Trescot Andrea M, Helm Standiford, Hansen Hans, Benyamin Ramsin, Glaser Scott E, Adlaka Rajive, Patel Samir, Manchikanti Laxmaiah
American Society of Interventional Pain Physicians, Paducah, KY 42001, USA.
Pain Physician. 2008 Mar;11(2 Suppl):S5-S62.
Opioid abuse has continued to increase at an alarming rate since our last opioid guidelines were published in 2005. Available evidence suggests a continued wide variance in the use of opioids, as documented by different medical specialties, medical boards, advocacy groups, and the Drug Enforcement Administration.
The objectives of opioid guidelines by the American Society of Interventional Pain Physicians (ASIPP) are to provide guidance for the use of opioids for the treatment of chronic non-cancer pain, to bring consistency in opioid philosophy among the many diverse groups involved, to improve the treatment of chronic non-cancer pain, and to reduce the incidence of abuse and drug diversion.
A broadly based policy committee of recognized experts in the field evaluated the available literature regarding opioid use in managing chronic non-cancer pain. This resulted in the formulation of the review and update of the guidelines published in 2006, a series of potential evidence linkages representing conclusions, followed by statements regarding the relationships between clinical interventions and outcomes.
The elements of the guideline preparation process included literature searches, literature synthesis, consensus evaluation, open forum presentations, formal endorsement by the Board of Directors of the American Society of Interventional Pain Physicians, and peer review. Based on the criteria of the U.S. Preventive Services Task Force, the quality of evidence was designated as Level I, II, and III, with 3 subcategories in Level II, with Level I described as strong and Level III as indeterminate. The recommendations were provided from 1A to 2C, varying from strong recommendation with high quality evidence to weak recommendation with low-quality or very low-quality evidence.
After an extensive review and analysis of the literature, which included systematic reviews and all of the available literature, the evidence for the effectiveness of long-term opioids in reducing pain and improving functional status for 6 months or longer is variable. The evidence for transdermal fentanyl and sustained-release morphine is Level II-2, whereas for oxycodone the level of evidence is II-3, and the evidence for hydrocodone and methadone is Level III. There is also significant evidence of misuse and abuse of opioids. The recommendation is 2A - weak recommendation, high-quality evidence: with benefits closely balanced with risks and burdens; with evidence derived from RCTs without important limitations or overwhelming evidence from observational studies, with the implication that with a weak recommendation, best action may differ depending on circumstances or patients' or societal values.
Opioids are commonly prescribed for chronic non-cancer pain and may be effective for short-term pain relief. However, long-term effectiveness of 6 months or longer is variable with evidence ranging from moderate for transdermal fentanyl and sustained-release morphine with a Level II-2, to limited for oxycodone with a Level II-3, and indeterminate for hydrocodone and methadone with a Level III. These guidelines included the evaluation of the evidence for the use of opioids in the management of chronic non-cancer pain and the recommendations for that management. These guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Because of the changing body of evidence, this document is not intended to be a "standard of care."
自我们上次于2005年发布阿片类药物指南以来，阿片类药物滥用情况持续以惊人的速度增加。现有证据表明，不同医学专科、医学委员会、倡导团体以及美国缉毒局记录显示，阿片类药物的使用仍存在很大差异。
美国介入性疼痛医师协会（ASIPP）制定阿片类药物指南的目标是，为使用阿片类药物治疗慢性非癌性疼痛提供指导，使众多不同相关团体在阿片类药物理念上保持一致，改善慢性非癌性疼痛的治疗，并减少滥用和药物转移的发生率。
一个由该领域公认专家组成的广泛政策委员会评估了有关阿片类药物用于管理慢性非癌性疼痛的现有文献。这导致了对2006年发布的指南进行审查和更新，形成了一系列代表结论的潜在证据联系，随后是关于临床干预与结果之间关系的声明。
指南制定过程的要素包括文献检索、文献综合、共识评估、公开论坛展示、美国介入性疼痛医师协会董事会的正式认可以及同行评审。根据美国预防服务工作组的标准，证据质量被指定为I级、II级和III级，II级有3个子类别，I级被描述为强证据，III级为不确定证据。建议从1A到2C不等，从高质量证据的强烈建议到低质量或极低质量证据的弱建议。
在对包括系统评价和所有现有文献在内的文献进行广泛审查和分析后，长期使用阿片类药物在减轻疼痛和改善功能状态6个月或更长时间的有效性证据参差不齐。透皮芬太尼和缓释吗啡的证据为II - 2级，而羟考酮的证据级别为II - 3级，氢可酮和美沙酮的证据为III级。也有大量阿片类药物滥用和误用的证据。建议为2A - 弱建议，高质量证据：益处与风险和负担密切平衡；证据来自无重要局限性的随机对照试验或来自观察性研究的压倒性证据，这意味着由于是弱建议，最佳行动可能因情况或患者或社会价值观而异。
阿片类药物常用于慢性非癌性疼痛的处方，可能对短期疼痛缓解有效。然而，6个月或更长时间的长期有效性参差不齐，证据从中度（透皮芬太尼和缓释吗啡为II - 2级）到有限（羟考酮为II - 3级），氢可酮和美沙酮为III级则不确定。这些指南包括对阿片类药物用于管理慢性非癌性疼痛的证据评估以及该管理的建议。这些指南基于现有最佳证据，并不构成僵化的治疗建议。由于证据不断变化，本文件无意成为“护理标准”。
