Pergolizzi Joseph V, Varrassi Giustino, Paladini Antonella, LeQuang JoAnn
NEMA Research, Inc, Naples, FL, USA.
Paolo Procacci Foundation and World Institute of Pain (WIP), Rome, Italy.
Pain Ther. 2019 Dec;8(2):163-176. doi: 10.1007/s40122-019-00135-6. Epub 2019 Aug 3.
With the rising concerns about long-term opioid use, particularly in patients with chronic noncancer pain, more and more patients are being considered for decreased doses or discontinuation of opioid therapy. This is a challenging clinical situation for both patient and clinician and should be presented in a shared decision-making model so that the patient understands the risks of opioid therapy and how the therapy will be discontinued. The patient should be aware of the long-range plan and its milestones. It is imperative that alternate pain control treatments be made available to the patient early, and that the patient never feels abandoned by the healthcare team. There can be many barriers in shared decision-making and multiple discussions between patient and provider may be required. Opioid use should not be decreased sharply or discontinued abruptly, but should be gradually decremented in a process known as tapering. Tapering should be systematic and planned in advance with the patient knowing the steps. Slow tapers (over months) are more comfortable for the patients but may not always be appropriate. There is guidance for planning the taper and the patient should be closely monitored throughout this process. If withdrawal symptoms occur, they can be managed, for example, with lofexidine. Patients should get full support as they explore new pain control options. For patients who have opioid use disorder, addiction counseling may be appropriate. Navigating opioid discontinuation can be slow work, but optimal results occur when the healthcare team works together and respectfully with the patient.
随着对长期使用阿片类药物的担忧日益增加，尤其是在患有慢性非癌性疼痛的患者中，越来越多的患者被考虑减少阿片类药物治疗的剂量或停药。这对患者和临床医生来说都是具有挑战性的临床情况，应采用共同决策模式，以便患者了解阿片类药物治疗的风险以及如何停药。患者应了解长期计划及其各个阶段。必须尽早为患者提供替代的疼痛控制治疗方法，并且患者绝不能感到被医疗团队抛弃。共同决策可能存在许多障碍，患者和医疗服务提供者之间可能需要进行多次讨论。阿片类药物的使用不应急剧减少或突然停药，而应在一个称为逐渐减量的过程中逐渐减少。逐渐减量应该是系统的且提前计划好的，让患者了解步骤。缓慢减量（持续数月）对患者来说更舒适，但并不总是合适的。有关于计划逐渐减量的指导，在此过程中应对患者进行密切监测。如果出现戒断症状，可以进行处理，例如使用洛非西定。患者在探索新的疼痛控制选择时应获得充分支持。对于患有阿片类药物使用障碍的患者，成瘾咨询可能是合适的。指导阿片类药物停药可能进展缓慢，但当医疗团队与患者共同协作并相互尊重时，会取得最佳效果。
