1例直肠肛管恶性肿瘤术后骨转移伴难治性癌痛患者的药物治疗

1例直肠肛管恶性肿瘤术后骨转移伴难治性癌痛患者的镇痛治疗过程中,临床药师对患者疼痛性质、程度及药物治疗所致的不良反应进行分析和评估,并提出个体化镇痛给药建议。治疗后,患者疼痛控制稳定,不良反应可耐受。临床药师参与癌痛患者的镇痛治疗,能够为患者提供个体化药物治疗方案,规范临床合理使用镇痛药物。     

关于华西医院肿瘤中心住院患者癌痛情况的调查分析

目的:了解四川大学华西医院肿瘤中心住院的癌症患者疼痛的发生率,癌性疼痛(以下简称癌痛)患者的疼痛情况、镇痛药物的使用情况,并分析癌痛患者镇痛治疗不足的相关因素。方法:采用问卷的方式调查癌症患者的疼痛发生率,癌痛患者的疼痛情况、镇痛药物的使用情况,以及癌痛患者所用镇痛药物的花费情况。结果:四川大学华西医院肿瘤中心住院的癌症患者中疼痛的发生率为46.4%,最痛时视觉模拟评分(Visual analogue scale,VAS)为66.01±23.07。癌症患者中发生疼痛的患者与非疼痛患者相比,其情绪、正常工作、睡眠、生活乐趣等均受到不良影响(P<0.05),且疼痛患者有更高的自杀倾向的发生率(P<0.05)。发生癌痛时仅有49.7%的患者使用镇痛药物。92.9%的癌痛患者镇痛药物花费占所有治疗总费用的比例≤1%。结论:在华西医院肿瘤中心住院的癌症患者中,癌痛是较为普遍存在的临床症状,癌痛的发生会显著影响患者的生活质量,目前尚存在癌痛患者镇痛不足的情况,应从医患两方面进行癌痛相关知识的宣教,推进癌痛的规范化诊疗。     

四川省癌痛规范化诊疗现状的调查分析

目的:通过2013年~2015年连续3年的调查及对比分析,了解四川省内各级医院的癌痛规范化诊疗情况,及四川省内医护人员对癌痛治疗相关知识的掌握情况,为进一步提高医护人员癌痛规范化诊疗相关知识及改善癌痛管理的现状提供理论依据。方法:采用自行设计的调查问卷对四川省内各医院的医护人员进行调查。2013年调查92家医院的120名医护人员,2014年调查84家医院的109名医护人员,2015年调查99家医院的129名医护人员。了解各医院癌痛病人的就诊情况及癌痛规范化诊疗的开展情况,以及医护人员对镇痛药物的使用、对阿片类药物的使用及不良反应预防知识的掌握,及癌痛的有创治疗和手术的应用情况,并对三年的调查结果进行对比分析。结果:四川省各医院开展癌痛规范化诊疗工作的比例由2013年的55%增加至2015年的69%,"癌痛规范化示范病房"医院由2013年的30%增加至2015年的37%。医护人员对癌痛病人常用的镇痛药物是阿片类药物(以吗啡和芬太尼缓释剂为主,羟考酮的使用逐年增加),且大多数医护人员关注了阿片类药物的不良反应。对于常规镇痛药物疗效不佳的癌痛病人主要采用神经阻滞和神经毁损缓解其疼痛。结论:近三年癌痛的规范化诊疗逐渐在四川省内各个医院开展,癌痛诊疗的状况也逐年得到改善。     

护理干预对癌性疼痛患者疼痛症状的影响

目的：探讨护理干预对癌性疼痛及生存质量的影响。方法纳入2013年11月至2014年11月所收治老年癌症疼痛患者100例,其中门诊与住院患者各50例,分别将其作为A、B组。 A组患者给予常规家庭护理,B组患者行疼痛评估,并根据评估的结果给予护理干预,比较两组患者的情绪变化情况、药物依赖性、疼痛缓解以及镇痛药物使用情况。结果所有患者均完成为期半年的随访,随访结束时,两组患者的情绪变化情况、药物依赖性、疼痛缓解以及镇痛药物使用情况存在明显差异（ P＜0.05）。结论在对癌痛患者进行临床护理时,通过对其疼痛情况进行有效评估,并给予针对性护理,不仅可以提高患者的护理效果,而且还可以提高患者的生存质量。     

麻醉镇痛药在癌痛治疗中的合理应用

选取收治的494例癌痛患者,根据住院号调取相应的住院病历,通过统计分析麻醉镇痛药物的应用数据,提出麻醉镇痛药在癌痛治疗中的合理应用措施。临床涉及麻醉镇痛药品主要有盐酸吗啡缓释片、吗啡口服液、盐酸吗啡针、盐酸羟考酮缓释片、磷酸可待因片、盐酸哌替啶。用药基本合理且符合用药三阶梯原则,但仍存在一些问题有待完善。在癌痛治疗中合理应用麻醉镇痛药能有效提高癌症患者生存质量,解除患者痛苦,延长其生存时间。     

集束干预策略对晚期癌症患者癌痛的影响

【目的】探讨集束干预策略对晚期癌症患者癌痛的影响。【方法】选择本院2012年3月至2013年9月住院的晚期癌症癌痛患者120例,随机分为观察组和对照组各60例,观察组实施集束干预策略,对照组实施常规疼痛护理。比较两组患者入院后的疼痛评分（NRS）,爆发痛次数,阿片类药物使用情况和阿片类药物不良反应发生率。【结果】观察组24小时后疼痛评分及爆发痛次数低于对照组（P＜0．05）,阿片类药物使用剂量较对照组显著增加,便秘、嗜睡及过度镇静不良反应较对照组明显减少（P＜0．05）。【结论】通过集束干预策略对癌痛患者进行规范化管理,完全可以控制癌痛,减轻肿瘤患者痛苦,提高生活质量。     

新疆维吾尔族肺癌患者初诊时癌痛情况调查分析

目的:通过对新疆肿瘤医院初诊的维吾尔族肺癌患者的临床基本特征及癌性疼痛(以下简称癌痛)进行统计分析,了解维吾尔族肺癌患者癌痛的发生率、疼痛情况及对疼痛的相关认知情况,为新疆地区维吾尔族肺癌患者的癌痛诊治提供可靠的临床资料。方法:收集并统计分析208例初次就诊的维吾尔族肺癌患者的年龄、性别、分期等基本信息,疼痛程度、部位、镇痛药物的使用情况以及对癌痛和镇痛药物认知情况等。结果:208例维吾尔族肺癌患者癌痛发生率为36.53%,晚期肺癌癌痛发生率合计41.32%,中重度癌痛合计占比54.65%,最主要的疼痛部位是胸部(27.63%)和肩背部(19.74%),服药率为57.89%,服用最多的药物为非甾体抗炎药,占癌痛患者27.63%,对疼痛及镇痛治疗及镇痛药物成瘾性认识存在诸多误区。结论:新疆地区维吾尔族肺癌患者就诊时伴发癌痛比率高,服药率低,疼痛控制情况差,对疼痛及止痛治疗认识不正确,对镇痛药物的成瘾性认识存在误区。应结合该民族文化心理特征对初诊患者进行癌痛相关知识的宣教,推进癌痛的规范化诊疗。     

门诊麻醉药品和精神药品的应用与管理

在癌痛治疗过程中，患者大多数的时间是在家里渡过的，需要在门诊领取阿片类镇痛药物。由于阿片类镇痛药物具有镇痛和心理依赖双重效应，必然存在管理问题。如果管理制度过严或手续繁琐，会阻碍患者获得足够的镇痛药物。如果管理过于松懈，容易出现阿片类药物流弊的问题，给吸毒或贩毒分子提供获取阿片类物质的机会，带来一系列的社会问题。过多的社会不法分子出现在癌痛门诊，也会给医护人员带来压力，减少给患者用药的品种和剂量，而导致用药不足。因此，门诊合理的管理和发放阿片类药物是癌痛治疗中非常重要的环节，值得临床医生、药剂工作者、及医院的管理者的重视。本文依据国家对麻醉药品、第一类精神药品管理的有关法律、法规以及卫生部规范麻醉药品、第一类精神药品采购、使用和管理的规定，介绍医疗机构具体贯彻落实的措施和办法。使临床医生熟知国家和相关法规，在法规的框架内充分提供患者所需的镇痛药物。同时建立合理严谨的门诊管理模式，减少管理的漏洞，避免不法分子的干扰。     

我院2013年住院患者麻醉性镇痛药物使用情况分析

目的:分析我院住院患者麻醉性镇痛药物使用情况,为临床合理用药提供依据。方法:统计2013年度我院住院患者麻醉性镇痛药物的相关数据,运用用药频数(DDDs)、消耗量等进行分析。结果:我院2013年住院患者麻醉性镇痛药物的使用基本合理,药物使用频度较高者为硫酸吗啡缓释片及芬太尼注射液。结论:对麻醉性镇痛药物的使用,医院在加强监管、防止非法滥用的同时,应进一步推广"癌症三级阶梯止痛"基本原则,保障患者合法需求,提高合理用药水平。     

乳腺手术围术期预防性使用抗菌药物干预前后调查分析

目的探讨分析临床药师对临床合理使用抗菌药物的干预作用。方法回顾性分析的148例住院行乳腺手术患者预防性使用抗菌药物的情况,根据是否进行抗菌药物预防性使用临床干预分为A、B两组,并进行临床用药效果评价分析。结果两组病人在抗菌药物合理使用、住院费用、住院天数等方面存在显著性差异。结论临床药师能够促进临床药物使用更加安全、有效、合理、经济。     

WHO stufe II—Klinische Realität oder didaktisches Instrument?

INTRODUCTION: In 1986 the World Health Organisation (WHO) proposed an analgesic ladder for the effective therapy of cancer pain. The three standard analgesics making up this ladder are aspirin (non-opioid), codeine (weak opioid) and morphine (strong opioid). Adjuvant drugs may be added at any level. However, before 1986 step II analgesics (weak opioids) had never been tested in cancer pain relief. METHODS: This report presents a computer-assisted Medline (US National Library of Medicine) literature search restricted to the years 1986-1994, which was conducted to test the validity of the WHO guidelines, and in particular that of step II. RESULTS: We found seven retrospective studies and one prospective study on cancer pain treatment according to the proposed WHO guidelines that had been published since 1986. Every publication decribed the use of all three steps of the analgesic ladder. We found no prospective controlled trials demonstrating the efficacy and safety of WHO step II in particular. DISCUSSION: The use of the WHO guidelines "by mouth, by the clock and by the ladder" is now the mainstay of cancer pain management. Because of the guidelines' simplicity they found general acceptance and helped to establish an international pain therapy standard for worldwide use. Nevertheless, there is no scientific validation of WHO step II. In the absence of prospective controlled randomized trials additional longterm results are necessary. We need more data on the use of WHO step II and an update of the published guidelines taking account of modern sustained-release drugs. Up to now, step II of the WHO guidelines for cancer pain is not a clinical reality but at best a didactic instrument.     

Non-opioid analgesics in cancer pain

Non-opioid analgesics such as NSAIDs play a central role for patients with cancer pain as well as for those with acute pain. Pain management using non-opioid analgesics need to avoid potential side effects, and the analgesic action of NSAIDs, cyclooxygenase inhibitors, would synergistically potentiate opioids' effects via the activation of the periaquaductal grey of the midbrain. The analgesic action of opioids would also be potentiated by the activation of alpha 2-adrenoceptors of the spinal cord. Thus the use of non-opioid analgesics for cancer patients taking opioid needs meticulous care. Undertreatment of pain is a persistent clinical problem for patients with cancer. Although changing medical practice is difficult and improving pain management with the rational use of combination of drugs may especially difficult, supplementation of non-opioid analgesics for opioid treatment would provide a better quality of life of cancer patients.     

Present status of the use of adjuvant analgesics in Japan

Adjuvant analgesics are drugs that have primary indications other than pain but are analgesic in selected circumstances. Antidepressants, anticonvulsants, local anesthetics, and NMDA receptor antagonists are drugs used in the treatment of neuropathic cancer pain. Assessment of pain is very important in selecting appropriate adjuvant analgesics. The assessment includes visual analog scale for pain intensity, McGill Pain Questionaire for quality of pain, and the location of pain. It is also important to assess the effectiveness of immediate release opioids. Most neuropathic pain is thought to be refractory to opioids. In Japan, effective adjuvant analgesics such as gabapentin and pregabalin are not available. The main adjuvant analgesics are still tricyclic antidepressants such as amytriptylin and amoxapin, and anticonvulsants such as carbamazepin and clonazepam. Another problem is that morphine is the only rescue drug available for the assessment of opioid responsiveness since morphine is the only opioid with an immediately release form among the strong opioids available in Japan which are morphine, oxycodone, and fentanyl. Adjuvant analgesics also have side effects such as constipation and sleepiness, which may augment the side effects of morphine and may impair the QOL of cancer patients with neuropathic pain. There is a need to improve the systems of development and importation of adjuvant analgesics.     

出院患者使用强阿片类镇痛药物的随访分析

目的：了解我院中重度疼痛患者出院后使用强阿片类镇痛药物的依从性和不良反应。方法：采集我院2020年 8月-9月出院开具强阿片类镇痛药品（硫酸吗啡缓释片，规格30mg、10mg；盐酸羟考酮缓释片，规格40mg、10mg；芬太尼透皮贴剂，规格4.2mg、2.5mg、4.125mg）的患者信息，并对患者进行电话随访，比较各组临床资料及随访数据差异。结果：总计获得291例疼痛患者出院带药数据。三种强阿片类镇痛药物在患者个人一般情况、电话应答率、疼痛类型、合并使用其他镇痛药比例等方面存在显著差异。吗啡缓释片组存在用药顾虑的患者比例最高，为18.4%，显著高于另外两组（P＜0.001）。吗啡缓释片组、羟考酮缓释片组及芬太尼透皮贴剂组不良反应发生率分别为45.65%、24.14%及14.29%，差异有统计学意义(P=0.001)。三组药物在用药依从性和疼痛控制效果方面无明显差异。结论：疼痛的处理除了遵守“WHO三阶梯止痛应用原则”选择合适的镇痛药物控制疼痛外，还和患者个人生活习惯、规范用药和正确药物认知存在必然联系，药师应积极转变药学服务模式，指导服务覆盖出院后患者，促进合理、规范、有效地使用医生开具的镇痛药物，缓解疼痛的同时，减少和避免不良反应，提高患者生存质量。     

Paediatric cancer pain management using the WHO analgesic ladder--results of a prospective analysis from 2265 treatment days during a quality improvement study.

OBJECTIVE: To collect data on pain management in paediatric oncology with respect to the WHO ladder approach. SETTING, DESIGN, PATIENTS AND METHODS: Eight German tertiary care paediatric oncology centres prospectively documented all their in-patient pain treatment courses from June 1999 to December 2000. Pain was scored using a 1-6 faces scale. RESULTS: Two hundred and twenty four patients (median age, 9 years; range 0.2-32.1) were enrolled. Three hundred and thirty three pain episodes comprising a total of 2265 treatment days were documented. Pain was mostly therapy associated. The most frequently administered non-opioid analgesics were dipyrone and paracetamol. On WHO step 2, tramadol was almost the only opioid used. During tramadol monotherapy average daily pain scores were lower than with a combination of tramadol and non-opioid analgesics. On WHO step 3, morphine was at least part of the analgesic regimen on most treatment days. Strong opioids were combined with a non-opioid analgesic on 41% of the treatment days. The mean intravenous morphine equivalence dose was 0.034 mg/kg/h. During opioid and non-opioid combination therapy, adverse effects were more frequent, and average pain scored higher than on opioid monotherapy. CONCLUSIONS: WHO-guidelines were closely followed in Germany and seem to provide effective analgesia for children with cancer pain. In our patient group there is no evidence that a combination of an opioid with a non-opioid is more effective than opioid therapy alone in in-patient paediatric oncology pain treatment.     

Physicians' knowledge and attitudes toward the use of analgesics for cancer pain management: a survey of two medical centers in Taiwan

The purposes of this study were to examine the attitudes of physicians regarding the optimal use of analgesics for cancer pain management (CPM), to evaluate their knowledge and attitudes toward opioid prescribing, and to comprehend their perceptions of the barriers to optimal CPM. A survey was conducted on 356 physicians with cancer patient care responsibilities practicing in two medical centers in Taiwan. A total of 204 (57%) physicians responded, including internists (28%), surgeons (27%), oncologists (11%), anesthesiologists (10%), and other specialties (24%). The majority of physicians displayed significantly inadequate knowledge and negative attitudes toward the optimal use of analgesics and opioid prescribing. Multivariate analyses showed that the following six categories of physicians would be inclined to have inadequate knowledge of opioid prescribing: 1) those with perception of good medical school training in CPM, 2) those with perception of poor residency or fellowship training in CPM, 3) those with a medical specialty in surgery, medicine, or oncology (vs. anesthesiology), 4) those with limited clinical experience in cancer patient care (number of patients less than 30), 5) those with a limited aim of pain relief, and 6) those with an underestimation of analgesic effect. Additionally, physicians with inadequate knowledge of opioid prescribing and with hesitation to intervene earlier with maximal dose of analgesia would be inclined to have reluctant attitudes toward opioid prescribing. The most important barriers to optimal CPM identified by physicians themselves were physician-related problems, such as inadequate guidance from a pain specialist, inadequate knowledge of CPM, and inadequate pain assessment. The results of this study suggest that active analgesic education programs are urgently needed in Taiwan.     

A Canadian survey of issues in cancer pain management

We report the analysis of a cancer management survey mailed to a representative group of health professionals in 1994. The goals of the study were to gather information on cancer pain treatment practices, and to obtain health professional views on obstacles to ideal pain management. The survey, designed by a working party of pharmacists, nurses and physicians, was distributed to 14,628 physicians. A total of 2,686 physicians responded to the survey, including 39% of medical or radiation oncologists, and 18.19% of physicians who listed their primary interest as Family Medicine. Reflecting the modest emphasis placed on palliative care and cancer pain management in the current Canadian milieu, 67% of physicians rated their past teaching experience as only “fair” or “poor.” Lack of exposure to pain education was reflected in the response to a series of hypothetical case scenarios exploring physician choices in managing severe cancer pain. For example, in the initial management of a cancer patient with severe pain, 50% of physicians would not use a strong opioid in the absence of other contraindications to opioid use. A wide variety of analgesics and non-pharmacologic techniques is available to Canadian physicians to assist patients with pain. Few physicians identified the unavailability of analgesics or analgesic techniques as limiting factors in pain management. We condude that greater emphasis should be placed on pain education in our training programmes. We suggest that further surveys of this type, sponsored by our provincial colleges and medical organizations, can provide feedback which will enhance the adherence by Canadian physicians to published guidelines for pain management.     

Drug therapy of pain in cancer

Conclusion Most pain in cancer should be easily relieved because it responds in a predictable way to opioid analgesic drugs. Some pains do not respond so well but can usually be ameliorated by the judicious use of adjuvant analgesics, non-drug measures, and the active involvement of the multidisciplinary team     

Prescribed Opioids Adherence Among Taiwanese Oncology Outpatients

The purpose of this study was to evaluate adherence to prescribed opioids in Taiwanese oncology outpatients and to examine the associations between various demographic and medical characteristics and prescribed opioids adherence. Ninety-two outpatients who had taken prescribed opioid analgesics for cancer-related pain at least once in the past week participated in this study. Patients were asked to recall the dose of each opioid analgesic that they had taken in the past 24 hours. Mean adherence rates were calculated for analgesic adherence. For mean adherence rates, all opioid analgesics were converted to morphine equivalents. The results of this study reveal a priority issue of poor opioid analgesic adherence. The adherence rate of 63.6% for the around-the-clock opioid analgesics in this study is well below acceptable levels. Also, an adherence rate of 30.9% for the as-needed opioid analgesics is very low. This study identified that women tend to be less adherent to their prescribed opioid analgesic regimen than men. Findings of this study suggest that to improve pain control, efforts to promote patients’ opioid regimen adherence should be given high priority. Clinicians should be particularly aware that there may be some gender difference in adherence to prescribed opioid analgesics. There is a need for better programmatic efforts to improve analgesic adherence.