Mackey Katherine, Anderson Johanna, Bourne Donald, Chen Emilie, Peterson Kim
Evidence Synthesis Program (ESP) Coordinating Center, VA Portland Health Care System, R&D 71 3710 SW U.S. Veterans Hospital Road, Portland, OR, USA.
J Gen Intern Med. 2020 Dec;35(Suppl 3):935-944. doi: 10.1007/s11606-020-06253-8. Epub 2020 Nov 3.
Many clinicians are reevaluating the use of long-term opioid therapy (LTOT) for chronic pain in response to the opioid crisis and calls from organizations including the Centers for Disease Control & Prevention to limit prescribing of high-dose opioids. However, this practice change is occurring largely in the absence of data regarding patient outcomes. A 2017 systematic review found inconclusive evidence on the impact of LTOT dose reduction and discontinuation on pain severity and function, quality of life, withdrawal symptoms, substance abuse, and adverse effects. This rapid systematic review provides an updated evidence synthesis of patient outcomes following LTOT dose reduction including serious harms such as overdose and suicide.
We systematically searched numerous bibliographic databases from January 2017 (the end search date of the 2017 systematic review) through May 2020. One reviewer used prespecified criteria to assess articles for inclusion, evaluate study quality, abstract data, and grade strength of evidence, with a second reviewer checking.
We included 49 studies-1 systematic review, 34 studies included in that systematic review, and 14 new studies. We prioritized evidence synthesis of 19 studies with the most applicability to the Veteran population and outpatient settings. Among these studies, improvements in mean pain scores were common among patients tapering opioids while participating in intensive multimodal pain interventions and mostly unchanged with less intensive or nonspecific co-interventions. Our confidence in these findings is low due to methodological limitations of the studies. Observational data suggests that serious harms such as opioid overdose and suicidal ideation can occur following opioid dose reduction or discontinuation, but the incidence of these harms at the population level is unknown.
The net balance of benefits and harms of LTOT dose reduction for patients with chronic pain is unclear. Clinicians should closely monitor patients during the tapering process given the potential for harm.
鉴于阿片类药物危机以及包括疾病控制与预防中心在内的各组织呼吁限制高剂量阿片类药物的处方，许多临床医生正在重新评估长期阿片类药物治疗（LTOT）用于慢性疼痛的情况。然而，这种做法的改变很大程度上是在缺乏关于患者结局数据的情况下发生的。一项2017年的系统评价发现，关于LTOT剂量减少和停药对疼痛严重程度、功能、生活质量、戒断症状、药物滥用及不良反应影响的证据尚无定论。这项快速系统评价提供了LTOT剂量减少后患者结局的最新证据综合分析，包括过量用药和自杀等严重危害。
我们系统检索了从2017年1月（2017年系统评价的末次检索日期）至2020年5月的众多文献数据库。一名评审员使用预先设定的标准评估纳入的文章、评估研究质量、提取数据并对证据强度进行分级，另一名评审员进行核查。
我们纳入了49项研究——1项系统评价、该系统评价中包含的34项研究以及14项新研究。我们优先对19项对退伍军人人群和门诊环境适用性最强的研究进行证据综合分析。在这些研究中，在参与强化多模式疼痛干预的同时逐渐减少阿片类药物用量的患者中，平均疼痛评分改善较为常见，而在强度较低或非特异性联合干预的情况下大多没有变化。由于研究的方法学局限性，我们对这些发现的信心较低。观察性数据表明，阿片类药物剂量减少或停药后可能发生阿片类药物过量和自杀意念等严重危害，但这些危害在人群层面的发生率尚不清楚。
LTOT剂量减少对慢性疼痛患者的利弊净平衡尚不清楚。鉴于存在潜在危害，临床医生在逐渐减少用药过程中应密切监测患者。
