skills of internists, clinical pharmacists, and a psychiatrist. Patients were either receiving opioids or being considered for opioid therapy. The intervention consisted of structured clinical assessments, monthly follow-up, pain contracts, medication titration, and psychiatric consultation. Pain, mood, and function were assessed at baseline and 3 months using the Brief Pain Inventory (BPI), the Center for Epidemiological Studies-Depression Scale scale (CESD) and the Pain Disability Index (PDI). Patients were monitored for substance misuse.
RESULTS
Eighty-five patients were enrolled. Mean age was 51 years, 60% were male, 78% were Caucasian, and 93% were receiving opioids. Baseline average pain was 6.5 on an 11 point scale. The average CESD score was 24.0, and the mean PDI score was 47.0. Sixty-three patients (73%) completed 3 month follow-up. Fifteen withdrew from the program after identification of substance misuse. Among those completing 3 month follow-up, the average pain score improved to 5.5 (p = 0.003). The mean PDI score improved to 39.3 (p < 0.001). Mean CESD score was reduced to 18.0 (p < 0.001), and the proportion of depressed patients fell from 79% to 54% (p = 0.003). Substance misuse was identified in 27 patients (32%).
CONCLUSIONS
A primary care disease management program improved pain, depression, and disability scores over three months in a cohort of opioid-treated patients with chronic non-cancer pain. Substance misuse and depression were common, and many patients who had substance misuse identified left the program when they were no longer prescribed opioids. Effective care of patients with chronic pain should include rigorous assessment and treatment of these comorbid disorders and intensive efforts to insure follow up.
背景
慢性非癌性疼痛是一个常见问题，常伴有精神疾病合并症和功能障碍。在一项为期3个月的前后对照试验中，对一个多学科疼痛管理项目的有效性进行了测试。
方法
一家学术性普通内科诊所的医护人员将患有慢性非癌性疼痛的患者转介至一个整合了内科医生、临床药剂师和精神科医生技能的项目。患者当时要么正在接受阿片类药物治疗，要么正在考虑接受阿片类药物治疗。干预措施包括结构化临床评估、每月随访、疼痛契约、药物滴定和精神科会诊。使用简明疼痛量表（BPI）、流行病学研究中心抑郁量表（CESD）和疼痛功能障碍指数（PDI）在基线和3个月时评估疼痛、情绪和功能。对患者的药物滥用情况进行监测。
结果
85名患者入组。平均年龄为51岁，60%为男性，78%为白种人，93%正在接受阿片类药物治疗。基线时平均疼痛程度在11分制量表上为6.5分。平均CESD评分为24.0，平均PDI评分为47.0。63名患者（73%）完成了3个月的随访。15名患者在被发现有药物滥用情况后退出了该项目。在完成3个月随访的患者中，平均疼痛评分改善至5.5（p = 0.003）。平均PDI评分改善至39.3（p < 0.001）。平均CESD评分降至18.0（p < 0.001），抑郁患者比例从79%降至54%（p = 0.003）。27名患者（32%）被发现有药物滥用情况。
结论
在一组接受阿片类药物治疗的慢性非癌性疼痛患者中，一个初级保健疾病管理项目在3个月内改善了疼痛、抑郁和功能障碍评分。药物滥用和抑郁情况很常见，许多被发现有药物滥用情况的患者在不再开具阿片类药物处方后离开了该项目。对慢性疼痛患者的有效护理应包括对这些合并症进行严格评估和治疗，并大力确保随访。
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