诊断使用阿片类药物治疗慢性疼痛的患者中的处方阿片类药物使用障碍。
Diagnosing Prescription Opioid Use Disorder in Patients Using Prescribed Opioids for Chronic Pain.
机构信息
Department of Psychiatry, Columbia University Medical Center (Hasin, Shmulewitz, Aharonovich, Scodes, Wall) and New York State Psychiatric Institute (Hasin, Shmulewitz, Stohl, Greenstein, Aharonovich, Scodes, Wall), New York; Epidemiology, Pfizer, Inc., New York (Petronis); Kaiser Permanente Washington Health Research Institute, Seattle (Von Korff); Department of Anesthesiology, Rutgers University, Newark, N.J. (Datta); Department of Anesthesiology, Columbia University Medical Center, New York (Sonty, Weinberger); Department of Psychiatry, New York University, New York (Ross); Cornell University Medical College, New York (Inturrisi).
出版信息
Am J Psychiatry. 2022 Oct;179(10):715-725. doi: 10.1176/appi.ajp.21070721. Epub 2022 Jun 15.
OBJECTIVE
The diagnostic criteria for opioid use disorder, originally developed for heroin, did not anticipate the surge in prescription opioid use and the resulting complexities in diagnosing prescription opioid use disorder (POUD), including differentiation of pain relief (therapeutic intent) from more common drug use motives, such as to get high or to cope with negative affect. The authors examined the validity of the Psychiatric Research Interview for Substance and Mental Disorders, DSM-5 opioid version, an instrument designed to make this differentiation.
METHODS
Patients (N=606) from pain clinics and inpatient substance treatment who ever received a ≥30-day opioid prescription for chronic pain were evaluated for DSM-5 POUD (i.e., withdrawal and tolerance were not considered positive if patients used opioids only as prescribed, per DSM-5 guidelines) and pain-adjusted POUD (behavioral/subjective criteria were not considered positive if pain relief [therapeutic intent] was the sole motive). Bivariate correlated-outcome regression models indicated associations of 10 validators with DSM-5 and pain-adjusted POUD measures, using mean ratios for dimensional measures and odds ratios for binary measures.
RESULTS
The prevalences of DSM-5 and pain-adjusted POUD, respectively, were 44.4% and 30.4% at the ≥2-criteria threshold and 29.5% and 25.3% at the ≥4-criteria threshold. Pain adjustment had little effect on prevalence among substance treatment patients but resulted in substantially lower prevalence among pain treatment patients. All validators had significantly stronger associations with pain-adjusted than with DSM-5 dimensional POUD measures (ratios of mean ratios, 1.22-2.31). For most validators, pain-adjusted binary POUD had larger odds ratios than DSM-5 measures.
CONCLUSIONS
Adapting POUD measures for pain relief (therapeutic intent) improved validity. Studies should investigate the clinical utility of differentiating between therapeutic and nontherapeutic intent in evaluating POUD diagnostic criteria.
目的
最初为海洛因开发的阿片类药物使用障碍诊断标准并没有预见到处方类阿片药物使用的激增，以及由此导致的诊断处方类阿片药物使用障碍（POUD）的复杂性，包括区分缓解疼痛（治疗目的）与更常见的药物使用动机，如获得快感或应对负面情绪。作者研究了精神疾病研究访谈：物质和精神障碍，DSM-5 阿片类药物版本的有效性，该工具旨在进行这种区分。
方法
来自疼痛诊所和住院物质治疗的患者（N=606），他们曾因慢性疼痛接受过≥30 天的阿片类药物处方，根据 DSM-5 POUD（即，如果患者仅按规定使用阿片类药物，根据 DSM-5 指南，不考虑戒断和耐受为阳性）和疼痛调整后的 POUD（如果缓解疼痛[治疗目的]是唯一动机，则不考虑行为/主观标准为阳性）进行评估。双变量相关结果回归模型表明，10 个效标与 DSM-5 和疼痛调整后的 POUD 测量值之间存在关联，对于维度测量值使用均值比，对于二分测量值使用优势比。
结果
分别在≥2 项标准和≥4 项标准的阈值下，DSM-5 和疼痛调整后的 POUD 的患病率分别为 44.4%和 30.4%和 29.5%和 25.3%。疼痛调整对物质治疗患者的患病率影响不大，但对疼痛治疗患者的患病率影响较大。所有效标与疼痛调整后的 POUD 维度测量值的相关性均显著强于 DSM-5 测量值（均值比的比值为 1.22-2.31）。对于大多数效标，疼痛调整后的二分 POUD 的优势比大于 DSM-5 测量值。
结论
为缓解疼痛（治疗目的）调整 POUD 测量值可提高其有效性。研究应调查区分治疗性和非治疗性意图在评估 POUD 诊断标准中的临床实用性。
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