Veazie Stephanie, Mackey Katherine, Peterson Kim, Bourne Donald
Evidence Synthesis Program (ESP) Coordinating Center, VA Portland Health Care System, Portland, OR, USA.
J Gen Intern Med. 2020 Dec;35(Suppl 3):945-953. doi: 10.1007/s11606-020-06256-5. Epub 2020 Nov 3.
Managing acute pain in patients with opioid use disorder (OUD) on medication (methadone, buprenorphine, or naltrexone) can be complicated by patients' higher baseline pain sensitivity and need for higher opioid doses to achieve pain relief. This review aims to evaluate the benefits and harms of acute pain management strategies for patients taking OUD medications and whether strategies vary by OUD medication type or cause of acute pain.
We systematically searched multiple bibliographic sources until April 2020. One reviewer used prespecified criteria to assess articles for inclusion, extract data, rate study quality, and grade our confidence in the body of evidence, all with second reviewer checking.
We identified 12 observational studies-3 with control groups and 9 without. Two of the studies with control groups suggest that continuing buprenorphine and methadone in OUD patients after surgery may reduce the need for additional opioids and that ineffective pain management in patients taking methadone can result in disengagement in care. A third controlled study found that patients taking OUD medications may need higher doses of additional opioids for pain control, but provided insufficient detail to apply results to clinic practice. The only case study examining naltrexone reported that postoperative pain was managed using tramadol. We have low confidence in these findings as no studies directly addressed our question by comparing pain management strategies and few provided adequate descriptions of the dosage, timing, or rationale for clinical decisions.
We lack rigorous evidence on acute pain management in patients taking medication for OUD; however, evidence supports the practice of continuing methadone or buprenorphine for most patients during acute pain episodes. Well-described, prospective studies of adjuvant pain management strategies when OUD medications are continued would add to the existing literature base. Studies on nonopioid treatments are also needed for patients taking naltrexone.
PROSPERO; CRD42019132924.
对于正在使用药物（美沙酮、丁丙诺啡或纳曲酮）治疗阿片类物质使用障碍（OUD）的患者，急性疼痛管理可能会因患者较高的基线疼痛敏感性以及需要更高剂量的阿片类药物来缓解疼痛而变得复杂。本综述旨在评估针对正在服用OUD药物的患者的急性疼痛管理策略的益处和危害，以及这些策略是否因OUD药物类型或急性疼痛原因而异。
我们系统检索了多个文献来源，直至2020年4月。一名评审员使用预先设定的标准评估文章是否纳入，提取数据，评估研究质量，并对证据的可信度进行分级，所有这些均由第二名评审员进行核对。
我们确定了12项观察性研究，其中3项有对照组，9项没有。两项有对照组的研究表明，OUD患者术后继续使用丁丙诺啡和美沙酮可能会减少对额外阿片类药物的需求，并且服用美沙酮的患者疼痛管理无效可能会导致脱离护理。第三项对照研究发现，服用OUD药物的患者可能需要更高剂量的额外阿片类药物来控制疼痛，但提供的细节不足，无法将结果应用于临床实践。唯一一项研究纳曲酮的病例报告称，术后疼痛使用曲马多进行管理。我们对这些发现的信心较低，因为没有研究通过比较疼痛管理策略直接解决我们的问题，而且很少有研究对临床决策的剂量、时机或基本原理进行充分描述。
我们缺乏关于正在服用OUD药物的患者急性疼痛管理的严格证据；然而，证据支持在大多数患者急性疼痛发作期间继续使用美沙酮或丁丙诺啡的做法。当继续使用OUD药物时，对辅助疼痛管理策略进行详细描述的前瞻性研究将增加现有文献基础。对于服用纳曲酮的患者，也需要进行非阿片类治疗的研究。
PROSPERO；CRD42019132924。
