Buprenorphine、Methadone用于慢性疼痛成瘾者的效果相当


  【24drs.com】新研究显示,对于慢性疼痛且有鸦片类制剂成瘾者,methadone和buprenorphine是现有的止痛治疗选项,不过,就安全性而言,buprenorphine有其优势。
  
  纽约州立大学家庭医学科成瘾治疗计画Anne Neumann博士等人在美国成瘾医疗协会(ASAM)第43届年度医学科学研讨会中发表研究结果。
  
  Buprenorphine是半合成的鸦片类制剂,以多种剂量用于治疗鸦片成瘾或控制急性/慢性疼痛,不过,根据Neumann博士表示,它相对于methadone对接受鸦片类制剂处方治疗慢性疼痛以及鸦片类成瘾者的相关安全性,还需要更多证据。
  
  这篇随机控制试验试图比较buprenorphine和methadone对于鸦片类制剂成瘾之慢性疼痛患者的治疗结果,治疗期间为6个月。
  
  共有54名病患被随机指派接受buprenorphine或methadone,这些病患都有鸦片类制剂成瘾(定义为精神疾患诊断与统计手册第四版(DSM-IV)),且有慢性疼痛症状,还需要曾经进行过禁慾导向治疗但是不成功的经验。
  
  Buprenorphine/naloxone组接受剂量为4-16 mg/天,每天平均剂量为14.93 mg buprenorphine/3.73 mg naloxone。Methadone组剂量为10-60 mg/天,平均日剂量为29.09 mg/天。
  
  每组各有13名病患(共26名病患)完成6个月治疗并接受分析。
  
  与纳入试验时的疼痛程度相比,buprenorphine组和methadone组在6个月治疗后都减少了12.75%的疼痛,buprenorphine及methadone治疗在止痛药剂量和功能上也相当。
  
  需另外使用鸦片类制剂方面,methadone治疗组优于buprenorphine组(分别是0人与5人),不过,buprenorphine治疗的安全性资料优于methadone治疗,因为它减少过量死亡和呼吸抑制的可能性。
  
  Neumann博士表示,buprenorphine与低剂量methadone都是医师治疗慢性疼痛和短效鸦片类制剂成瘾时的治疗选项。
  
  不过,她指出,methadone的平均剂量相当低(29 mg/天),研究选定的剂量范围为10-60 mg,原本预期会有许多病患服用最高剂量(60 mg)的methadone。
  
  根据Neumann博士表示,临床上,处方的methadone剂量更高。虽然用了低剂量methadone,6个月时,慢性疼痛和鸦片类制剂成瘾病患仍有显著止痛效果,且没有再使用鸦片类制剂。
  
  她指出,研究中有许多病患表示,在这6个月内,功能有所改善,不过,研究资料并未显示功能有任何改变,或许是我们的功能测量分数(0 – 10分)不够敏感,因此,仍不清楚这些药物是否实际上改善功能,我们目前进行追踪研究来探讨这个问题。再者,需要探讨这些药物之作用的神经生理机转以及长期效果(治疗后3-5年)。
  
  Herbert L. Malinoff医师发表评论时表示,这篇研究认为methadone和buprenorphine对于治疗慢性疼痛之鸦片类制剂成瘾患者效果相当,但是buprenorphine在安全性方面较优。
  
  他表示,医师可能会选择buprenorphine用于治疗鸦片类制剂成瘾患者的疼痛,而不是将他们转诊到联邦授权的methadone门诊。
  
  Malinoff医师任职于密西根大学健康体系的麻醉科,认为对医师而言重要的是,治疗鸦片类制剂成瘾患者的疼痛时需要持续监测恢复状态、非处方药物之使用与毒性。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=6800&x_classno=0&x_chkdelpoint=Y
  

Buprenorphine, Methadone Equal for Chronic Pain in Addiction

By Emma Hitt, PhD
Medscape Medical News

April 23, 2012 (Atlanta, GA) — Methadone and buprenorphine are viable analgesic treatment options for patients with chronic pain and comorbid opioid addiction. However, when it comes to safety, buprenorphine has the advantage, new research shows.

Anne Neumann, PhD, from the Addiction Medicine Program in the Department of Family Medicine at the State University of New York at Buffalo, and colleagues presented the findings here at the American Society of Addiction Medicine (ASAM) 43rd Annual Medical-Scientific Conference.

Buprenorphine is a semisynthetic opioid that is used at varying doses either to treat opioid addiction or to control acute or chronic pain. However, according to Dr. Neumann, more evidence is needed regarding its efficacy relative to methadone in chronic pain patients who receive prescription opioids for chronic pain and who subsequently develop opioid addiction.

The randomized clinical trial sought to compare buprenorphine treatment with methadone treatment in chronic pain patients with opioid addiction. The treatment period was 6 months.

Superior Safety Profile

A total of 54 patients were randomly assigned to receive either buprenorphine or methadone. Patients were required to have opioid addiction, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), as well as chronic pain disorder/syndrome. They were also required to have had a previous unsuccessful attempt at abstinence-oriented treatment.

The buprenorphine/naloxone group received 4 to 16 mg/day, with a daily average of 14.93 mg buprenorphine/3.73 mg naloxone. The methadone group received 10 to 60 mg/day of methadone, with a daily average of 29.09 mg/day.

A total of 13 patients in each treatment group (a total of 26 patients) completed the 6-month treatment and were analyzed.

Both buprenorphine and methadone treatment resulted in a 12.75% reduction of pain after 6 months of treatment compared with the level of pain present at the initial visit, and buprenorphine and methadone treatment were comparable in the amount of analgesia and functioning, the researchers found.

Methadone treatment resulted in less opioid use than buprenorphine treatment (0 vs 5 patients, respectively). However, buprenorphine treatment had a superior safety profile compared with methadone treatment, owing to its reduced likelihood of overdose death and respiratory depression.

Alternative to Opioids

"Buprenorphine and low doses of methadone are treatment options that primary care physicians can use to treat chronic pain and addiction to short-acting opioids," Dr. Neumann told Medscape Medical News.

However, she pointed out that the average dose of methadone was very low (29 mg/day). "The dose range we chose for the study was 10 to 60 mg, and I expected many patients to take the highest dose of methadone: 60 mg," she said.

According to Dr. Neumann, in the clinical setting, much higher doses of methadone are prescribed.

"Despite these low doses of methadone, patients with chronic pain and opioid addiction reported significant analgesia and no additional opioid use at 6 months," she said.

She added that many patients in the study reported an improvement of functioning during these 6 months. However, she noted, "our data did not show any changes in functioning, presumably because our measure for functioning (0 - 10 point scale) was not sensitive enough. Therefore, it remains unclear whether these medications can indeed improve function, and we are currently conducting a follow-up study to address this question."

"Furthermore, the neuropsychological mechanisms of action of these medications need to be explored, as do the long-term effects (after 3 to 5 years of treatment)," she said.

Need for Ongoing Monitoring

Commenting on the findings for Medscape Medical News, Herbert L. Malinoff, MD, said the study suggests that methadone and buprenorphine appear to have equal efficacy in the treatment of chronic pain in opioid addicted patients, but buprenorphine has advantages in terms of safety.

"Clinicians may choose to use buprenorphine in an office-based setting to treat pain in their opioid-addicted patients rather than referring them to federally licensed methadone clinics," he said.

Dr. Malinoff, who is in the Department of Anesthesiology at the University of Michigan Health System in Ann Arbor, adds that it is important for clinicians to remember that treating pain in the opioid-addicted patient requires ongoing monitoring for recovery status, nonprescribed drug use, and toxicity.

American Society of Addiction Medicine (ASAM) 43rd Annual Medical-Scientific Conference. Abstract P7, presented April 20, 2012.

    
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