Argoff Charles E, Viscusi Eugene R
Department of Neurology, Albany Medical College, Albany, New York, USA.
Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
Am J Gastroenterol Suppl. 2014 Sep 10;2(1):3-8. doi: 10.1038/ajgsup.2014.3.
Chronic noncancer pain is common and consequential, affecting ∼100 million people in the United States alone and costing, when direct and indirect costs are combined, in excess of $635 billion. For certain individuals, opioids may be an effective option for the management of chronic pain; however, a series of critical decisions must be made before prescribing opioids to ensure that their potential benefits and possible risks are appropriately and realistically addressed. A thorough history, physical examination, and appropriate testing, including an assessment of risk for substance abuse, misuse, or addiction, should be conducted in patients who are being considered for opioid therapy. Proactively developing a treatment plan that matches the needs and expectations of the patient, while minimizing the potential for substance abuse, is central to the success of pain management. Current standard of care suggests that for most patients, a trial of nonopioid therapies should generally be tried first. There is no single opioid of choice that universally provides the best outcomes for all patients; thus, it is critical for the health-care practitioner to become familiar with the available subclasses, formulations, and modes of administration, and base the treatment plan on clinical experience with the drug, prior patient experience, the availability of the formulation, and cost and coverage. Pain is a dynamic phenomenon in that its characteristics and response to treatment evolve over time, as does the patient's general health state. Both positive and negative changes over time may necessitate a change in medication. Opioids can be prescribed safely and effectively, and when used with appropriate attention to individual patient characteristics may have a positive impact on pain and function. When contemplating initiation of opioid analgesics, clinicians would do well to make it clear to their patient that they will be prescribed on a trial basis with a clear exit strategy for discontinuing such treatment if there is no clear benefit including lack of analgesia, insurmountable adverse effects, and/or frank misuse or abuse of the prescribed drug.
慢性非癌性疼痛很常见且后果严重，仅在美国就影响约1亿人，直接和间接成本加起来超过6350亿美元。对于某些个体而言，阿片类药物可能是管理慢性疼痛的有效选择；然而，在开具阿片类药物之前必须做出一系列关键决策，以确保其潜在益处和可能风险得到妥善且现实的处理。对于考虑接受阿片类药物治疗的患者，应进行全面的病史询问、体格检查以及适当的检测，包括对药物滥用、误用或成瘾风险的评估。积极制定符合患者需求和期望的治疗计划，同时尽量减少药物滥用的可能性，是疼痛管理成功的关键。当前的护理标准表明，对于大多数患者，通常应首先尝试非阿片类治疗。没有一种阿片类药物能普遍为所有患者带来最佳疗效；因此，医护人员熟悉现有的亚类、剂型和给药方式，并根据药物的临床经验、患者既往经验、剂型可得性以及成本和医保覆盖范围来制定治疗计划至关重要。疼痛是一种动态现象，其特征和对治疗的反应会随时间演变，患者的总体健康状况也是如此。随着时间推移，无论是积极还是消极的变化都可能需要调整用药。阿片类药物可以安全有效地开具，并且在适当关注个体患者特征的情况下使用，可能会对疼痛和功能产生积极影响。在考虑开始使用阿片类镇痛药时，临床医生最好向患者明确表示，将在试验基础上开具此类药物，并制定明确的退出策略，即如果没有明显益处，包括镇痛效果不佳、无法克服的不良反应和/或明显误用或滥用所开药物，则停止此类治疗。
