Opioide bei chronischen nicht-tumorbedingten Schmerzen – sind sie Nichtopioidanalgetika überlegen?

ZusammenfassungHintergrundManche Meinungsbildner in der deutschen Schmerzmedizin vertreten die These, dass es chronische nicht-tumorbedingte opioidpflichtige Schmerzen (CNTS) gibt. In der vorliegenden Arbeit wurde untersucht, ob Opioide Nichtopioidanalgetika beim Management von CNTS in Studien über mindestens 4 Wochen überlegen sind.MethodenBis Oktober 2013 wurden MEDLINE, Scopus und das Cochrane Central Register of Controlled Trials (CENTRAL) wie auch die Literaturverzeichnisse von Originalarbeiten und systematischen Übersichtsbeiträgen zu randomisierten, kontrollierten Studien (RCT) mit Opioiden bei CNTS durchsucht. Wir schlossen doppelblinde RCT ein, die Opioide über einen Zeitraum von mindestens 4 Wochen mit Nichtopioidanalgetika verglichen. Mithilfe eines Random-effects-Modells wurde für kategoriale Daten die relative Risikoreduktion (RD) und für kontinuierliche Variablen die standardisierte Mittelwertdifferenz (SMD) berechnet.ErgebnisseInsgesamt 10 RCT mit 3046 Teilnehmern wurden eingeschlossen. Die Studiendauer betrug im Median 6 Wochen (Spannweite: 4–12 Wochen). Tramadol wurde in 5 Studien mit nichtsteroidalen Antirheumatika (NSAR) bei Arthroseschmerz verglichen, in einer Studie mit Flupirtin bei Kreuzschmerz. Morphin wurde bei verschiedenen neuropathischen Schmerzsyndromen mit Antidepressiva (2 Studien), mit einem Antikonvulsivum (eine Studie) und einem Antiarrhythmikum (eine Studie) verglichen. Bezüglich der Schmerzreduktion bestand kein signifikanter Unterschied zwischen Opioiden und Nichtopioidanalgetika: SMD: 0,03 [95 %-Konfidenzintervall (KI): −0,18 – 0,24]; p = 0,76. Nichtopioidanalgetika waren Opioiden in der Verbesserung der körperlichen Funktionsfähigkeit überlegen: SMD: 0,17 (95 %-KI: 0,02 – 0,32); p = 0,03. Unter Opioiden waren Behandlungsabbrüche aufgrund von unerwünschten Ereignissen häufiger als unter Nichtopioidanalgetika: RD: 0,09 (95 %-KI: 0,06 – 0,13); p < 0,0001. Hinsichtlich schwerer unerwünschter Ereignisse oder der Abbruchrate wegen fehlender Wirksamkeit fand sich kein signifikanter Unterschied zwischen Opioiden und Nichtopioidanalgetika.SchlussfolgerungenIn der Kurzzeittherapie (4–12 Wochen) von neuropathischem Schmerz, Kreuz- und Arthroseschmerz sind Nichtopioidanalgetika Opioiden in Bezug auf die Verbesserung der körperlichen Funktionsfähigkeit und hinsichtlich der Verträglichkeit überlegen. Die Ergebnisse dieser Arbeit sprechen nicht für das Konzept eines „opioidpflichtigen“ CNTS.AbstractBackgroundSome leading German pain medicine experts postulate that there is a type of chronic non-cancer pain (CNCP) with an opioid requirement. We tested whether opioids are superior to nonopioid analgesics in the management of CNCP in studies of at least 4 week’s duration.MethodsWe screened MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) up until October 2013, as well as the reference sections of original studies and systematic reviews of randomised controlled trials (RCTs) of opioids in CNCP. We included double-blind RTCs comparing opioids to nonopioid analgesics of at least 4 week’s duration. Relative risks differences (RD) of categorical data and standardized mean differences (SMD) of continuous variables were calculated using a random effects model.ResultsWe included 10 RCTs with 3046 participants. Median study duration was 6 weeks (range 4–12 weeks). Five studies compared tramadol with nonsteroidal anti-inflammatory drugs (NSAIDs) in osteoarthritis pain and one trial compared tramadol to flupirtine in low back pain. Morphine was compared to antidepressants (two studies), an anticonvulsant (one study) and an antiarrhythmic (one study) in different neuropathic pain syndromes. There was no significant difference between opioids and nonopioid analgesics in pain reduction (SMD 0.03 [95 % confidence interval, CI − 0.18, 0.24]; p = 0.76). Nonopioid analgesics were superior to opioids in improving physical function (SMD 0.17 [95 % CI 0.02, 0.32]; p = 0.03). Patients dropped out due to adverse events more frequently with opioids than with nonopioid analgesics (RD 0.09 [95 % CI 0.06, 0.13]; p < 0.0001). There was no significant difference between opioids and nonopioid analgesics in terms of serious adverse events or dropout rates due to lack of efficacy.ConclusionNonopioid analgesics are superior to opioids in terms of improvement of physical function and tolerability in short-term (4–12 weeks) therapy of neuropathic, low back and osteoarthritis pain. Our results do not support the concept of an“opioid-requiring” CNCP.The English full-text version of this article is freely available at SpringerLink (under “Supplemental”).

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