Timko Christine, Lor Mai Chee, Kertesz Stefan, Kroenke Kurt, Macia Kathryn, Nevedal Andrea, Hoggatt Katherine J
Center for Innovation to Implementation, Department of Veterans Affairs Health Care System, Palo Alto, California, USA.
Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA.
Pain Pract. 2025 Jan;25(1):e13440. doi: 10.1111/papr.13440. Epub 2024 Nov 18.
Although long-term opioid therapy (LTOT) for chronic pain has declined, it remains common in the U.S. Providers do not have clinical practice guidelines for vulnerable LTOT patients, in whom both LTOT continuation and tapering to discontinuation pose risks of harm and in whom opioid use disorder (OUD) is absent.
To begin to meet the gap in guidelines, the study used a multiple case study approach. Five cases were constructed to systematically vary key elements of LTOT continuation and discontinuation harms among patients reporting LTOT's lack of efficacy (experience of pain and poor function). For each, treatment approaches were collected from 28 opioid safety experts identified through their participation in a national policy panel (19 were physicians) and analyzed using template analysis.
For patients receiving LTOT with harms of continuation and discontinuation, experts recommended attempting a slow taper (even with a prior unsuccessful taper, possibly with adjuvant medications to manage withdrawal) and not maintaining opioid therapy. Experts considered switching to buprenorphine, especially if the patient had aberrant behaviors. They also considered adding non-opioid pain therapies (especially re-trying such therapies if they were unhelpful before) and engaging in shared decisionmaking, although with little consensus on specific approaches. Some experts would address co-occurring conditions related to patient safety (alcohol use, mental health symptoms, opioid side effects). Few experts referenced assessing or addressing OUD or overdose risk. In quantitative data, 36% of experts agreed LTOT is beneficial, 36% agreed most LTOT patients should be discontinued, and 57% agreed patients experience harm from tapering and from discontinuation.
Evidence is needed to build on and test these experts' recommendations to attempt tapering and add non-opioid pain therapies for patients reporting harms of continued LTOT who may experience harms from tapering. Such evidence informs the development of clinical practice guidelines that provide comprehensive protocols to support the safety and functioning of this group of patients.
尽管用于慢性疼痛的长期阿片类药物治疗（LTOT）有所减少，但在美国仍然很常见。医疗服务提供者没有针对脆弱的LTOT患者的临床实践指南，对于这些患者，继续使用LTOT和逐渐减量至停药都存在伤害风险，且不存在阿片类药物使用障碍（OUD）。
为了开始填补指南中的空白，该研究采用了多案例研究方法。构建了五个案例，以系统地改变报告LTOT无效（疼痛体验和功能不佳）的患者中LTOT继续使用和停药伤害的关键要素。对于每个案例，从通过参与国家政策小组确定的28位阿片类药物安全专家（19位是医生）那里收集治疗方法，并使用模板分析进行分析。
对于接受LTOT且存在继续使用和停药伤害的患者，专家建议尝试缓慢减量（即使之前减量未成功，可能使用辅助药物来管理戒断反应），而不是维持阿片类药物治疗。专家考虑改用丁丙诺啡，特别是如果患者有异常行为。他们还考虑增加非阿片类疼痛治疗方法（特别是如果之前无效则重新尝试此类治疗方法）并进行共同决策，尽管在具体方法上几乎没有共识。一些专家会处理与患者安全相关的共病情况（饮酒、心理健康症状、阿片类药物副作用）。很少有专家提及评估或处理OUD或过量风险。在定量数据中，36%的专家同意LTOT是有益的，36%的专家同意大多数LTOT患者应该停药，57%的专家同意患者在减量和停药时会受到伤害。
需要证据来完善和检验这些专家的建议，即对于报告继续使用LTOT有伤害且减量可能也会受到伤害的患者，尝试减量并增加非阿片类疼痛治疗方法。此类证据为临床实践指南的制定提供依据，这些指南提供全面的方案以支持这组患者的安全和功能。
