晚期癌症相关疼痛和阿片类药物滥用或使用障碍患者阿片类药物管理

SCI

18 July 2022

Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder

(JAMA Oncology, IF: 33.006)

• Katie Fitzgerald Jones, Dmitry Khodyakov, Robert Arnold, Hailey Bulls, Emily Dao, Jennifer Kapo, Diane Meier, Judith Paice, Jane Liebschutz, Christine Ritchie, Jessica Merlin

• CORRESPONDENCE TO: jonesafq@bc.edu

IMPORTANCE 重要性

Opioid misuse and opioid use disorder (OUD) are important comorbidities in people with advanced cancer and cancer-related pain, but there is a lack of consensus on treatment.

阿片类药物滥用和阿片类药物使用障碍（OUD）是晚期癌症和癌症相关疼痛患者的重要合并症，但在治疗方面缺乏共识。

OBJECTIVE 目的

To develop consensus among palliative care and addiction specialists on the appropriateness of various opioid management strategies in individuals with advanced cancer-related pain and opioid misuse or OUD.

在姑息治疗专家和成瘾管理专家之间在晚期癌症相关疼痛和阿片类药物滥用或OUD患者中就各种阿片类药物管理策略的适当性达成共识。

DESIGN, SETTING, AND PARTICIPANTS 设计、设置与参与者

For this qualitative study, using ExpertLens, an online platform and methodology for conducting modified Delphi panels, between August and October 2020, we conducted 2 modified Delphi panels to understand the perspectives of palliative and addiction clinicians on 3 common clinical scenarios varying by prognosis (weeks to months vs months to years). Of the 129 invited palliative or addiction medicine specialists, 120 participated in at least 1 round. A total of 84 participated in all 3 rounds.

对于这项定性研究，在2020年8月至10月期间，我们使用在线平台ExpertLens和方法进行了2次改进的Delphi小组，以了解姑息治疗和成瘾管理的临床医生对3种常见临床场景的看法，这些场景因预后而异（数周到数月，数月到数年）。在129名受邀的姑息治疗或成瘾管理医学专家中，120人至少参加了一轮。共有84人参加了所有3轮比赛。

MAIN OUTCOMES AND MEASURES 主要成果和措施

Consensus was investigated for 3 clinical scenarios:(1) a patient with a history of an untreated opioid use disorder, (2) a patient taking more opioid than prescribed, and (3) a patient using nonprescribed benzodiazepines.

对3种临床场景的共识进行了调查：（1）有未经治疗的阿片类药物使用障碍病史的患者，（2）阿片类药物服用量超过处方量的患者，以及（3）使用非处方苯二氮卓类药物的患者。

RESULTS 结果

Participants were mostly women (47 [62%]), White (94 (78 [65%]), and held MD/DO degrees (115 [96%]). For a patient with untreated OUD, regardless of prognosis, It was deemed appropriate to begin treatment with buprenorphine/naloxone and inappropriate to refer to a methadone clinic. Beginning split-dose methadone was deemed appropriate for patients with shorter prognoses and of uncertain appropriateness for those with longer prognoses. Beginning a full opioid agonist was deemed of uncertain appropriateness for those with a short prognosis and inappropriate for those with a longer prognosis. Regardless of prognosis, for a patient with no medical history of OUD taking more opioids than prescribed, it was deemed appropriate to increase monitoring, inappropriate to taper opioids, and of uncertain appropriateness to increase the patient’s opioids or transition to buprenorphine/naloxone. For a patient with a urine drug test positive for non-prescribed benzodiazepines, regardless of prognosis, it was deemed appropriate to increase monitoring, inappropriate to taper opioids and prescribe buprenorphine/naloxone. 

参与者大多为女性（47[62%]）、白人（94（78[65%]）和持有医学博士/博士学位（115[96%]）。对于未经治疗的OUD患者，无论预后如何，均认为开始使用丁丙诺啡/纳洛酮治疗是合适的，而不适合前往美沙酮应用诊所。开始分剂量美沙酮被认为适用于预后较短的患者，对于预后较长的患者，其分剂量美沙酮适用性不确定。对于预后较短的患者，开始使用完全阿片类激动剂的合适性不确定，对于预后较长的患者则不合适。无论预后如何，对于没有服用过量阿片类药物病史的患者，增加监测是合适的，减少阿片类药物的应用是不合适的，增加患者的阿片类药物或过渡到丁丙诺啡/纳洛酮是否合适尚不确定。对于非处方苯二氮卓类药物尿药试验阳性的患者，无论预后如何，均认为应加强监测，而不应减少阿片类药物的使用，并应开丁丙诺啡/纳洛酮。

CONCLUSIONS AND RELEVANCE 结论和相关性

The findings of this qualitative study provide urgently needed consensus-based guidance for clinicians and highlight critical research and policy gaps.

这项定性研究的结果为迫切需要的基于共识指南的临床医生提供了指导，并突出了关键的研究和政策差距。