American Society of Interventional Pain Physicians, USA.
Pain Physician. 2012 Jul;15(3 Suppl):S67-116.
Part 2 of the guidelines on responsible opioid prescribing provides the following recommendations for initiating and maintaining chronic opioid therapy of 90 days or longer. 1. A) Comprehensive assessment and documentation is recommended before initiating opioid therapy, including documentation of comprehensive history, general medical condition, psychosocial history, psychiatric status, and substance use history. (
good) B) Despite limited evidence for reliability and accuracy, screening for opioid use is recommended, as it will identify opioid abusers and reduce opioid abuse. (
limited) C) Prescription monitoring programs must be implemented, as they provide data on patterns of prescription usage, reduce prescription drug abuse or doctor shopping. (
good to fair) D) Urine drug testing (UDT) must be implemented from initiation along with subsequent adherence monitoring to decrease prescription drug abuse or illicit drug use when patients are in chronic pain management therapy. (
good) 2. A) Establish appropriate physical diagnosis and psychological diagnosis if available prior to initiating opioid therapy. (
good) B) Caution must be exercised in ordering various imaging and other evaluations, interpretation and communication with the patient, to avoid increased fear, activity restriction, requests for increased opioids, and maladaptive behaviors. (
good) C) Stratify patients into one of the 3 risk categories - low, medium, or high risk. D) A pain management consultation, may assist non-pain physicians, if high-dose opioid therapy is utilized. (
fair) 3. Essential to establish medical necessity prior to initiation or maintenance of opioid therapy. (
good) 4. Establish treatment goals of opioid therapy with regard to pain relief and improvement in function. (
good) 5. A) Long-acting opioids in high doses are recommended only in specific circumstances with severe intractable pain that is not amenable to short-acting or moderate doses of long-acting opioids, as there is no significant difference between long-acting and short-acting opioids for their effectiveness or adverse effects. (
fair) B) The relative and absolute contraindications to opioid use in chronic non-cancer pain must be evaluated including respiratory instability, acute psychiatric instability, uncontrolled suicide risk, active or history of alcohol or substance abuse, confirmed allergy to opioid agents, coadministration of drugs capable of inducing life-limiting drug interaction, concomitant use of benzodiazepines, active diversion of controlled substances, and concomitant use of heavy doses of central nervous system depressants. (
fair to limited) 6. A robust agreement which is followed by all parties is essential in initiating and maintaining opioid therapy as such agreements reduce overuse, misuse, abuse, and diversion. (
fair) 7. A) Once medical necessity is established, opioid therapy may be initiated with low doses and short-acting drugs with appropriate monitoring to provide effective relief and avoid side effects. (
fair for short-term effectiveness, limited for long-term effectiveness) B) Up to 40 mg of morphine equivalent is considered as low dose, 41 to 90 mg of morphine equivalent as a moderate dose, and greater than 91 mg of morphine equivalence as high dose. (
fair) C) In reference to long-acting opioids, titration must be carried out with caution and overdose and misuse must be avoided. (
good) 8. A) Methadone is recommended for use in late stages after failure of other opioid therapy and only by clinicians with specific training in the risks and uses. (
limited) B) Monitoring recommendation for methadone prescription is that an electrocardiogram should be obtained prior to initiation, at 30 days and yearly thereafter. (
fair) 9. In order to reduce prescription drug abuse and doctor shopping, adherence monitoring by UDT and PMDPs provide evidence that is essential to the identification of those patients who are non-compliant or abusing prescription drugs or illicit drugs. (
fair) 10. Constipation must be closely monitored and a bowel regimen be initiated as soon as deemed necessary. (
good) 11. Chronic opioid therapy may be continued, with continuous adherence monitoring, in well-selected populations, in conjunction with or after failure of other modalities of treatments with improvement in physical and functional status and minimal adverse effects. (
fair).
The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a "standard of care."
指南第二部分提供了关于起始和维持 90 天或更长时间的慢性阿片类药物治疗的以下建议。1. A）建议在开始阿片类药物治疗之前进行全面评估和记录，包括全面的病史、一般医疗状况、社会心理病史、精神状态和物质使用史的记录。（证据：好）B）尽管对于可靠性和准确性的证据有限，仍建议进行阿片类药物使用筛查，因为它可以识别阿片类药物滥用者并减少阿片类药物滥用。（证据：有限）C）必须实施处方监测计划，因为它们提供了处方使用模式的数据，减少了处方药物滥用或医生购物。（证据：好到公平）D）必须从起始开始实施尿液药物测试（UDT），并随后进行后续的依从性监测，以减少慢性疼痛管理治疗期间处方药物滥用或非法药物使用。（证据：好）2. A）如果在开始阿片类药物治疗之前可以进行适当的身体诊断和心理诊断，则应进行诊断。（证据：好）B）在进行各种影像学和其他评估、解释和与患者沟通时，必须谨慎，以避免增加恐惧、活动受限、要求增加阿片类药物和不良行为。（证据：好）C）将患者分层为低、中或高风险类别之一。D）如果使用高剂量阿片类药物治疗，疼痛管理咨询可能会帮助非疼痛医生。（证据：公平）3. 在开始或维持阿片类药物治疗之前，建立医疗必要性至关重要。（证据：好）4. 确定阿片类药物治疗的疼痛缓解和功能改善目标。（证据：好）5. A）仅在严重难治性疼痛的特定情况下，建议使用高剂量长效阿片类药物，这些疼痛对短效或中等剂量的长效阿片类药物不敏感，因为长效和短效阿片类药物在有效性或不良反应方面没有显著差异。（证据：公平）B）必须评估慢性非癌症疼痛中使用阿片类药物的相对和绝对禁忌症，包括呼吸不稳定、急性精神不稳定、无法控制的自杀风险、活跃或有酒精或物质滥用史、对阿片类药物过敏、同时使用能够诱导生命限制药物相互作用的药物、同时使用苯二氮䓬类药物、主动转移受控物质以及同时使用大剂量中枢神经系统抑制剂。（证据：公平到有限）6. 在起始和维持阿片类药物治疗时，必须达成各方遵守的强有力协议，因为这样的协议可以减少过度使用、滥用、滥用和转移。（证据：公平）7. A）一旦确定了医疗必要性，就可以用低剂量和短效药物开始阿片类药物治疗，并进行适当的监测，以提供有效的缓解并避免副作用。（证据：短期有效性公平，长期有效性有限）B）40 毫克吗啡当量被认为是低剂量，41 至 90 毫克吗啡当量是中等剂量，大于 91 毫克吗啡当量是高剂量。（证据：公平）C）在长效阿片类药物方面，必须谨慎进行滴定，并避免过量和滥用。（证据：好）8. A）建议在其他阿片类药物治疗失败后晚期使用美沙酮，并仅由具有特定风险和用途培训的临床医生使用。（证据：有限）B）美沙酮处方的监测建议是在开始时、第 30 天和此后每年获得心电图。（证据：公平）9. 为了减少处方药物滥用和医生购物，通过 UDT 和 PMDP 进行依从性监测提供了识别不遵守或滥用处方药物或非法药物的患者的必要证据。（证据：公平）10. 必须密切监测便秘，并在需要时尽快开始肠道治疗。（证据：好）11. 在精心选择的人群中，在与其他治疗方式联合或失败后，在身体和功能状态改善且不良反应最小的情况下，可以继续进行慢性阿片类药物治疗，并进行持续的依从性监测。（证据：公平）。
该指南基于最佳可用证据，不构成僵化的治疗建议。由于证据不断变化，本文档并非旨在成为“护理标准”。
