Deborah Dowell, et. al.
JAMA. Published online March 15, 2016. doi:10.1001/jama.2016.1464
http://jama.jamanetwork.com/article.aspx?articleid=2503508
非がん性慢性疼痛に対し、麻薬取扱者免許無くても処方できるオピオイド、そしてその種類増加し、その使用著増の可能性がある。適正に、適応使用検討され、インフォームドコンセント必須なのは自明。
一方、 慢性疼痛へのオピオイドのサイエンスは明らかであり、大多数の患者にとって、既知・重大な、頻回な致死的リスクの方が一過性のベネフィットや存在すらあやしいベネフィットより重大であるという事実
12の recommendations stateを含む推奨
慢性疼痛に対しオピオイドは第一選択薬剤ではないこと！
あくまで、非薬物治療、即ち、運動や認知行動療法を第一に考慮すべき
他、治療開始前尿検査にてモルヒネ 90 mg当量以上を避ける最小量開始し、長時間持続オピオイドを避け、急性疼痛に対しては７日を超えない処方とする
このような治療法はあくまで「非がん」疼痛に対する推奨
ソース：http://www.medscape.com/viewarticle/860452#vp_2
http://www.cdc.gov/drugoverdose/prescribing/resources.html
Centers
for Disease Control and Prevention Recommendations for Prescribing
Opioids for Chronic Pain Outside of Active Cancer, Palliative, and
End-of-Life Care
Determining When to Initiate or Continue Opioids for Chronic Pain
- 1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
- 2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
- 3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.
Opioid Selection, Dosage, Duration, Follow-up, and Discontinuation
- 4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.
- 5. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to 50 morphine milligram equivalents (MME) or more per day, and should avoid increasing dosage to 90 MME or more per day or carefully justify a decision to titrate dosage to 90 MME or more per day.
- 6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than 7 days will rarely be needed.
- 7. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.
Assessing Risk and Addressing Harms of Opioid Use
- 8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/d), or concurrent benzodiazepine use are present.
- 9. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.
- 10. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
- 11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
- 12. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.
