Ghitza Udi E
U.S. Department of Health and Human Services (HHS), Center for the Clinical Trials Network (CCTN), National Institute on Drug Abuse (NIDA), National Institutes of Health (NIH) , Bethesda, MD , USA.
Front Psychiatry. 2016 May 2;7:80. doi: 10.3389/fpsyt.2016.00080. eCollection 2016.
Over the past two decades, a steeply growing number of persons with chronic non-cancer pain have been using opioid analgesics chronically to treat it, accompanied by a markedly increased prevalence of individuals with opioid-related misuse, opioid use disorders, emergency department visits, hospitalizations, admissions to drug treatment programs, and drug overdose deaths. This opioid misuse and overdose epidemic calls for well-designed randomized-controlled clinical trials into more skillful and appropriate pain management and for developing effective analgesics that have lower abuse liability and are protective against stress induced by chronic non-cancer pain. However, incomplete knowledge regarding effective approaches to treat various types of pain has been worsened by an under-appreciation of overlapping neurobiological mechanisms of stress, stress-induced relapse to opioid use, and chronic non-cancer pain in patients presenting for care for these conditions. This insufficient knowledge base has unfortunately encouraged common prescription of conveniently available opioid pain-relieving drugs with abuse liability, as opposed to treating underlying problems using team-based multidisciplinary, patient-centered, collaborative-care approaches for addressing pain and co-occurring stress and risk for opioid use disorder. This paper reviews recent neurobiological findings regarding overlapping mechanisms of stress-induced relapse to opioid misuse and chronic non-cancer pain, and then discusses these in the context of key outstanding evidence gaps and clinical-treatment research directions that may be pursued to fill these gaps. Such research directions, if conducted through well-designed randomized-controlled trials, may substantively inform clinical practice in general medical settings on how to effectively care for patients presenting with pain-related distress and these common co-occurring conditions.
在过去二十年中，患有慢性非癌性疼痛的人数急剧增加，他们长期使用阿片类镇痛药来治疗疼痛，与此同时，与阿片类药物相关的滥用、阿片类药物使用障碍、急诊就诊、住院、进入药物治疗项目以及药物过量死亡的发生率也显著上升。这种阿片类药物滥用和过量流行的情况，需要精心设计的随机对照临床试验，以实现更巧妙、恰当的疼痛管理，并研发出滥用可能性更低且能抵御慢性非癌性疼痛所致压力的有效镇痛药。然而，对于治疗各类疼痛的有效方法，人们了解并不完整，而对于前来就医的患者，压力、压力诱发的阿片类药物复吸以及慢性非癌性疼痛的重叠神经生物学机制认识不足，这使得情况更加糟糕。不幸的是，这种知识基础的不足助长了常见的做法，即开具容易获得但有滥用风险的阿片类止痛药物，而不是采用以团队为基础、多学科、以患者为中心的协作护理方法来治疗潜在问题，以解决疼痛以及同时出现的压力和阿片类药物使用障碍风险。本文回顾了关于压力诱发阿片类药物滥用复吸和慢性非癌性疼痛重叠机制的近期神经生物学研究结果，然后在关键的突出证据空白以及为填补这些空白可能采取的临床治疗研究方向的背景下进行讨论。如果通过精心设计的随机对照试验来开展此类研究方向，可能会为普通医疗环境中的临床实践提供实质性信息，告知如何有效护理伴有疼痛相关困扰以及这些常见并发疾病的患者。
