Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia.
BMJ. 2022 Apr 4;377:e066375. doi: 10.1136/bmj-2021-066375.
To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events.
Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions.
Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted.
Original research in English. Case reports and cross sectional studies were excluded.
Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation).
Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05).
Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed.
PROSPERO CRD42020140943.
综述慢性非癌性疼痛患者长期阿片类药物治疗的干预措施，评估其在减少剂量和停药、疼痛、功能、生活质量、戒断症状、物质使用和不良事件方面的疗效。
对随机对照试验和非随机研究的系统评价和荟萃分析。
从建库到 2021 年 7 月，检索了 Medline、Embase、PsycINFO、CINAHL 和 Cochrane 图书馆。还检索了参考文献列表和先前的综述，并联系了专家。
原始研究为英文。病例报告和横断面研究被排除在外。
两名作者独立选择研究、提取数据，并使用 Cochrane 随机和非随机研究偏倚工具（RoB 2 和 ROBINS-I）。作者将干预措施分为五类（疼痛自我管理、补充和替代医学、药理学和生物医学设备和干预、阿片类药物替代治疗和减药方法），使用随机效应荟萃分析模型估计汇总效应，并使用 GRADE（推荐、评估、发展和评估分级）评估证据的确定性。
符合纳入标准的 166 项研究中，有 130 项（78%）被认为具有关键偏倚风险，因此被排除在证据综合之外。在纳入的 36 项研究中，很少有可比的治疗组，且样本量通常较小。因此，超过 90%（41/44）的 GRADE 结局的证据确定性为低或极低，包括所有非阿片类药物患者结局。尽管存在这些局限性，但有中等确定性的证据表明，支持医生遵循指南的干预措施增加了患者停止阿片类药物治疗的可能性（调整后的优势比 1.5，95%置信区间 1.0 至 2.1），并且这些医生干预措施以及疼痛自我管理计划比对照组减少了阿片类药物剂量（干预 对照组，平均差异-6.8 毫克（标准误差 1.6）每日口服吗啡当量，P<0.001；疼痛计划 对照组，-14.31 毫克每日口服吗啡当量，95%置信区间-21.57 至-7.05）。
关于慢性疼痛患者长期阿片类药物治疗减少的证据仍然受到研究方法不佳的限制。特别令人关注的是缺乏可能危害的证据。迫切需要制定和报告减少阿片类药物治疗的研究的商定标准。
PROSPERO CRD42020140943。
