National Institute on Drug Abuse, Rockville, Maryland 20852; email:
Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut 06510; email:
Annu Rev Med. 2018 Jan 29;69:451-465. doi: 10.1146/annurev-med-011817-044739. Epub 2017 Oct 13.
The prescribing of opioid analgesics for pain management-particularly for management of chronic noncancer pain (CNCP)-has increased more than fourfold in the United States since the mid-1990s. Yet there is mounting evidence that opioids have only limited effectiveness in the management of CNCP, and the increased availability of prescribed opioids has contributed to upsurges in opioid-related addiction cases and overdose deaths. These concerns have led to critical revisiting and modification of prior pain management practices (e.g., guidelines from the Centers for Disease Control and Prevention), but the much-needed changes in clinical practice will be facilitated by a better understanding of the pharmacology and behavioral effects of opioids that underlie both their therapeutic effects (analgesia) and their adverse effects (addiction and overdose). With these goals in mind, this review first presents an overview of the contemporary problems associated with opioid management of CNCP and the related public health issues of opioid diversion, overdose, and addiction. It then discusses the pharmacology underlying the therapeutic and main adverse effects of opioids and its implications for clinical management of CNCP within the framework of recent clinical guidelines for prescribing opioids in the management of CNCP.
自 20 世纪 90 年代中期以来，美国用于疼痛管理（特别是慢性非癌症疼痛 (CNCP) 管理）的阿片类镇痛药的处方量增加了四倍多。然而，越来越多的证据表明，阿片类药物在 CNCP 的治疗中仅具有有限的效果，而且处方阿片类药物的可获得性增加导致了阿片类药物相关成瘾和过量死亡病例的激增。这些担忧促使人们对先前的疼痛管理实践（例如，疾病控制与预防中心的指南）进行了批判性的重新审视和修改，但临床实践急需改变，这需要更好地了解阿片类药物的药理学和行为效应，这些效应既包括它们的治疗效果（镇痛），也包括它们的不良影响（成瘾和过量）。基于这些目标，本综述首先概述了与 CNCP 的阿片类药物管理相关的当代问题以及与阿片类药物转移、过量和成瘾相关的公共卫生问题。然后，它讨论了阿片类药物的药理学，这些药理学是阿片类药物的治疗和主要不良反应的基础，以及它对 CNCP 临床管理的影响，这是最近关于 CNCP 管理中开具阿片类药物处方的临床指南的框架内进行的。
