社区阿片类药物依赖者自愿美沙酮脱毒治疗护理干预

目的：探讨社区阿片类药物依赖者应用美沙酮脱毒治疗的护理干预效果。方法对阿片类药物依赖者应用美沙酮脱毒治疗期间采用家庭关系疏导、心理护理、集体心理治疗、认知行为治疗、电话随访以及健康教育等措施进行护理干预。结果经过相应的护理干预后,患者治疗依从性显著提高,增加了脱毒信心,生活质量明显改善。结论对社区阿片类药物依赖者应用美沙酮脱毒治疗过程中进行综合护理干预,能增强患者戒毒的信心,提高患者及家庭的生活质量,帮助患者回归社会。     

Opioid dependence and addiction during opioid treatment of chronic pain

Throughout the long history of opioid drug use by humans, it has been known that opioids are powerful analgesics, but they can cause addiction. It has also been observed, and is now substantiated by multiple reports and studies, that during opioid treatment of severe and short-term pain, addiction arises only rarely. However, when opioids are extended to patients with chronic pain, and therapeutic opioid use is not confined to patients with severe and short-lived pain, compulsive opioid seeking and addiction arising directly from opioid treatment of pain become more visible. Although the epidemiological evidence base currently available is rudimentary, it appears that problematic opioid use arises in some fraction of opioid-treated chronic pain patients, and that problematic behaviors and addiction are problems that need to be addressed. Since the potentially devastating effects of addiction can substantially offset the benefits of opioid pain relief, it seems timely to reexamine addiction mechanisms and their relevance to the practice of long-term opioid treatment for pain. This article reviews the neurobiological and genetic basis of addiction, its terminology and diagnosis, the evidence on addiction rates during opioid treatment of chronic pain and the implications of biological mechanisms in formulating rational opioid treatment regimes.     

Complications of accelerated opioid detoxification

All accelerated opioid detoxifications under anesthesia, which were performed at our district hospital during 3 years (1999 to 2002), have been retrospectively analyzed. A total of 48 detoxifications were made in 43 patients. Three serious complications were recorded. In the first case, there was incomplete detoxification using naltrexone. The naloxone test was negative. After recovery from anesthesia, the patient developed a severe withdrawal syndrome that required repeated detoxification. In the second case, the patient developed bedsores at the site of the sacrum and scapulae after 7-hour detoxification. Reddening and edema disappeared on day 3 without treatment. In the third case, there was insufficient artificial ventilation due to inspiratory valvular defect. Capnography was not applied. The symptoms of hypercapnia, such hypertension, hyperemia, sweating, were regarded as the symptoms of abstinence so anesthesia was intensified. Valvular defect was detected when the patient developed hypoxia. All the patients were discharged from hospital in a satisfactory condition.     

Therapeutical potentialities of rapid opioid detoxification

The influences of rapid detoxification (RD) versus the routine approach to abolishing the withdrawal syndrome on the clinical manifestations of opioid dependence were evaluated. The use of RD revealed a therapeutical dissociation: its effective influence on somatoneurological manifestations of the withdrawal syndrome and its very insignificant impact on mental disorders, including drug addiction. It is concluded that RS is a modern and promising method to arrest the opioid withdrawal syndrome, which is alternative to other therapeutical approaches, but inadequate to treat drug addiction.     

Doctors and patients in pain: Conflict and collaboration in opioid prescription in primary care

Use of chronic opioid therapy (COT) for chronic noncancer pain has dramatically increased in the United States. Patients seek compassionate care and relief while physicians struggle to manage patients’ pain effectively without doing harm. This study explores the narratives of chronic noncancer pain patients receiving chronic opioid therapy and those of their physicians to better understand the effects of COT on the doctor–patient relationship. A mixed method study was conducted that included in-depth interviews and qualitative analysis of 21 paired patients with chronic pain and their physicians in the following groups: patients, physicians, and patient–physician pairs. Findings revealed that patients’ narratives focus on suffering from chronic pain, with emphasis on the role of opioid therapy for pain relief, and physicians’ narratives describe the challenges of treating patients with chronic pain on COT. Results elucidate the perceptions of ideal vs difficult patients and show that divergent patterns surrounding the consequences, utility, and goals of COT can negatively affect the doctor–patient relationship. The use of paired interviews through a narrative lens in this exploratory study offers a novel and informative approach for clinical practice and research. The findings have significant implications for improving doctor–patient communication and health outcomes by encouraging shared decision making and goal-directed health care encounters for physicians and patients with chronic pain on COT.PerspectiveThis study found patterns of understanding pain, opioid pain medications, and the doctor–patient relationship for patients with chronic pain and their physicians using a narrative lens. Thematic findings in this exploratory study, which include a portrayal of collaborative vs conflictual relationships, suggest areas of future intervention and investigation.     

Nurses' perceptions of medication safety and medication reconciliation practices

Medication reconciliation (MR) involves the accurate transfer of medication information across the continuum of care. The aim of this study was to measure nurses perceptions of patient safety, medication safety and current MR practice at transition points in a patient's hospital stay. Surveys were distributed to 111 nursing staff in three general medicine units at Capital Health District, Nova Scotia, in August 2005. A total of 39 nurses (35% response rate) completed the survey. "Teamwork within units" was the safety culture dimension with the highest positive response (98.1%), while the processes of handoffs and transitions received the lowest positive response (42.8%). Key areas identified for improvement relative to the current level of MR practice include institutional patient safety systems (e.g., low confidence in existing systems and procedures), inconsistent practices (e.g., wide variation in whether community pharmacists are contacted to verify medication profiles), lack of communication (e.g., between healthcare professionals) and staffing resources (e.g., MR is perceived as a very time-consuming process). Addressing these challenges prior to implementing a formalized MR program should help to ensure success of the project. The insights gained through the use of this survey may prove valuable to other Canadian healthcare organizations that are implementing MR services.     

Mechanism of opioid dependence and interaction between opioid receptors

Clinical studies have demonstrated that when opiates are used to control cancer pain, psychological dependence and analgesic tolerance are not a major concern. The present study was, therefore, designed to investigate the modulation of rewarding effects of opiates under inflammatory chronic pain. Formalin or carrageenan was injected into the plantar surface of the rat paw. Formalin and carrageenan reduced the paw pressure threshold. The hyperalgesia lasted for 9–13 days. The rewarding effect of morphine was evaluated by conditioned place preference paradigm. Morphine produced a significant place preference. This effect was significantly attenuated in inflamed groups compared with the respective non-inflamed groups. Furthermore, the morphine-induced place preference in the inflamed group gradually recovered to the respective control level as the inflammation healed. We also found that κ-receptor agonists markedly inhibited the rewarding effect of μ-receptor agonists. Therefore, to elucidate the mechanism of this attenuation, the effects of pretreatment with κ- and δ-receptor antagonists, nor-binaltorphimine (nor-BNI) and naltrindole (NTI), on the development of the morphine-induced place preference under inflammation were examined. Nor-BNI, but not NTI, eliminated the suppression of the morphine-induced place preference in inflamed groups. The morphine-induced increase in dopamine (DA) turnover in the limbic forebrain was suppressed under inflammation, and the suppression was abolished by the pretreatment with nor-BNI. These results suggest that endogenous κ-opioid systems may be activated by chronic inflammatory nociception, and then the activation of κ-opioid system may inhibit DA release in nucleus accumbens, resulting in the suppression of the development of rewarding effects produced by morphine.     

Regulations of opioid dependence by opioid receptor types

Three major types of opioid receptors, designated mu, delta, and kappa, are widely expressed in the CNS. Development of selective receptor ligands and recent cloning of each receptor have contributed greatly to our increasing knowledge of the neuropharmacological profile of each opioid receptor type. It is of interest to note that they include noncompetitive and allosteric interactions among their types. This review focuses on the functional interaction among these opioid receptor types that contribute to opioid dependence. Various studies provide arguments to support substantial roles for mu-opioid receptors and the possible involvement of delta-opioid receptors in the development of physical and psychological dependence on morphine. Noradrenergic transmission originating in the locus coeruleus is most likely to play the primary causal role in the expression of physical dependence on morphine. In contrast, many studies have pointed to the mesolimbic dopaminergic pathway projecting from the ventral tegmental area to the nucleus accumbens as a critical site for the initiation of psychological dependence on opioids. It is noteworthy as the broad existence of opposing interactions between mu/delta- and kappa-receptors in the brain. The activation of kappa-receptors leads to the suppression of unpleasant mu/delta-mediated side effects such as the rewarding effect. Considering the functional interaction among opioid receptor types, the co-administration of morphine-like compounds with kappa-receptor agonists may constitute a preferable and superior approach to the treatment of pain with fewer side effects.     

Relationships between nurses' observations and patients' self-reports of pain

Pain researchers and clinicians alike are often troubled by a lack of correspondence between non-verbal behavior and patients' self-reports of level of pain. This paper discusses some of the variables which can effect the relationship between these measures. In addition, the paper reports on the reliability of nurses' observations of pain behavior and of their inferences about the intensity of a patient's pain. In general, though these observations and inferences have adequate reliability, the correspondence between such inferences and patients' reports of pain intensity are modest, though significant. Discrepancies between observers' and patients' ratings of pain are greater in a chronic pain sample (N = 37) than in an acute pain sample (N = 34). Theoretical implications of these results are discussed.     

解毒通络方对脑缺血损伤大鼠海马与皮质神经递质变化的影响

目的:观察解毒通络方对脑缺血大鼠恢复期海马与皮质中单胺类递质和乙酰胆碱含量的影响。方法:实验于2005-05/2006-02在北京中医药大学病理实验室与中国中医科学院西苑中医院药理实验室完成。选择健康SD大鼠150只,采用双侧颈总动脉夹闭结合低血压状态制作脑缺血模型,将造模成功的150只大鼠随机数字表法分为5组,正常组、模型组及解毒通络方低剂量组、中剂量组、高剂量组,各30只。每组又分为造模后4,8周2个时相点,每个时相点15只。各剂量治疗组每天按不同剂量灌服解毒通络口服液(由栀子、丹参、黄芪、天麻等组成),低、中、高剂量分别相当于生药1.85,3.7,7.4g/kg,配置成给药体积为5mL/kg的溶液;模型组、正常组同时灌胃相应体积的洁净水。以改进的柱前、柱后双酶柱结合高效液相电化学方法检测大鼠海马与皮质的乙酰胆碱含量;以高效液相电化学方法检测大鼠海马与皮质的单胺类神经递质及其代谢产物的含量。结果:纳入动物150只,均进入结果分析。①脑缺血后4周模型组大鼠海马去甲肾上腺素水平与正常组比较显著升高[分别为(797.29±60.04),(528.90±149.13)μg/L,P<0.01]、乙酰胆碱水平显著降低[分别为(19.72±10.09),(39.73±22.31)μg/L,P<0.01],皮质去甲肾上腺素、高香草酸水平与正常组比较显著降低[分别为(52.81±21.71),(258.65±125.82)μg/L,P<0.01;(5.22±3.19),(9.02±2.27)μg/L,P<0.05],海马与皮质多巴胺、5-羟色胺及其他代谢物及皮质乙酰胆碱水平均无明显变化。②脑缺血后8周模型组大鼠海马去甲肾上腺素、多巴胺水平与正常组比较显著升高[分别为(346.88±125.98),(110.76±18.56)μg/L,P<0.05;(7.16±3.52),(3.78±0.44)μg/L,P<0.01],5-羟色胺、乙酰胆碱水平显著降低[分别为(79.38±26.47),(127.64±23.03)μg/L,P<0.01;(14.75±5.21),(22.59±6.58)μg/L,P<0.05],皮质去甲肾上腺素水平也显著降低[分别为(57.67±18.30),(133.43±39.15)μg/L,P<0.01],皮质单胺类递质代谢产物及乙酰胆碱水平则无明显变化。解毒通络方可使上述各项指标的绝大部分恢复到接近正常大鼠水平。结论:解毒通络方能够有效促进脑缺血大鼠海马与皮质中单胺类递质和乙酰胆碱代谢紊乱状态的恢复。     

解毒通络方对脑缺血损伤大鼠海马与皮质神经递质变化的影响

目的：观察解毒通络方对脑缺血大鼠恢复期海马与皮质中单胺类递质和乙酰胆碱含量的影响。方法：实验于2005-05／2006—02在北京中医药大学病理实验室与中国中医科学院西苑中医院药理实验室完成。选择健康SD大鼠150只，采用双侧颈总动脉夹闭结合低血压状态制作脑缺血模型，将造模成功的150只大鼠随机数字表法分为5组，正常组、模型组及解毒通络方低剂量组、中剂量组、高剂量组，各30只。每组又分为造模后4，8周2个时相点，每个时相点15只。各剂量治疗组每天按不同剂量灌服解毒通络口服液（由栀子、丹参、黄芪、天麻等组成），低、中、高剂量分别相当于生药1．85，3．7，7．4g／kg，配置成给药体积为5mL／kg的溶液；模型组、正常组同时灌胃相应体积的洁净水。以改进的柱前、柱后双酶柱结合高效液相电化学方法检测大鼠海马与皮质的乙酰胆碱含量；以高效液相电化学方法检测大鼠海马与皮质的单胺类神经递质及其代谢产物的含量。结果：纳入动物150只，均进入结果分析。①脑缺血后4周模型组大鼠海马去甲。肾上腺素水平与正常组比较显著升高[分别为（797．29&;#177;60．04），（528．90&;#177;149．13）μg/L，P〈0．01]、乙酰胆碱水平显著降低[分别为（19．72&;#177;10．09），（39．73&;#177;22131）μg/L，P〈0．011，皮质去甲肾上腺素、高香草酸水平与正常组比较显著降低[分别为（52.81&;#177;21．71），（258．65&;#177;125．82）μg/L，P〈0．01；（5．22&;#177;3．19），（9.02&;#177;2．27）μg/L，P〈0．05]，海马与皮质多巴胺、5-羟色胺及其他代谢物及皮质乙酰胆碱水平均无明显变化。②脑缺血后8周模型组大鼠海马去甲。肾上腺素、多巴胺水平与正常组比较显著升高[分别为（346．88&;#177;125．98），（110．76&;#177;18．56）μg/L，P〈0．05；（7．16&;#177;3．52），（3．78&;#177;0．44）μg/L，P〈0．01]，5-羟色胺、乙酰胆碱水平显著降低[分别为（79．38&;#177;26．47），（127．64&;#177;23．03）μg/L，P〈0．01；（14．75&;#177;5．21），（22．59&;#177;6．58）μg/L，P〈0．05]，皮质去甲。肾上腺素水平也显著降低[分别为（57．67&;#177;18．30），（133．43&;#177;39．15）μg/L，P〈0．01]，皮质单胺类递质代谢产物及乙酰胆碱水平则无明显变化。解毒通络方可使上述各项指标的绝大部分恢复到接近正常大鼠水平。结论：解毒通络方能够有效促进脑缺血大鼠海马与皮质中单胺类递质和乙酰胆碱代谢紊乱状态的恢复。     

Anticonvulsants for neuropathic pain and detoxification

It is now well demonstrated that several anticonvulsants have a role in the treatment of neuropathic pain and also in withdrawal from benzodiazepines, sedatives, and perhaps alcohol. Valproic acid, carbamazepine, gabapentin, clonazepam, and lamotrigine are appropriate treatments for neuropathic pain, effective to a degree dependent on the underlying pathophysiology. While less effective than newer agents, there are situations in which phenytoin remains useful. Currently, a limited understanding of both the processes responsible for pain and the specific effects of each agent prevents prediction of individual response to these drugs, often necessitating trials of several drugs before the best one is found. It is interesting that the anticonvulsant drugs most useful for neuropathic pain are the same ones effective in sedative withdrawal, bipolar disorder, and several anxiety disorders. Issues of neural hypersensitivity and kindling, therefore, may prove to be unifying concepts for these conditions.     

Chronic pain and genetic background interact and influence opioid analgesia, tolerance, and physical dependence

Opioids are commonly used in the treatment of moderate to severe pain. However, their chronic use is limited by analgesic tolerance and physical dependence. Few studies have examined how chronic pain affects the development of tolerance or dependence, and essentially no studies have looked at the role of both genetics and pain together. For these studies we used 12 strains of inbred mice. Groups of mice from each strain were tested at baseline for morphine analgesic sensitivity, mechanical nociceptive threshold, and thermal nociceptive threshold. Mice were then given morphine in a 4-day escalating morphine administration paradigm followed by reassessment of the morphine dose-response relationship. Finally, physical dependence was measured by administering naloxone. Parallel groups of mice underwent hind paw injection of complete Freund's adjuvant (CFA) to induce chronic hind paw inflammation 7 days prior to the beginning of testing. The data showed that CFA treatment tended to lower baseline ED(50) values for morphine and enhanced the degree of analgesic tolerance observed after 4 days of morphine treatment. In addition, the degree of jumping behavior indicative of physical dependence was often altered if mice had been treated with CFA. The influence of background strain was substantial for all traits measured. In silico haplotypic mapping of the tolerance and physical dependence data demonstrated that CFA pretreatment altered the pattern of the predicted associations and greatly reduced their statistical significance. We conclude that chronic inflammatory pain and genetics interact to modulate the analgesic potency of morphine, tolerance, and physical dependence.