多准则决策分析比较慢性神经性疼痛的药物治疗,包括大麻素和基于大麻的医疗产品。
A Multicriteria Decision Analysis Comparing Pharmacotherapy for Chronic Neuropathic Pain, Including Cannabinoids and Cannabis-Based Medical Products.
机构信息
Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, United Kingdom.
Department of Management, Emeritus Professor of Decision Science, London School of Economics and Political Science, London, United Kingdom.
出版信息
Cannabis Cannabinoid Res. 2022 Aug;7(4):482-500. doi: 10.1089/can.2020.0129. Epub 2021 Mar 17.
Pharmacological management of chronic neuropathic pain (CNP) still represents a major clinical challenge. Collective harnessing of both the scientific evidence base and clinical experience (of clinicians and patients) can play a key role in informing treatment pathways and contribute to the debate on specific treatments (e.g., cannabinoids). A group of expert clinicians (pain specialists and psychiatrists), scientists, and patient representatives convened to assess the relative benefit-safety balance of 12 pharmacological treatments, including orally administered cannabinoids/cannabis-based medicinal products, for the treatment of CNP in adults. A decision conference provided the process of creating a multicriteria decision analysis (MCDA) model, in which the group collectively scored the drugs on 17 effect criteria relevant to benefits and safety and then weighted the criteria for their clinical relevance. Cannabis-based medicinal products consisting of tetrahydrocannabinol/cannabidiol (THC/CBD), in a 1:1 ratio, achieved the highest overall score, 79 (out of 100), followed by CBD dominant at 75, then THC dominant at 72. Duloxetine and the gabapentinoids scored in the 60s, amitriptyline, tramadol, and ibuprofen in the 50s, methadone and oxycodone in the 40s, and morphine and fentanyl in the 30s. Sensitivity analyses showed that even if the pain reduction and quality-of-life scores for THC/CBD and THC are halved, their benefit-safety balances remain better than those of the noncannabinoid drugs. The benefit-safety profiles for cannabinoids were higher than for other commonly used medications for CNP largely because they contribute more to quality of life and have a more favorable side effect profile. The results also reflect the shortcomings of alternative pharmacological treatments with respect to safety and mitigation of neuropathic pain symptoms. Further high-quality clinical trials and systematic comprehensive capture of clinical experience with cannabinoids is warranted. These results demonstrate once again the complexity and multimodal mechanisms underlying the clinical experience and impact of chronic pain.
慢性神经性疼痛(CNP)的药物治疗仍然是一个主要的临床挑战。综合利用科学证据基础和临床经验(临床医生和患者的经验)可以在为治疗途径提供信息方面发挥关键作用,并有助于就特定治疗方法(例如大麻素)展开辩论。一组专家临床医生(疼痛专家和精神科医生)、科学家和患者代表聚集在一起,评估 12 种药物治疗方法(包括口服大麻素/基于大麻的药物)治疗成人 CNP 的相对益处-安全性平衡。决策会议提供了创建多准则决策分析(MCDA)模型的过程,在该模型中,专家组对与益处和安全性相关的 17 个药物作用标准进行了集体评分,然后根据其临床相关性对标准进行加权。四氢大麻酚/大麻二酚(THC/CBD)比例为 1:1 的基于大麻的药物产品获得了最高的总体评分 79(满分 100),其次是 CBD 主导的药物 75 分,然后是 THC 主导的药物 72 分。度洛西汀和加巴喷丁类药物的评分在 60 分左右,阿米替林、曲马多和布洛芬在 50 分左右,美沙酮和羟考酮在 40 分左右,吗啡和芬太尼在 30 分左右。敏感性分析表明,即使 THC/CBD 和 THC 的止痛和生活质量评分减半,其获益-安全性平衡仍优于非大麻素药物。大麻素的获益-安全性特征高于其他常用于 CNP 的药物,主要是因为它们对生活质量的贡献更大,并且具有更有利的副作用特征。结果还反映了替代药物治疗在安全性和减轻神经性疼痛症状方面的不足。需要进一步进行高质量的临床试验和系统地全面了解大麻素的临床经验。这些结果再次证明了慢性疼痛的临床经验和影响背后的复杂性和多模式机制。