经典高分文献阅读· 柳叶刀社论反思慢性疼痛 （慢性疼痛系列开篇语）​Rethinking chronic pain

 

 

经典高分文献阅读·

柳叶刀社论反思慢性疼痛

（慢性疼痛系列开篇语）

Rethinking chronic pain

 

by Riozhou

The Lancet Article

May 29, 2021: 397 (10289), P2023

https://doi.org/10.1016/S0140-6736(21)01194-6

To live with chronic pain is to live with daily challenges around simple tasks that others take for granted. It often means being disbelieved, stigmatised for not getting better, or judged as not coping. It might mean living with poor mental health and self-esteem, absenteeism from school or work, the breakdown of relationships, and socioeconomic disadvantage. For society, the costs are staggering: low back pain is the leading cause of years lost to disability and chronic pain costs billions of dollars through health system expenditures, productivity losses, reduced quality of life, and informal care.

活在慢性疼痛中，就是每天面对别人认为理所当然的简单任务的挑战。这通常意味着被怀疑，因为没有好转而受到耻辱，或者被认为没有应对。这可能意味着精神健康和自尊心差，缺课或缺勤，人际关系破裂，社会经济处于不利地位。对社会来说，代价是惊人的：腰痛是导致残疾多年的主要原因，慢性疼痛通过医疗系统支出、生产力损失、生活质量下降和非正规护理花费了数十亿美元。

The Lancet Series on chronic pain debunks a common misconception of chronic pain as an indicator of ongoing injury, requiring suspension of activity. Instead, chronic pain is often a product of abnormal neural signalling, with biopsychosocial dimensions requiring a multimodal treatment approach. But chronic pain is complex and treatment can be fraught, as concerns about UK guidelines show. Many clinicians and patients lack an understanding of treatment options; they might rely on medication alone. Use of costly neuromodulation techniques is also rising, despite a limited evidence base, as synthesised in the Series. Over-reliance on drugs or devices may be spurred on by aggressive industry marketing, lack of access to multidisciplinary services, such as physiotherapy or psychology, and perverse financial incentives for shorter consultations, drug prescribing, and invasive interventions. In low-income and middle-income countries (LMICs), limited access to any opioids, fear of opioids, and cultural beliefs about pain are further barriers.

《柳叶刀》关于慢性疼痛的系列文章揭露了一种常见的误解，即慢性疼痛是持续性损伤的指标，需要暂停活动。相反，慢性疼痛通常是神经信号异常的产物，生物心理社会层面需要多模式治疗方法。但慢性疼痛是复杂的，治疗可能是令人担忧的，正如对英国指南的担忧所显示的那样。许多临床医生和病人缺乏对治疗方案的了解；他们可能仅仅依靠药物治疗。尽管证据基础有限，昂贵的神经调节技术的使用也在增加，正如本系列文章综合的那样。过度依赖药物或器械可能是由积极的行业营销、缺乏获得多学科服务（如物理治疗或心理治疗）的机会，以及对缩短咨询时间、开药方和侵入性干预措施的不当经济刺激。在低收入和中等收入国家（LMIC），获得任何阿片类药物的机会有限、对阿片类药物的恐惧以及对疼痛的文化信仰是进一步的障碍。

The opioid crisis has prompted clinical and regulatory attempts to curb all opioid prescribing, leaving patients feeling angry, abandoned, and further stigmatised. The right balance needs to be struck. For some people (eg, those with cancer pain), opioids might be essential; for others, opioid deprescribing might be appropriate. But either path should be embedded in a multimodal treatment plan, with appropriate safeguards and support, and treatment for dependence if needed.

阿片类药物危机促使临床和监管部门试图遏制所有阿片类药物的处方，让患者感到愤怒、被遗弃，并进一步受到羞辱。需要找到正确的平衡。对于一些人（如癌症疼痛患者），阿片类药物可能是必不可少的；对其他人来说，阿片类药物的抑制可能是合适的。但这两种方法都应纳入多模式治疗计划，并提供适当的保障和支持，必要时还应进行依赖性治疗。

Thinking on chronic pain needs to be reset. For clinicians, a strong therapeutic alliance is critical to help patients understand their pain, shift expectations, and set realistic, individualised goals that prioritise function and quality of life, rather than complete pain relief. Shared decision making can empower people to manage their pain, with more nuanced discussion of therapeutic options and the risk–benefit ratio. Patients need reassurance that they will be believed, respected, and supported, and not blamed if a treatment does not work. Language is a powerful tool to enable and encourage. The Series discusses a new pain category—nociplastic pain—exemplified by conditions, such as fibromyalgia, that lack biomarkers. Naming a condition enables management and research to be refined, as well as validating the experiences of patients hitherto dismissed by clinicians.

对慢性疼痛的思考需要重新开始。对于临床医生来说，一个强大的治疗联盟对于帮助患者理解他们的疼痛、改变期望、设定现实的、个性化的目标至关重要，这些目标优先考虑功能和生活质量，而不是完全缓解疼痛。通过更细致地讨论治疗方案和风险-效益比，共同决策可以使人们有能力管理他们的痛苦。如果治疗无效，患者需要得到信任、尊重和支持，而不是受到指责。语言是一种强有力的工具，可以帮助和鼓励。该系列讨论了一个新的疼痛类别伤害可塑性疼痛（nociplastic pain），例如缺乏生物标志物的纤维肌痛。命名一种状况可以使管理和研究更加完善，同时也可以验证迄今为止被临床医生错过的病人的经历。

Care for chronic pain should be grounded in the community, not by default (due to lengthy waiting lists for pain clinics, or an absence of clinics in LMICs), but by design, provided by a broad base of well trained, multidisciplinary health workers, with pain clinics to support more complex cases. The Essential Pain Management course, for example, has proven useful in over 60 countries. Financial incentives for quick fixes must be removed and longer consults and high-value care rewarded.

慢性疼痛的护理应以社区为基础，而不是默认的（由于疼痛诊所的等待名单很长，或者LMICs没有诊所），而是通过设计，由训练有素的多学科卫生工作者提供广泛的基础，并提供疼痛诊所，以支持更复杂的病例。例如，基本疼痛管理课程在60多个国家被证明是有用的。必须取消急功近利的经济激励措施，奖励长期咨询和高价值护理。

Clinical studies should incorporate patient priorities alongside meaningful comparators and outcomes (covering benefits, harms, and costs). Population studies should seek effective and feasible solutions that integrate health promotion with non-communicable diseases, healthy ageing, and rehabilitation. Policy makers and regulators must prioritise pain, seeing the cost of inaction. For the wider public, measures are needed to raise awareness of chronic pain, dispelling misconceptions that discourage care seeking and removing stigma.

临床研究应包括患者的优先事项以及有意义的比较和结果（包括益处、危害和成本）。人口研究应寻求有效可行的解决方案，将健康促进与非传染性疾病、健康老龄化和康复结合起来。政策制定者和监管者必须优先考虑痛苦，看到不作为的代价。对于广大公众来说，需要采取措施提高对慢性疼痛的认识，消除阻碍寻求护理的误解，消除耻辱感。

In Patrick Radden Keefe's searing analysis of the opioid epidemic, Empire of Pain, he anatomises how the phenomenon of chronic pain was weaponised by a pharmaceutical company to serve a marketing campaign for Oxycontin. The results were devastating—abuse, addiction, and thousands of preventable deaths. There are many guilty parties to be held accountable—from doctors who seemed to see no limit to the prescription of opioids for chronic pain, to regulators who failed to ask crucial questions about the consequences of more liberal treatment regimens. One perverse outcome of this public health emergency is that chronic pain now risks being stigmatised, marginalised in the shadows of societal suffering. Such an outcome would be a further human tragedy. Chronic pain is real. It deserves to be taken more seriously. And this Lancet series explains why.

在Patrick Radden Keefe对阿片类药物流行的激烈分析《痛苦帝国》中，他剖析了一家制药公司如何将慢性疼痛现象武器化，以服务于Oxycontin的营销活动。结果导致了毁灭性的滥用、上瘾和数以千计的可预防的死亡。有许多有罪的当事方要被追究责任，从那些似乎认为对慢性疼痛的阿片类药物处方没有限制的医生，到未能就更自由的治疗方案的后果提出关键问题的监管者。这场公共卫生紧急事件的一个反常结果是，慢性疼痛现在有可能被污名化，被社会痛苦的阴影边缘化。这样的结果将是进一步的人类悲剧。慢性疼痛是真实的。它应该得到更认真的对待。这个柳叶刀系列文章解释了原因。

1. Christopher Eccleston, Dominic Aldington, Andrew Moore, Amanda C de C Williams. Pragmatic but flawed: the NICE guideline on chronic pain. The Lancet, Volume 397, Issue 10289, 29 May–4 June 2021, Pages 2029-2031

2. Steven P Cohen, Lene Vase, William M Hooten. Chronic pain: an update on burden, best practices, and new advances. The Lancet, Volume 397, Issue 10289, 29 May–4 June 2021, Pages 2082-2097

3. Mary-Ann Fitzcharles, Steven P Cohen, Daniel J Clauw, Geoffrey Littlejohn, Chie Usui, Winfried Häuser. Nociplastic pain: towards an understanding of prevalent pain conditions. The Lancet, Volume 397, Issue 10289, 29 May–4 June 2021, Pages 2098-2110

4. Helena Knotkova, Clement Hamani, Eellan Sivanesan, María Francisca Elgueta Le Beuffe, Jee Youn Moon, Steven P Cohen, Marc A Huntoon. Neuromodulation for chronic pain. The Lancet, Volume 397, Issue 10289, 29 May–4 June 2021, Pages 2111-2124