CHAllenges in Managing and Preventing Pain Clinical Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania.
Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania.
JAMA Netw Open. 2021 Dec 1;4(12):e2139968. doi: 10.1001/jamanetworkopen.2021.39968.
Opioid use disorder (OUD) is an important comorbidity in individuals with advanced cancer, in whom pain is common. Full-agonist opioid medications are the cornerstone of cancer pain management, but the existing literature does not address how to manage cancer pain in patients with OUD.
To conduct an expert panel to develop consensus on the appropriateness of management of cancer pain in individuals with co-occurring advanced cancer and OUD.
A 3-round modified Delphi process was completed from August to October 2020 with 2 cases: patient with advanced cancer, pain, and OUD treated with buprenorphine-naloxone or methadone. Participants rated management strategies in round 1, discussed results in round 2, and provided final responses in round 3. ExpertLens, an online approach to conducting modified Delphi panels, was used. Participants were experts in palliative care, addiction, or both, recruited by email from palliative care and addiction-focused professional groups, lists from prior studies, and snowball sampling. Data analysis was performed from November 2020 to July 2021.
Of 120 experts (median age, 40-49 years), most were White (78 participants [94%]), female (74 participants [62%]), and held MD or DO degrees (115 participants [96%]); 84 (70%) participated in all rounds. For a patient with OUD taking buprenorphine-naloxone, it was deemed appropriate to continue buprenorphine-naloxone with thrice-daily dosing. Continuing buprenorphine-naloxone and adding a full-agonist opioid was deemed to be appropriate for patients with a prognosis of weeks to months and of uncertain appropriateness for patients with a prognosis of months to years. For a patient with OUD taking methadone dispensed at a methadone clinic, it was deemed appropriate to take over prescribing and dose twice or thrice daily. Continuing methadone daily while adding another full-agonist opioid was deemed appropriate for patients with a prognosis of weeks to months and of uncertain appropriateness for those with a prognosis of months to years.
The findings of this qualitative study provide urgently needed, consensus-based guidance for clinicians and highlight critical research and policy gaps needed to facilitate implementation.
阿片类药物使用障碍（OUD）是晚期癌症患者的重要合并症，此类患者常伴有疼痛。完全激动型阿片类药物是癌症疼痛管理的基石，但现有文献并未探讨如何管理伴有 OUD 的癌症疼痛患者。
进行专家小组讨论，以达成关于同时患有晚期癌症和 OUD 的个体的癌症疼痛管理的共识。
采用三轮改良 Delphi 法进行研究，时间为 2020 年 8 月至 10 月，共纳入 2 个病例：接受丁丙诺啡-纳洛酮或美沙酮治疗的晚期癌症疼痛合并 OUD 的患者。参与者在第一轮中对管理策略进行评分，在第二轮中讨论结果，并在第三轮中给出最终回复。使用 ExpertLens 这一在线改良 Delphi 小组研究方法。参与者为姑息治疗、成瘾或二者兼具的专家，通过姑息治疗和成瘾专业团体的电子邮件、先前研究的名单以及滚雪球抽样进行招募。数据分析于 2020 年 11 月至 2021 年 7 月进行。
在 120 名专家（中位年龄，40-49 岁）中，大多数为白人（78 名[94%]）、女性（74 名[62%]），并拥有医学博士或骨科博士学位（115 名[96%]）；84 名（70%）参加了所有 3 轮研究。对于接受丁丙诺啡-纳洛酮治疗的 OUD 患者，建议继续使用丁丙诺啡-纳洛酮，每日 3 次给药。对于预计生存期为数周至数月的患者，继续使用丁丙诺啡-纳洛酮并添加完全激动型阿片类药物被认为是合适的，而对于预计生存期为数月至数年的患者，这种方法的适用性则存在争议。对于接受美沙酮诊所配给美沙酮的 OUD 患者，接管处方并将剂量增加至每日 2 次或 3 次被认为是合适的。对于预计生存期为数周至数月的患者，继续每日使用美沙酮并添加另一种完全激动型阿片类药物是合适的，而对于预计生存期为数月至数年的患者，这种方法的适用性存在争议。
这项定性研究的结果为临床医生提供了急需的、基于共识的指导，并突出了实施所需的关键研究和政策差距。
