Commentary on Hayes <i>et al</i>. (2020): The harms of opioid dose escalation in the management of chronic non‐cancer pain
Notice bibliographique
Résumé
Opioid dose escalation in the management of chronic non-cancer pain is associated with an increased risk for several opioid-related adverse outcomes. When prescribing opioids for chronic non-cancer pain, clinicians should establish goals with patients, consider how opioids will be discontinued and plan to monitor the patient's response to treatment. Concerning trends in opioid prescribing continue to devastate global harm reduction efforts targeted at reducing opioid-related morbidity and mortality 1-3. In addition to risks of opioid use disorder 4 and opioid overdose 5, a number of other harms have been identified as sequalae of long-term opioid use 6. Due to their potent central nervous system depressant effects, chronic opioid use can lead to myriad medical sequalae, including cognitive dysfunction, nausea and vomiting, constipation, pruritus/itching, sedation/drowsiness and hypogonadism 7. Nevertheless, opioids are considered the mainstay of pain management. While opioids are frequently prescribed for the treatment of acute pain and cancer-related pain 8, 9, there is less consistent evidence for their use in the treatment of chronic non-cancer pain 10, 11. As many individuals who develop opioid use disorders may do so in the context of prescription opioid use for chronic non-cancer pain 12, prescribing patterns may play a significant role in the development of opioid-related problems in this population. This was demonstrated clearly by Hayes and colleagues’ 13 recent study, which arrived at an important and timely conclusion: escalating opioid dosing for the treatment of chronic non-cancer pain is associated with an increased risk for several opioid-related adverse outcomes. Given the dose–response relationship in their data, Hayes and colleagues posited that opioid-induced hyperalgesia—which is defined as a state of nociceptive sensitization caused by exposure to opioids—may mediate this observation, diminishing the perceived benefits and increasing the associated harms of opioid use for chronic non-cancer pain 14. To that end, recent literature suggests that hyperalgesia may be linked to the development of opioid tolerance 15. Hyperalgesia is particularly problematic as further opioid prescribing is largely futile 15, and when combined with opioid tolerance both contribute to poorly controlled pain and dose escalation 15. Opioid-induced allodynia—a condition when a normally benign stimulus is perceived as pain—may further dampen the efficacy of opioid pharmacotherapy for chronic pain management, as it may dampen the perceived benefits of treatment from the patient's perspective 16. Practically speaking, non-opioid therapies remain preferred for treatment of chronic non-cancer pain, while opioids are reserved for scenarios when the benefits for pain and function are expected to outweigh the risks 6. Before initiating treatment, clinicians should establish goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks, and a plan to monitor the patient's response to treatment should be discussed at the outset 12. If opioids must be prescribed, several harm reduction strategies can be utilized, such as the avoidance of concurrent central nervous system depressants (such as other opioids or benzodiazepines) or the use of the lowest effective dose of opioids. In a similar vein, take-home naloxone can be co-prescribed to reduce the risk of overdose mortality 17. Evocative treatments, such as ketamine, have even begun to permeate into the emergency management of acute pain and may prevent the initiation of opioid prescribing 18. As Hayes and colleagues (13) identified, morbidity among individuals with chronic non-cancer pain who receive opioid therapy is high, but unless there are drastic changes in our approaches to the treatment of this subpopulation these statistics will not change. Taken together, these findings indicate that there is an urgent need for alternative evidence-based strategies to address chronic non-cancer pain. None.
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Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,000 | 0,000 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,000 | 0,000 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,001 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».