Department Internal Medicine 1, Klinikum Saarbrücken, Saarbrücken, Germany.
Department of Psychosomatic Medicine and Psychotherapy, Technische Universität München, Munich, Germany.
Eur J Pain. 2021 May;25(5):949-968. doi: 10.1002/ejp.1736. Epub 2021 Mar 2.
Opioid use for chronic non-cancer pain (CNCP) is complex. In the absence of pan-European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC).
The clinical practice recommendations were developed by eight scientific societies and one patient self-help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence-based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case-series, case-control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment.
The key clinical practice recommendations suggest: (a) first optimizing established non-pharmacological treatments and non-opioid analgesics and (b) considering opioid treatment if established non-pharmacological treatments or non-opioid analgesics are not effective and/or not tolerated and/or contraindicated. Evidence- and clinical consensus-based potential indications and contraindications for opioid treatment are presented. Eighteen GCP recommendations give guidance regarding clinical evaluation, as well as opioid treatment assessment, monitoring, continuation and discontinuation.
Opioids remain a treatment option for some selected patients with CNCP under careful surveillance.
In chronic pain, opioids are neither a universal cure nor a universally dangerous weapon. They should only be used for some selected chronic noncancer pain syndromes if established non-pharmacological and pharmacological treatment options have failed in supervised pain patients as part of a comprehensive, multi-modal, multi-disciplinary approach to treatment. In this context alone, opioid therapy can be a useful tool in achieving and maintaining an optimal level of pain control in some patients.
慢性非癌痛（CNCP）患者使用阿片类药物的情况较为复杂。由于缺乏全欧范围内针对这一问题的指导意见，欧洲疼痛联合会（EFIC）委托撰写了这份立场文件。
临床实践建议由 EFIC 协调的 8 个科学协会和 1 个患者自助组织制定。对 MEDLINE 进行了系统的文献检索（截至 2020 年 1 月）。提出了两类指导意见：基于系统评价随机对照试验或观察性研究证据的循证建议和基于间接证据或病例系列、病例对照研究和临床经验的良好临床实践（GCP）声明。应用 GRADE 系统从证据到建议。建议和 GCP 声明由多专业工作组（包括护理、服务用户、医生、物理治疗师和心理学家）制定，并通过多步骤程序正式达成了一套共识建议。临床实践建议由来自北美和欧洲的 5 位外部评审员进行了审查，并向公众征求了意见。
主要临床实践建议包括：（a）首先优化已确立的非药物治疗和非阿片类镇痛药；（b）如果已确立的非药物治疗或非阿片类镇痛药无效和/或不能耐受和/或禁忌使用，则考虑阿片类药物治疗。提出了基于证据和临床共识的阿片类药物治疗的潜在适应证和禁忌证。18 条 GCP 建议为临床评估以及阿片类药物治疗评估、监测、持续和停止提供了指导。
在仔细监测下，阿片类药物仍然是某些慢性非癌痛患者的治疗选择。
在慢性疼痛中，阿片类药物既不是普遍的治愈方法，也不是普遍危险的武器。只有在监督下的疼痛患者中，已确立的非药物和药物治疗方案失败后，且作为综合、多模式、多学科治疗方法的一部分，对于某些选定的慢性非癌痛综合征，才可以使用阿片类药物。在这种情况下，阿片类药物治疗可以成为一些患者实现和维持最佳疼痛控制水平的有用工具。
