癌痛的药物治疗和三阶梯指导原则(三)

(接上期) 　　3强阿片类止痛药 　　这是一组以吗啡为“主打“药品的强力镇痛药,主要应用于重度癌痛的第三阶梯治疗阶段. 　　3.1药理作用在介绍弱阿片类止痛药时,曾简单地提及了阿片类药物的药理作用.鉴于还有许多人对该类药品的认识存有许多误区,至今仍在很大程度上影响着这类药品的正确应用和疗效的发挥.所以,在讲解强阿片类药物的治痛技术前,将阿片类药物的相关知识作一些延伸性的介绍. 　　……     

教育干预照顾者对癌痛患者口服阿片类药物依从性的影响

目的:为客观评价教育干预照顾者对癌痛患者口服阿片类药物依从性的影响评价,提高癌痛患者口服阿片类药物的依从性.方法:选取2016年1月-2016年12月在我院住院期间口服阿片类药物且依从性较差的患者88例.按纳入先后随机分为两组,其中对照组43例:按常规的疼痛服药护理,观察组45例:按常规的疼痛服药护理,辅以照顾者教育干预.评估比较两组口服阿片类药物的依从性、癌痛缓解程度和患者生活质量.结果:观察组患者口服阿片类药物的依从性、疼痛缓解程度及生活质量均高于对照组.P值<0.05.结论:教育干预患者照顾者可显著提高癌痛患者口服阿片类药物的依从性,有效的缓解患者的疼痛,提高患者的生活质量,具有良好的社会效应.     

癌痛药物管理政策亟待优化

正使用阿片类药物是治疗中重度癌痛的国际公认金标准,然而近日公布的一项大样本调查显示,近一半被评估为中度的癌痛患者处方仍使用非强阿片类药物,近25%被评估为重度的癌痛患者处方仍未使用强阿片类药物,甚至还有部分中重度患者未曾使用任何药物镇痛。专家呼吁,应消除患者及其家属对阿片类药物的认识误区,提高医护人员对癌痛规范化诊疗和重要性的认     

氟比洛芬酯微球注射液应用在大剂量阿片类药物治疗癌痛患者疗效安全性

目的 评价氟比洛芬酯微球注射液应用在大剂量阿片类药物治疗癌痛患者的疗效安全性.方法 41例大剂量使用阿片类药物治疗癌痛患者,联合使用0.9%生理盐水(100ml)+氟比洛芬酯注射液(50-100mg/次,静脉注射2次/d),对其疗效进行评价,并观察其不良反应.结果 通过实验证实,实验所加入的氟比洛芬酯微球注射液及原阿片类药物的使用剂量都有所减少,硫酸吗啡控释片与盐酸羟考酮控释片的全天使用剂量降低了25%左右;合并使用氟比洛芬酯微球注射液前后出现恶心、便秘、呕吐、头晕、尿潴留、嗜睡等不良反应的情况均有不同程度的降低.     

移情易性情志护理联合穴位按摩对改善癌痛的疗效观察

选择2014年1月-2014年12月上海市嘉定区中心医院肿瘤科收治的未采用癌痛规范化治疗癌痛患者60例,随机分为对照组30例采用常规治疗,实验组30例在常规治疗的基础上,予以移情异性情志护理联合穴位按摩,并探讨移情易性情志护理联合穴位按摩对改善癌痛的临床疗效。结果表明,在癌痛的患者中使用移情易性情志护理联合穴位按摩能有效缓解疼痛,并可延长疼痛间隔时间,减少止痛药物的使用频率。     

癌痛规范化管理对肿瘤患者依从性及治疗效果的影响

目的:对肿瘤患者采用癌痛规范化管理的效果进行分析和讨论。方法:本次76例研究对象均为我院2017年1月-2018年1月接收的癌痛患者,均接受癌痛规范化治疗病房规范化管理,对比管理前后患者用药依从性和癌痛知识掌握状况。结果:管理后,患者遵循医嘱服用药物依从性显著高于管理前(P0.05);在私自增加、删减或者停止药物以及未按照规定时间服用药物等情况低于管理前(P0.05);管理后,患者癌痛评估方法、癌痛定义以及对癌痛认识等知识掌握状况显著优于管理前(P0.05)。结论:癌痛规范化治疗病房规范化管理有助于提升患者用药依从性,帮助患者更好的认识和掌握疼痛相关知识。     

揭开阿片类药物的“神秘面纱”

<正>阿片类药物又称为“麻醉性镇痛药”，相关药物与阿片受体结合，作用于中枢神经系统，可选择性地消除或缓解人的痛觉，并改变因疼痛导致的情绪反应。目前，阿片类药物主要用于缓解中重度疼痛，如癌痛。分类与应用阿片类药物可分为弱阿片类药物和强阿片类药物。弱阿片类药物有曲马多、双氢可待因、丁丙诺啡等。强阿片类药物有吗啡注射液、盐酸吗啡片、美沙酮、     

服用缓控释制剂常见疑问解答

缓控释制剂的优点缓控释制剂是一类可以在用药后较长时间内持续释放药物,使药物按适当的速度缓慢进入体内的制剂。与普通剂型相比,缓控释制剂具有以下优点:①延长药物在体内的作用时间,减少服药次数,极大地提高了患者的用药便利性;②可在较长时间内维持一定的血药浓度,确保药物的治疗效果;③避免或减少血药浓度的峰谷现象,有利于降低药物的不良反应。     

针灸在肿瘤癌痛治疗的进展

肿瘤晚期患者常常出现疼痛症状,易造成患者生理和心理严重受损,影响其生存质量。目前传统治疗方法是世界卫生组织推荐的三阶梯治疗方案,主要以药物治疗为主。在临床治疗癌痛的过程中,也可以采用一些非药物治疗或单用非药物治疗,如物理疗法、心理疗法、音乐疗法,及中医的针灸治疗。其中针灸治疗具有明显的止痛效果,已广泛应用在临床治疗癌痛中,因此本文是对近十年来文献中针灸治疗癌痛的临床使用方法和疗效回顾,进一步体现针灸治疗癌痛的作用。     

药学监护促进癌痛药物合理性使用的作用研究

目的 回顾性分析癌痛药物使用的情况,探讨药学监护在癌痛规范化治疗中的作用。方法 制定癌痛规范化治疗标准,随机抽取2019—2020年癌痛患者病历60份进行合理性评价;临床药师以癌痛药物不合理使用作为切入口,对癌痛患者实施药学监护,通过制定并调整给药方案,给予患者用药教育,为临床提供癌痛药学服务。结果 癌痛患者多为60岁以上者（56.7%）,止痛药物使用最多的是盐酸羟考酮缓释片,其次为氨酚曲马多片。32例患者存在不合理使用情况,主要表现为使用阿片类药物未滴定。给予患者药学监护和用药教育可以促进合理使用。结论 临床药师提供癌痛药学监护可以促进癌痛药物的合理性使用,癌痛规范化治疗有利于临床合理用药。     

Treatment of pain in cancer with systemically administered opioids

The World Health Organization guidelines for cancer pain relief have been proven efficacious in 90% of the patients with cancer pain. The patient's self-report of pain is the focus of treatment. When initiating treatment, controlled-release preparations of opioids are generally favoured, and are combined with immediate release morphine to prevent or treat 'breakthrough' pain and to enable the optimum opioid dosage to be calculated. (Breakthrough pain is a transient increase in pain in a patient who has stable, persistent pain treated with opioids.) In patients with an unfavourable balance between analgesia and side effects, the following strategies may be useful, together with appropriate treatment of the side effects: Sequential opioid trials (so-called opioid rotation) is an approach which is effective in 50-70% of the patients. Changing the route of opioid administration is successful in 70-95% of the patients. When selecting an invasive technique, continuous subcutaneous infusion is medically preferred. Spinal analgesia is an alternative. Knowledge of the relative potency of opioid drugs and of their biologic availability is needed to guide changes in drugs or routes of administration.     

盐酸羟考酮控释片联合加巴喷丁治疗糖尿病性神经痛的临床应用

目的 探讨盐酸羟考酮控释片联合加巴喷丁治疗糖尿病性神经痛的疗效和安全性.方法 将80例糖尿病性神经痛患者按照随机数字表法分成两组,每组40例,A组单纯使用盐酸羟考酮控释片治疗,B组联合使用加巴喷丁,观察比较两组疼痛缓解程度、用药量、生活质量及不良反应情况.结果 两组疼痛均明显缓解,B组治疗后21～28 d的疼痛缓解率明显优于A组[95.0%(38/40)比62.5%(25/40)],差异有统计学意义(P＜0.05);B组和A组治疗后28 d的疼痛程度分别为1.2±0.3和2.8±0.5,差异有统计学意义(P＜0.01);B组治疗后28 d,盐酸羟考酮控释片使用剂量低于A组[(32.2±4.3)mg比(40.3±5.5)mg],差异有统计学意义(P＜0.05);B组患者的生活质量评分优于A组,差异有统计学意义(P＜0.05或＜0.01);B组治疗后7、14 d头晕发生率高于A组[35.0%(14/40)比15.0%(6/40)和30.0%(12/40)比10.0%(4/40)],差异有统计学意义(P＜0.05).结论 盐酸羟考酮控释片联合加巴喷丁治疗中重度糖尿病性神经痛疗效确切,安全可行.     

羟考酮缓释片在缓解晚期肺癌疼痛中的效果观察

[目的]观察羟考酮缓释片在多西他赛二线治疗伴随疼痛的晚期肺癌患者的疗效及安全性。[方法]对2007年2月—2011年7月收治的40例中、重度肿瘤疼痛者采用羟考酮缓释片止痛,同时予多西他赛75 mg/m2静脉滴注1 h,第1天,每3周重复。观察治疗前后疗效、不良反应及生活质量评分。[结果]有效率27.5%,疾病控制率60%,中位生存期9.35个月,1年生存率37.5%。与治疗前比较,患者疼痛程度有较大的缓解,疼痛缓解率为97.5%,数字模拟评分法(NRS)评分明显降低,KPS评分明显升高,差异均具有统计学意义(P<0.05)。不良反应主要是血液学毒性和便秘,治疗后可以缓解。[结论]羟考酮缓释片联合多西他赛治疗中重度疼痛的肺癌安全有效,能明显改善病人的生活质量。     

羟考酮缓释片用于癌痛患者滴定治疗的可行性分析

目的：探讨羟考酮缓释片用于癌痛患者止痛滴定的可行性。方法：48例中重度疼痛的阿片未耐受癌症患者,中位年龄74.5岁,分为A（中度疼痛）、B（重度疼痛7～8分）、C（重度疼痛9～10分）三组,盐酸羟考酮缓释片初始剂量分别为10mg、10mg、20mg联合短效吗啡针剂5mg～10mg,根据患者疼痛情况及爆发痛治疗情况于12h和24h调整奥施康定的剂量。评估24h滴定完成率（疼痛评分3分以下）以及1h、12h、24h疼痛明显缓解率、不良反应及生活质量的变化。结果：24h评估时95.8%的患者完成滴定,疼痛评分降到3分以下。1h、12h、24h疼痛明显缓解率分别为66.7%、77.1%和95.8%。预防治疗可显著降低恶心、呕吐、便秘不良反应。止痛治疗后睡眠质量明显改善。结论：奥施康定用于阿片未耐受中重度癌痛患者滴定,有效、简便、快速。     

盐酸吗啡缓释片不同给药途径对缓解癌症疼痛的分析研究

目的：分析研究盐酸吗啡缓释片不同给药途径对肿瘤患者癌症性疼痛的缓解作用。方法：选择中、晚期癌症患者168例,均接受盐酸吗啡缓释片进行疼痛治疗,根据给药途径不同随机分为接受口服给药的对照组和接受直肠给药的观察组,分析两组患者治疗后的疼痛缓解程度、镇痛起效时间以及不良反应发生率等指标差异。结果：治疗后观察组患者的总缓解率为94.05%（79/84）,与对照组患者无明显差异;治疗后观察组患者的平均起效时间为（0.68＆#177;0.17）h,明显短于对照组患者,且各时间段的镇痛起效百分率均高于对照组患者;治疗后观察组患者的不良反应总发生率为2.38%（2/84）,明显低于对照组患者。结论：盐酸吗啡缓释片直肠给药途径可以显著缓解肿瘤患者的癌症性疼痛,提高镇痛起效时间,且不会增加患者不良反应发生,具有良好的治疗安全性。     

芬太尼贴剂联合盐酸吗啡缓释片治疗重度癌痛的疗效比较

目的 比较芬太尼贴剂联合盐酸吗啡缓释片治疗癌痛的临床疗效.方法将符合病例入选标准的80例癌痛患者随机分为观察组、对照组,每组40例.2组均给予盐酸吗啡缓释片,观察组给予芬太尼贴剂,每3日更换1次.2组均以服药10 d为1个疗程,治疗2个疗程后观察2组疼痛缓解程度、生活质量的改善情况及头晕、嗜睡、恶心、呕吐、便秘、排尿困难等不良反应的发生情况.结果 CR率观察组为57.50％,对照组为40.00％,2组相比差异有统计学意义(P＜0.05). (CR+PR+MR)率观察组为95.00％,对照组为75.00％,2组相比较差异有统计学意义(P＜0.05).食欲、睡眠、日常活动、精神状态、情绪、与人交往、生活兴趣等方面2组治疗前后组内相比差异有统计学意义(P＜0.05)；2组治疗组间相比差异有统计学意义(P＜0.05).结论 芬太尼贴剂联合盐酸吗啡缓释片治疗癌痛临床疗效显著,不良反应小.     

Oral transmucosal fentanyl citrate for the treatment of breakthrough pain in cancer patients: an overview of its pharmacological and clinical characteristics

Breakthrough pain is a transitory flare of pain occurring in most cancer patients against a background of otherwise controlled persistent pain. Treatment of breakthrough pain is a challenging phenomenon. Oral transmucosal fentanyl citrate (Actiq, Cephalon, Inc, West Chester, PA), a new opioid formulation with a unique delivery system, reflects the characteristics of breakthrough pain (rapid onset of action and short duration), making it an effective treatment for cancer patients who already receive opioids and experience flares of pain. This review article aims to present the role of oral transmucosal fentanyl citrate in the management of breakthrough pain in cancer patients. In particular, it is going to discuss the synthesis, clinical pharmacology, pharmacokinetic and pharmacodynamic properties, toxicity, and clinical efficacy of this novel agent.     

Multimodal analgesia as an alternative to the risks of opioid monotherapy in surgical pain management

Clinicians have long been aware of the danger of overreliance on opioids to manage acute pain, such as the pain accompanying surgery. The risk of adverse drug events is higher with opioids than with any other common class of drugs. Overreliance on opioids increases length of stay and hospital costs, while decreasing patient satisfaction. Opioids can lead to problems that continue well after discharge, including chronic pain, abuse and addiction, and even death. Increasingly, prescribed opioids have proved to lead to heroin addiction. Studies show that the same professionals who prescribe, administer, and monitor opioids lack basic knowledge about their safe and effective use. The alternative to opioid monotherapy in controlling acute pain is multimodal analgesia, an approach that relies on a nonopioid foundation with addition of adjunctive opioids as needed. An increasing number of nonopioid analgesics have proved effective in this role, with fewer side effects and a higher degree of safety than opioids. Accordingly, multimodal analgesia is recommended as best practice by most recognized authorities. Increasingly, governmental authorities hold prescribing clinicians and institutions legally liable for the downstream negative effects of opioids, including abuse and addiction. Addressing this issue should be a top priority for hospital risk managers.     

Management of lung cancer-related pain

Pain occurs in seventy-four percent of patients suffering from advanced lung cancer, and eighty-two percent of patients feels that the applied treatment of pain was inefficient. The management of cancer-related pain is based on the WHO analgesic ladder. The ladder has three steps. Step one involves the use of nonsteroidal anti-inflammatory drugs for mild pain, step two mild opioids for moderate pain and step three strong opioids for the treatment of heavy pain. This management - in case of emergency - is supplemented by interventional procedures (nerve blockades, surgery). The most effective pain-killing intervention is the all-round oncological and surgical therapy. The different treatments (oncological, radiological, surgical, drug and interventional) are applied in combination with each other. The paper is dealt with the possibility offered by the drug and interventional treatments.     

Principles of cancer pain management. Use of long-acting oral morphine

Oral morphine is increasingly recognized as the pharmacologic standard for cancer pain management. Yet for the primary care physician and oncologist alike, misconceptions of the safety and efficacy of oral morphine along with lack of recognized guidelines for use have often resulted in inadequate cancer pain therapy. Use of controlled-release oral morphine sulfate (MSC) requires additional guidelines for optimum analgesia. Proposed are ten principles of dosing oral morphine, especially MSC, which were followed in a clinical trial involving cancer patients. MSC dosed at 8-, 10-, and 12-hour intervals was compared with immediate-release morphine (IRMS) dosed every four hours, and with prestudy analgesics. Patients achieved satisfactory analgesia at daily doses (mean +/- SE) of 118.0 +/- 8.6 mg and 111.4 +/- 12.6 mg (P greater than .05) for IRMS and MSC, respectively. Dosing endpoints were determined by titration with IRMS and MSC to a minimal and equivalent amount of supplemental short-acting analgesic. Side effects were typical for opioids and tolerated except for one dropout on IRMS (nausea and constipation). The ten principles have been incorporated into a dosing scheme as a practical guide for MSC therapy.