镇痛药物的选择

疼痛的类型 （1）剧烈的疼痛：它通常是和损伤、外科手术以及外伤密切联系的，在这类疼痛中患者期望伤害消除或者外科手术伤口痊愈后能够康复；（2）慢性或持续性疼痛：持续时间超过正常的治愈时间（虽然它们通常和外伤没有关系），并且通常是典型的疼痛持续时间在6个月以上，持续性是它最明显的特征。慢性下背部疼痛（Chronic lower backpain）、关节痛、肌痛是常见的例子。疼痛通常很难区分，并且通常不能揭示疼痛的根本原因。重复的慢性疼痛对身体的刺激改变了身体对痛感的反应，使疼痛信号更快和更强烈地被传递。这一种类的疼痛耗尽了患者自身的疼痛阻滞物质，比如去甲肾上腺素和5-羟色胺；（3）神经性疼痛：通常是由于中枢神经或者外周神经的损伤引起。糖尿病也会导致神经性疼痛；而疱疹的神经痛、胸廓切开术疼痛综合征、三叉神经痛是另外的例子。     

镇痛药物及其应用

镇痛药物是医生们进行疼痛治疗的重要工具。镇痛药物根据作用机制可分为阿片类镇痛药、非阿片类镇痛及辅助性镇痛药。阿片类镇痛药以吗啡、芬太尼等为代表药物，近年其他人工合成的可待因衍生物如羟可酮、氢可酮等也逐渐被用于临床。非阿片类镇痛药物主要包括非甾体类抗类药，其中环氧化酶－2抑制剂如塞来昔布等高选择抑制剂具有副作用较小的优点。此外氯胺酮、可乐定等非阿片类药物的镇痛作用近来也被重新研究和应用。辅助性镇痛药物以抗惊厥、抗精神病药物为主，对于阿片类药物不敏感的患，可作为辅助用药。     

中度疼痛癌症患者使用强阿片类镇痛药物的疗效和安全性评估

目的：观察中度癌症疼痛患者（NRS评分4～6分）直接使用强阿片类镇痛药物的疗效，生存质量改变及毒副反应评估。方法：共入选病理确诊的有疼痛主诉（NRS评分为中度疼痛）恶性肿瘤患者31例，直接给予强阿片类药物治疗，观察起效时间、疗效、生存质量改变及毒副反应。结果：（1）止痛疗效。起效时间为8～15h，中位时间为11h；治疗后第48小时疼痛评估临床获益97％（30／31），总有效率81％（25／31）；治疗后第72小时临床获益100％（31／31），总有效率97％（30／31）。（2）生存质量评估。治疗后第72小时ECOG评分，显效19％（6／31），有效55％（17／31）；治疗后第7天ECOG评分，显效23％（7／31），有效65（20／31）。（3）毒副反应。治疗过程中发生便秘5例（16％）、恶心2例（6％）、呕吐2例（6％）、疲倦7例（23％）、头晕1例（3％）。研究过程中未发现呼吸抑制的不良反应。结论：未使用过阿片类药物的中度疼痛癌症患者直接使用强阿片类药物，止痛疗效满意，患者生存质量得到提高和改善，毒副反应可以耐受     

儿科如何正确使用抗生素及解热镇痛药物

探讨儿科如何正确使用抗生素、解热镇痛药物。由于儿童生理因素较成人易感染而致感染性疾病。抗感染治疗就成了儿科临床上常用的治疗方法。又因小儿体温调节中枢发育不完善,发热,成了儿童常见的症状,那么抗生素、解热镇痛药物的应用就相对较多,如何正确使用,值得每一位儿科医生认真总结。     

癌症患者麻醉性镇痛药使用情况评估

对120例癌症患者门诊400张麻醉性镇痛药处方使用情况统计分析。处方书写规范,管理有方,麻醉性镇痛药品种少。医务人员对三阶梯用药原则理解偏面,对麻醉性镇痛药存在误解,对其“成瘾”,“耐受”与临床必须认识不清,存在按需给药情况,采用麻醉性镇痛药治疗癌痛患者剂量偏少。     

不同镇痛药物用于人工流产术效果比较

目的:比较4种镇痛药物用于人工流产术镇痛的效果。方法:将拟行用镇痛药物做人工流产术的早孕妇女450例随机分为4组:异丙酚一芬太尼组120例,米索前列醇组120例,仕泰栓组100例,利多卡因组110例。记录各组镇痛效果、宫口松驰、阴道出血量、手术时间及人工流产综合征的发生情况。结果:4组镇痛药物均能提供有效的镇痛,异丙酚-芬太尼对呼吸、循环有抑制作用,使用时须严密监测,并备好复苏设备和抢救药品。结论:4组镇痛各有优点,临床中应根据不同受术者的情况选择使用。     

麻醉苏醒室患者应用镇痛药物的观察及护理

目的探讨使用镇痛药物后对患者镇痛效果、镇静程度、心率（HR）、血压、呼吸（RR）、血氧饱和度（SpO2）的影响,观察其并发症,评价其安全性及护理对策。方法352例外科手术后入麻醉苏醒室的患者使用镇痛药物前后疼痛视觉模拟标尺法（VAS）评分、用Ramsay镇静评分法进行镇静评分[1]、HR、收缩压（SBP）、舒张压（DSP）、RR、SpO2的比较,观察有无呼吸抑制等并发症。结果患者镇痛前后VAS评分、Ramsay镇静评分、HR、SBP、DSP、RR、SpO2相比有显著性意义（P〈0.01）。镇痛后有3例呼吸抑制时无气管导管,均及时处理后恢复,未出现其他并发症。结论虽然术后患者使用镇痛药物后会出现呼吸抑制,但术后使用镇痛药物对于减轻患者疼痛仍然是一种安全有效的治疗方法。     

临床药师干预对老年病肿瘤科癌痛镇痛药物使用的影响

目的分析临床药师干预对老年病肿瘤科癌痛镇痛药物使用的影响。方法2018年临床药师宣传癌痛规范化治疗,对治疗不合理情况进行干预。通过Pharm Assist系统,调查2017年和2018年该科癌痛患者镇痛药物使用情况。分别比较该科室住院、门诊患者干预前、后镇痛药物的使用数量、DDDs、使用金额等指标,评价癌痛合理治疗改善情况。结果临床药师干预后,该科住院癌痛患者强阿片类药物用量大幅增加,哌替啶用量显著下降;门诊强阿片药物使用明显增加,镇痛药物使用结构渐趋合理。结论临床药师干预可使癌痛治疗得到重视,促进老年病肿瘤科强阿片类药物使用的增加,使镇痛药物使用渐趋合理。     

因疼痛研究引发镇痛药物的创新

目的：回顾近年来镇痛药的研究进展，从其最新的研究手段和方法、对中枢性致敏现象的药物及镇痛模型几方面进行概述。资料来源：应用计算机检索NCBI数据库1996—01／2001-01的文章，检索词“analgesic，analgetic，pain”，限定文章语言种类为英文；同时检索近3年http：／／www．wanfangdata．com．cn文章，检索词“镇痛；镇痛药；神经节阻滞药”，限定文章语言种类为中文。资料选择：共检索出50000多篇与镇痛药物有关文献，对资料进行初审。纳入条件：①基础研究。②临床研究。排除条件：①综述文献。②内容重复。资料提炼：共收集100篇基础研究文献，选择反映镇痛药研究进展的相关文献15篇，排除综述类及重复研究文献82篇。资料综合：①新的研究手段和方法：原癌基因c-fos是一类DNA结合蛋白质，可以调节一些与疼痛密切相关的基因的表达；有研究发现抑制P物质的合成可能是其发挥中枢性镇痛作用的一个主要机制。②新的研究思路：开发针对中枢性致敏现象的药物是目前研究的方向。③新模型的研究：新建立包括培养脊髓背根神经节神经元模型及吞咽反应模型。结论：充分利用各种新的研究方法和模型对疼痛产生的影响进行研究，以寻找更多的新药；并从细胞、分子水平深入研究神经递质和递质受体的克隆，寻找药物的新作用靶点；进一步深入认识关于人类慢性疼痛的整体性，将随着神经科学研究的进展取得更多的突破。     

护理干预对骨科手术患者术后镇痛药使用的影响

目的：探讨护理干预对骨科手术患者术后镇痛药使用的影响。方法：将132例骨科择期手术患者随机分为观察组68例和对照组64例,对照组采用常规传统护理方法,观察组采用系统的护理干预,观察并比较两组患者术后疼痛程度。结果：观察组镇痛有效率高于对照组（P〈0．05）,两组镇痛药使用率比较有极显著性差异（P〈0．01）。结论：对骨科手术患者进行系统的护理干预,能有效缓解术后疼痛,减轻患者痛苦,减少骨科患者术后镇痛药的使用。     

A pilot study into the problematic use of opioid analgesics in chronic non-cancer pain patients.

Controversy surrounds the use of strong opioid analgesic drugs for chronic non-cancer pain. Specialists have concluded that fears of problematic drug use are often unfounded. In contrast, others claim the existence of significant problems.'Problematic drug use' includes the following definitions; addiction, abuse, physiological dependence and tolerance.We present a case study and the results of a pilot, longitudinal, cohort study, via a pilot questionnaire, of 22 chronic pain clinic patients following a trial of opioid drugs.The results suggest that chronic non-cancer pain patients can be maintained on opioids with few problems, and likewise can withdraw with minimal adverse effects, other than a return of pain.     

The use of analgesics in patients with acute abdominal pain

Analgesics in patients with acute abdominal pain are often withheld for fear that they may change physical examination findings and thus may be unsafe. We conducted a randomized, prospective, placebo-controlled trial to investigate changes in physical examination following the administration of placebo, 5 mg, or 10 mg of morphine to 49 patients with acute abdominal pain. One patient was withdrawn secondary to inadequate documentation. Of the 48 patients who completed the trial, a statistically significant change in physical examination was noted in both groups receiving analgesics, but not in the placebo group. No adverse events or delays in diagnosis were attributed to the administration of analgesics. We conclude that physical examination does change after the administration of analgesics in patients with acute abdominal pain and that a larger study is needed to evaluate analgesic safety in this subpopulation of emergency department patients.     

Time-scheduled vs. pain-contingent opioid dosing in chronic opioid therapy

Some expert guidelines recommend time-scheduled opioid dosing over pain-contingent dosing for patients receiving chronic opioid therapy (COT). The premise is that time-scheduled dosing results in more stable opioid blood levels and better pain relief, fewer adverse effects, less reinforcement of pain behaviors, and lower addiction risk. We report results of a survey of 1781 patients receiving COT for chronic noncancer pain, in which 967 reported time-scheduled opioid dosing only and 325 reported pain-contingent opioid dosing only. Opioid-related problems and concerns were assessed with the Prescribed Opioids Difficulties Scale. We hypothesized that respondents using time-scheduled opioid dosing would report significantly fewer problems and concerns than those using pain-contingent dosing. Patients receiving time-scheduled dosing received substantially higher average daily opioid doses than those using pain-contingent dosing (97.2 vs. 37.2 mg average daily dose morphine equivalents, P < .0001). Contrary to expectation, time-scheduled opioid dosing was associated with higher levels of patient opioid control concerns than pain-contingent dosing (6.2 vs. 4.8, P = .008), after adjusting for patient and drug regimen differences. Opioid-related psychosocial problems were somewhat greater among patients using time-scheduled dosing, but this difference was nonsignificant after controlling for patient and drug regimen differences (5.9 vs. 5.0, P = .14). Time-scheduled dosing typically involved higher dosage levels and was associated with higher levels of patient concerns about opioid use. Controlled comparative effectiveness research is needed to assess benefits and risks of time-scheduled opioid dosing relative to pain-contingent opioid dosing among COT patients in ambulatory care.     

Opiate and opioid use in patients with refractory headache

Opiate and opioid analgesics are commonly used for pain in general and presumably for headache. Codeine, oxycodone and propoxyphene, among the most commonly prescribed, do carry some risk of abuse, and their efficacy in headache patients has not been well studied. In many patients with other kinds of pain, however, both of neoplastic and non-neoplastic origin, chronic opiate use has been demonstrated to be of benefit without adverse side effects. The type of headache patient with intractable pain who needs frequent opiate analgesic and who does not develop addiction or drug abuse is an important subject for research.     

小汤山医院680例SARS患者药品不良反应分析

目的 研究小汤山医院SARS患者用药过程中药品不良反应的发生情况.方法通过制定和下发合理用药手册,成立临时药品不良反应监测小组等方式指导合理用药,跟踪随访并实时收集所有不良反应报告.采用WHO不良反应分级、分类标准,参考解放军总医院医院信息系统(Hospital Information System,HIS)的原始数据,回顾性系统分析不良反应的发生情况及规律.结果小汤山医院680例SARS患者中,共发生药品不良反应193例(251例次,男性87例,女性106例),发生率28.38%.女性和老年SARS患者的不良反应发生率高于男性和青年患者;重症和原有糖尿病的SARS患者更易发生不良反应;大剂量和合并用药更易引起药品不良反应;激素类药物是本次SARS治疗中引起药品不良反应的主要因素;而且注射剂比各种口服制剂引起的不良反应发生率更高.本次发生的各种药品不良反应主要集中在血液系统异常、胃肠系统异常和内分泌异常.结论 SARS药物治疗涉及品种多、剂量大,不良反应的发生率较高,SARS治疗需慎重使用激素类药物.     

Reduction of opioid use and improvement in chronic pain in opioid-experienced patients after topical analgesic treatment: an exploratory analysis

Objective: There is a need to identify safe and effective opioid-sparing multimodal alternative treatment strategies and approaches, including topical analgesics, for opioid-experienced chronic pain patients to mitigate the risk of addiction, misuse, and abuse of opioids.

Methods: This subset analysis from a prospective, observational study evaluated changes in opioid use, other concurrent medication use, and pain severity and interference in opioid-experienced patients (OEP) treated with topical analgesics for chronic pain with measures obtained at baseline and 3- and 6- month follow-up.

Results: The 3-month opioid-experienced patient (3-month OEP) group included 121 patients who completed baseline and 3-month follow-up assessments; 27 opioid-experienced patients completed baseline and 6-month follow-up assessments (6-month OEP). Demographic characteristics, and mean pain severity and interference scores were similar between groups at baseline. After treatment with topical analgesics, 49% of patients in the 3-month and 56% of patients in the 6-month group reported they had completely discontinued use of opioids. In addition, 31% of patients at the 3-month assessment and 30% at the 6-month assessment reported that they were no longer taking any pain medication. Other concurrent medications decreased by 65% after 3 months, and 74% after 6 months. There were statistically significant decreases from baseline in pain severity and interference scores within the 3- (CI:0.7–1.4, 1.4–2.2) and 6-month (CI:0.7–2.4 (severity); CI:1.2–3.5 (interference)) OEP groups.

Conclusions: Opioid use and other concurrent medications decreased among opioid-experienced chronic pain patients after 3- and 6- months of treatment with topical analgesics. Pain severity and interference scores also decreased. The topical analgesics were reported to be effective and safe for the treatment of chronic pain, with randomized controlled trials needed to confirm these findings.     

对出院精神分裂症患者进行电话随访的依从性效果分析

目的探讨电话随访对出院精神分裂症患者的干预效果。方法将268例精神分裂症患者按出院日单双号分为观察组136例及对照组132例。对观察组患者最少进行为期1年电话随访;对照组出院后不进行电话随访。1年后对患者服药、复诊、参加社会活动、复发等情况作调查。结果回收调查表观察组126份、对照组119份,两组出院后1年的服药依从、参加社会活动、按时复诊、复发率及满意率比较,差异有统计学意义（P〈0．01）。结论实施电话回访,有利于精神病患者出院后提高服药依从性,促进患者参加社会活动、按时复诊等,从而降低复发率,提高患者满意率。