title: [Good clinical practice guide for opioids in pain management: the three Ts - titration (trial), tweaking (tailoring), transition (tapering)].
abstract: OBJECTIVE
  Achieving good clinical practice in the use of opioids as part of a comprehensive pain management regimen can face significant challenges. Despite guidelines from governmental and pain society/organization sources, there are still significant hurdles. A review of some basic tenets of opioid analgesia based on current published knowledge and experiences about this important healthcare imperative is warranted.
  
  
  BACKGROUND
  Consistent with guidelines, the literature supports using the lowest total opioid dose that provides adequate pain control with the fewest adverse effects. Titration (or trial) during opioid initiation is a way of starting low and going slow (and assessing the appropriateness of a specific opioid and formulation). Recognizing that multiple factors contribute to an individual's personal experience of pain, the physical, psychological, social, cultural, spiritual, pharmacogenomic, and behavioral factors of the individual patient should be taken into account (tweaking, or tailoring). Finally, for those patients for whom transition (tapering) from opioid is desired, doing so too rapidly can have negative consequences and minimization of problems during this step can be achieved by proper tapering.
  
  
  CONCLUSIONS
  We conclude that a simultaneously aggressive, yet conservative, approach is advocated in the literature in which opioid therapy is divided into three key steps (the 3 T's): titration (or trial), tweaking (or tailoring), and transition (or tapering). Establishment of the 3 T's along with the application of other appropriate good medical practice and clinical experience/judgment, including non-pharmacologic approaches, can assist healthcare providers in the effort to achieve optimal management of pain.
authors.affiliation: Departamento de Medicina, Ciências Cirúrgicas e Biotecnologias, Sapienza University of Rome, Rome, Itália.
authors.forename: Flaminia
authors.initials: F
authors.lastname: Coluzzi
authors.affiliation: Nema Research Inc., Naples, EUA.
authors.forename: Robert
authors.initials: R
authors.lastname: Taylor
authors.affiliation: Johns Hopkins University, Baltimore, EUA; Departamento de Farmacologia, Temple University School of Medicine, Philadelphia, EUA; Georgetown University School of Medicine, Washington, EUA.
authors.forename: Joseph V
authors.initials: JV
authors.lastname: Pergolizzi
authors.affiliation: Departamento de Medicina, Ciências Cirúrgicas e Biotecnologias, Sapienza University of Rome, Rome, Itália.
authors.forename: Consalvo
authors.initials: C
authors.lastname: Mattia
authors.affiliation: Departamento de Ciências Farmacêuticas, Temple University School of Pharmacy, Philadelphia, EUA. Electronic address: robert.raffa@temple.edu.
authors.forename: Robert B
authors.initials: RB
authors.lastname: Raffa
keywords: Ajuste; Opioid; Opioide; Pain management; Redução gradual; Tailoring; Tapering; Titration; Titulação; Tratamento da dor