† 謝宜哲、王心榆等二位作者在本論文貢獻度相當，因此並列為第一作者。

Introduction: Insomnia is a common phenomenon in patients with chronic pain. Insomnia and pain bi-directionally influence each other and can affect patients’ daily activities. Simultaneous control of pain and sleep problems is crucial for effective pain management. Although many patients resort to sleep medications for sleep problems, the American College of Physicians (ACP) clinical guidelines suggest that all adult patients should receive cognitive behavioral therapy (CBT) as the initial treatment for insomnia and that a shared-decision making (SDM) model should be adopted before adding pharmacological treatment. The present study presents 3 cases in which SDM was adopted to treat insomnia in non-cancer patients with chronic pain.
Case Presentation: Each participant was initially evaluated by a pain physician, pharmacist, and clinical psychologist. Clinicians intervened regarding the patients’ sleep medication use habits and provided opportunities for non-pharmacological treatment. For 3 consecutive months, participants attended the clinic for a monthly followup evaluation and adjustments to their pharmacological and non-pharmacological treatments. Participants’ levels of depression, anxiety, sleep disturbances, and pain showed a decreasing trend over time. One patient gained knowledge about overdosing, and 2 patients successfully tapered their sleep medication doses. The category of prescribed medications also decreased in 2 patients.
Discussion: The current study showed that after patients chose the combination of sleep medications and non-pharmacological approaches, the SDM model was generally effective at helping patients taper their sleep medications. 

簡介：慢性疼痛患者通常也伴隨有失眠的問題，失眠和疼痛亦會互相影響，對慢性疼痛患者日常活動造成干擾。因此，疼痛控制中，對於失眠的治療也是重要的環節。美國內科學會 (American College of Physicians, ACP) 的指引建議所有失眠的患者應該先接受認知行為療法 (cognitive behavioral therapy, CBT)，當CBT 療效不彰，應以醫病共享決策 (shared-decision making, SDM) 的模式討論是否搭配藥物治療。然而在臺灣，多數病人並未接受相關介入，導致長期依賴安眠藥物甚至有多重用藥狀況。本研究探討了3 個疼痛個案在採用醫病共享決策來改善其失眠問題及安眠用藥異常的狀況。
案例：每個參與者在研究起初都經由醫師、藥師、臨床心理師評估其狀況，並且由3 個臨床人員介入其安眠藥使用行為以及提供給參與者非藥物療法的機會。在接下來的3 個月，參與者每個月會回診，除了接受評估以外，也會調整其藥物和非藥物的療法。經過SDM 的討論及治療後，參與者整體的憂鬱、焦慮、睡眠障礙及疼痛都有呈現降低的趨勢。其中一個參與者學習到了更多關於藥物過量的知識、有2 人成功的減少安眠藥處方或實際用量。
討論：本研究闡述了參與者經過SDM 的討論並且選擇用藥物和非藥物互相搭配的療法後，有機會可以安眠藥物減量、改善睡眠障礙及疼痛控制的歷程。


Summited for publication: 2019.7.1; Accepted for publication: 2019.9.26