从美国鸦片药滥用疫情战略报告看针灸发展的历史机遇

世界中医药网  2017-07-19 01:18:00复制链接我要评论()RSS

核心提示:美国“三科学院”7月13日发表的《报告》指出,处方止痛药物的滥用,尤其是鸦片类镇痛药物的过度使用,已经成为美国意外死亡的主要原因。美国针灸界普遍认为这将为促进针灸的发展带来新的历史机遇。

       世界中医药网讯 (本网驻美国纽约特约记者李永明报道)2017年7月13日,美国科学院、工程科学院、医学科学院(简称“三院”)联合发表了题为《疼痛的治疗和鸦片类药流行:处方鸦片类药物与社会及个人的风险和效益的平衡》的报告(简称《报告》)。

       《报告》指出:处方止痛药物的滥用,尤其是鸦片类镇痛药物的过度使用,已经成为美国意外死亡的主要原因。 慢性疼痛和滥用药物带来的危机已经成为当前美国社会的严重问题,关系到数百万人的疾病和健康,甚至可以导致残疾和永久功能丧失。 在鸦片类药物问题日益严重的情况下,美国食品和药物管理局(FDA)在2016年初启动了“鸦片类药物行动计划”。作为该计划的一部分,FDA要求国家科学院,工程科学院和医科学院召集一个委员会报告最新关于疼痛研究、护理和教育的状况,确定FDA和其他部门应该采取的行动。

       据悉,从奥巴马政府开始意识到美国处方鸦片类药滥用问题,并提出反滥用止痛处方药战略计划以来,美国白宫、参众两院及特朗普新政都一致支持要这个国家计划,并要投入大量资金。

       《报告》长达393页,系统第介绍了当前疼痛的治疗方法和问题。在非药物疗法部分,首先介绍了针灸治疗疼痛的情况、基础和临床研究的证据。显然,防治滥用止痛药的最好方法之一是推广非药物止痛疗法,西方医学科学界在广泛寻找非药物止痛疗法时,发现中医针灸是最特异的疗法,可以增加人体内源吗啡而镇痛。《报告》中提到的其他非药物止痛方法,包括整脊、物理疗法及行为认知疗法等都缺少对鸦片类药物的特异性。

       《报告》还在其他部分多次提到针灸疗法治疗疼痛的内容,包括有限的循证医学证据和有待进一步研究的方向,还建议医疗保险应该支付科学研究证明有效的非药物疗法,指出非药物镇痛疗法的应用价值。

       其实,目前美国已经有多个权威机构及医学专家委员会推荐针灸作为非药物止痛疗法。比如,几个月前,美国医师协会首次推荐针灸为治疗急性和慢性腰痛的一线疗法。近日,美国联合医院资格审查委员会要求从2018年起,医院治疗疼痛的服务需要包括针灸等非药物疗法,预计针灸治疗疼痛的需求将会增加。

       值得提及的是,上一次美国“三院”有关针灸的联合报告发表于1976年,题目为《针刺麻醉在中华人民共和国》。经“三院”派出的联合专家组到中国实地考察3周,专家组的最后结论是,针刺麻醉是真实的,此麻醉方法只适合少数患者,但针刺镇痛的临床意义重大,需要深入研究。可惜,报告发表时,正值中国文革结束和改革开放的开始,针灸疗法因故被遗弃,西医西药因开放而涌入,美国“三院”专家对针灸的中肯意见没有受到中国有关方面的重视,甚至这份报告至今仍没有中文版。

       有评论认为,美国目前的状况如同“新鸦片战争”,与旧鸦片战争不同的是,这次危机来自西方社会的内部,相同的是问题都源于人类的脆弱和贪婪,现在美国需要林则徐式的禁烟运动。《报告》中举例:买一个鸦片类药医生处方要500美元,买药需要30美元,但转手可卖3000美元,这就是动力。在这个利益链中,医生和患者都有参与和责任,制度也有问题,结果是美国因服止痛药后导致海洛因成瘾者,数字要远远高于其它原因的总和。

图片取自美国“三院”的鸦片药物问题研究报告

       《报告》在推荐针灸作为非药物止痛疗法同时,强调要按循证医学标准选择疗法,针刺疗法还需要做更深入的临床试验研究,以提供准确的针灸疗效信息和适应症。《报告》公布后,美国针灸界的普遍反应这是这是一则利好消息,一定会促进针灸发展的速度,推进针灸的科学研究,扩大目前的应用市场。对于这个历史机遇,美国和中国的中医针灸界都需要把握历史时机,积极参与疼痛的预防和治疗,用古老的中国针灸术为全世界民众服务。

【附】《报告》原文与针灸疗法有关的部分摘要

Copyright © National Academy of Sciences. All rights reserved.

Pain Management and the Opioid Epidemic:  Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use

PAIN MANAGEMENT AND THE OPIOID EPIDEMIC 

BALANCING SOCIETAL AND INDIVIDUAL BENEFITS AND RISKS OF PRESCRIPTION OPIOID USE 

Committee on Pain Management and Regulatory Strategies to Address  

Prescription Opioid Abuse 

Richard J. Bonnie, Morgan A. Ford, and Jonathan K. Phillips, Editors 

Board on Health Sciences Policy 

Health and Medicine Division 

A Consensus Study Report of National Academies of Sciences, Engineering, and Medicine.  2017. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24781.

非药物疗法治疗:针灸

Page 2-27

NONPHARMACOLOGIC TREATMENTS

Acupuncture The use of acupuncture for the treatment of pain has become widespread in recent decades. Acupuncture is a key component of traditional Chinese medicine that involves insertion of needles through the skin to acupuncture points. Pressure, heat, electrical current, laser light, and other means also may be used to stimulate these points. Investigations have demonstrated that the nervous system, neurotransmitters, and other endogenous substances respond to the needling stimulation to induce analgesia (Foster and Sweeney, 1987). It has been shown that acupuncture analgesia is mediated by opioids produced in the periaqueductal gray and can be reversed by naloxone, an opioid antagonist (Cheng and Pomeranz, 1980). Recent studies also suggest activation of cannabinoid receptors as a possible mechanism of action (Gondim et al., 2012). 

Systematic reviews evaluating the effect of acupuncture in treating pain have revealed mixed results. Some reviews have found minimal or no effect (Lee et al., 2008; Madsen et al., 2009), while others have found acupuncture to be superior to sham acupuncture and placebo (Berman et al., 1999; White et al., 2007), and still others have concluded that data are insufficient to support a recommendation (Furlan et al., 2005; Paley et al., 2015; Smith et al., 2016a; van Tulder et al., 1999). Recent reviews and meta-analyses examining the effect of acupuncture on musculoskeletal pain (neck and back pain, osteoarthritis, chronic headache and shoulder pain, fibromyalgia) have found that overall, acupuncture is superior to sham and no acupuncture, but with relatively modest differences between true and sham acupuncture (Vickers et al., 2012; Yuan et al., 2016). Although it has been suggested that acupuncture is an effective treatment for pain, additional factors, such as potent placebo and context effects, may play a role in its observed effect as well (Linde et al., 2010a,b; Vickers et al., 2012). It also has been suggested that acupuncture may have value in the treatment of chronic and tension headaches (Linde et al., 2009b; Vickers et al., 2012), as well as in prophylactic treatment for migraine (Linde et al., 2009a). Additional RCTs are needed to determine the effect of acupuncture on neuropathic and postsurgical pain.

非药物疗法,建议小结

Page 2-32

Summary Nonpharmacologic interventions for pain treatment, including acupuncture, physical therapy and exercise, CBT, and mindfulness meditation, represent powerful tools in the management of chronic pain. Many are components of successful self-management. While further research is needed to better understand the mechanism of action and the appropriate dosage and delivery for some nonpharmacologic approaches, they may provide effective pain relief for many patients in place of or in combination with pharmacologic approaches.  

Page 3-34

Recommendation 3-1. Invest in research to better understand pain and opioid use disorder. Given the significant public health burden of pain and opioid use disorder (OUD) in the United States, the National Institutes of Health, the Substance Abuse and Mental Health Services Administration, the U.S. Department of Veterans Affairs, industry, and other relevant research sponsors should consider greater investment in research on pain and OUD, including but not limited to research aimed at • improving understanding of the neurobiology of pain; • developing the evidence on promising pain treatment modalities and supporting the discovery of innovative treatments, including nonaddictive analgesics and nonpharmacologic approaches at the level of the individual patient; and • improving understanding of the intersection between pain and OUD, including the relationships among use and misuse of opioids, pain, emotional distress, and the brain reward pathway; vulnerability to and assessment of risk for OUD; and how to properly manage pain in individuals with and at risk for OUD. 

政府及保险支付建议 

Page 5-46

The committee recommends that states, with assistance from relevant federal agencies, particularly the Substance Abuse and Mental Health Services Administration, provide universal access to evidence-based treatment for opioid use disorder (OUD), including use of medication, in a variety of settings, including hospitals, criminal justice settings, and substance use treatment programs. Efforts to this end should be carried out with particular intensity in communities with a high burden of OUD. State licensing bodies should require training in treatment for OUD for all licensed substance use disorder treatment facilities and providers (Recommendation 5-6). The committee recommends that schools for health professional education, professional societies, and state licensing boards require and provide basic training in the treatment of opioid use disorder for health care providers, including but not limited to physicians, nurses, pharmacists, dentists, physician assistants, psychologists, and social workers (Recommendation 5-7).  The committee recommends that the U.S. Department of Health and Human Services and state health financing agencies remove impediments to full coverage of medications approved by the U.S. Food and Drug Administration for treatment of opioid use disorder (Recommendation 5-8).

Page 5-59

Recommendation 5-3. Facilitate reimbursement for comprehensive pain management. Public and private payers should develop reimbursement models that support evidence-based and cost-effective comprehensive pain management encompassing both pharmacologic and nonpharmacologic treatment modalities.

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