癌症患者疼痛的心理护理

我院于１９９４年１１月～１９９８年１０月共收治癌症伴有疼痛患者６２例,我们均予以心理分析,并予以相应的心理护理,现总结如下。１　临床资料：６２例癌症伴疼痛患者中,男性３８例,女性２４例。年龄１８～８９岁,平均５２岁。其中肝癌８例,胃癌８例,食道癌５例,胰腺癌５例,肠癌４例,肺癌６例,乳腺癌６例,子宫癌８例,膀胱癌６例,肾癌３例,淋巴瘤３例。２　观察与分析２１　癌症患者的疼痛的原因主要有３种：（１）癌症本身引起的疼痛,本组病例中共３３例,占５３２％;（２）癌症治疗引起的疼痛,如手术、放疗、化疗…     

癌痛的治疗

大部分癌症患均伴有不同程度的疼痛，这使得癌症患的生活质量受到明显的影响。据世界卫生组织（WHO)统计，目前全世界癌症患中30％-50％伴有不同程度的疼痛。我国最近调查表明综合医院和专科医院及各期癌症患中，伴有不同程度疼痛的占51％-62％。总之癌症的疼痛发生率是比较高的．需要医生加以注意和解决。     

69例癌痛患者的生活质量评价

作者对６９例癌症合并疼痛的患者进行了生活质量问卷调查，其中包括身体、心理和社会人际关系等三方面的因素。男性４９例，女性２０例，均为明确诊断的中、晚期癌症患者。结果：累度疼痛对患者的生活质量影响较小，而中、重度疼痛对患者的生活质量影响明显增大；疼痛时时≤６月的患者生活质量於分与〉６月的患者生活质量评分比较有明显差异；镇痛治疗有效者生活质量有改善，与治疗无效者比较有非常显著性差异。结论：１．疼痛是癌症     

54例乳腺癌患者止痛情况调查及对策

目的了解乳腺癌患者止痛情况，进一步贯彻和落实“癌痛患者三阶梯止痛”工作。方法对乳腺癌伴有疼痛的患者采取问卷式调查，由专人逐一询问并记录填写癌症疼痛及相关情况。结果共完成54例乳腺癌伴有疼痛患者的调查，除1例拒绝使用止痛药外，53例患者均接受过止痛药治疗。在接受止痛治疗的各种方法中，选用药物镇痛的占90．7％、理疗42．6％、中药9．3％、心理治疗5．6％、外科治疗5．6％、其他方法22．2％。患者对止痛治疗后的满意度为88．7％。在使用止痛药的态度方面，有24．1％患者认为使用止痛药可以成瘾，42．6％患者回答不知道，33．3％患者认为使用止痛药不会成瘾。结论世界卫生组织提出的“三阶梯止痛”治疗原则在本院基本得到实施，但还有部分患者对止痛药的使用方法缺乏了解，需进一步加强宣教。     

三阶梯药物疗法治疗中晚期癌痛患者的护理

采用ＷＨＯ推荐的三阶梯药物疗法治疗中晚期癌痛患者１３例，８例疼痛完全缓解，占６１．５％，４例部分缓解，占３０．８％。其中６０％～７０％患者精神状态稳定，饮食量改善，睡眠时间６～７ｈ／ｄ。作者认为该方案既能使大部分癌症患者疼痛得到缓解，又可明显提高患者的生活质量。     

个性化心理护理对癌痛患者止痛效果的影响

在癌症患者的自觉症状中，疼痛的发生率最高，WHO统计：全世界癌症患者伴有疼痛的比例为30％～50％，晚期患者为60％～90％。疼痛给患者带来了极大的痛苦，并加重癌症本身带给患者的精神心理负担，明显降低了生存质量。我们对49例癌痛患者尝试了个性化心理护理，取得了满意的效果，现总结如下。     

癌症患者自杀行为原因分析与护理对策

目的探讨住院癌症患者发生自杀行为的相关因素，制定有针对性的心理护理及安全管理措施。方法按时间顺序逐个调查2004年7月-2007年6月在东南大学附属中大医院肿瘤科住院期间发生自杀行为的29例患者临床资料，进行自杀行为分类，并分析自杀原因，在此基础上采取相应心理护理、安全管理措施，比较针对性护理措施后的效果。结果29例发生自杀行为的患者中，自杀成功3例，占10．3％，自杀未遂8例，占27．6％，有自杀准备4例，占13．8％，有自杀计划2例，占6．9％，有自杀意念12例，占41．4％。发生自杀行为的原因与心理障碍、情感支持缺乏、疼痛、生活质量下降和经济负担过重等有关。通过有针对性的干预，自杀行为人数逐渐下降（P〈0．05）。结论加强对患者的心理疏导，强化病区护理安全管理，增强医护人员法律意识，能使住院癌症患者自杀行为减少。     

癌症疼痛的护理

癌症病人的自觉症状中，疼痛发生率最高，据统计．我国各期癌症病人中，有50％的患者伴有不同程度的疼痛．70％的晚期癌症患者的疼痛为主要症状，30％癌症病人承受着难以忍受的剧烈疼痛。癌症疼痛的治疗需要医生、护士、病人家属以及社会上所有人的共同关心协作，才能达到令人满意的效果，而护士在其中起着相当重要的作用，本文就癌症病人的疼痛的治疗、护理谈以下体会。     

癌痛的评估与护理措施

肿瘤镇痛治疗及护理是晚期肿瘤患者的重要问题。疼痛首先损害患者心理及精神状态，使其产生忧郁和恐惧心理，这种心理状态反过来可使疼痛加剧，形成恶性循环。有统计表明全世界每年新生癌症患者1000万，其中30％～50％伴有不同程度的疼痛，而我国约51％～61．1％的癌症患者伴有疼痛，如何减轻癌症患者的疼痛，提高患者的生活质量，是当前医务工作者共同关注的问题。     

癌症疼痛的药物治疗

癌症是严重威胁人类生命的主要疾病之一，尤其是晚期癌症多伴有程度不同的疼痛，严重者影响生活．部分患者因剧痛不可忍受而自杀。据统计全世界每年发生恶性肿瘤约400万例，其中有疼痛者约360万例，在晚期肿瘤患者中癌痛的发病率高达SO％以上。癌症浸润或压迫神经是导致疼痛的主要原因，另外手术和放射治疗亦可造成新的疼痛医。为使患者在无病状态下顺利度过其生命的最后阶段，药物、神经阻滞以及其他疗法都是必要的措施，现分述如下。且药物治疗治疗疼痛应采用定时给药的方法，以维持血浆药物浓度在相当的治疗水平，而不是在疼痛发作后再…     

Buprenorphine TDS: use in daily practice,benefits for patients

In Germany and many other countries, buprenorphine has been used for a long time for the management of pain in both cancer and non-cancer patients. Although a transdermal delivery system for buprenorphine (Transtec) has recently been introduced, the clinical experience in daily practice with this drug, delivered in a matrix patch, is only now being evaluated. In preliminary data from a survey of 3,255 patients with chronic pain, 26% had cancer pain, while the most common diagnoses of the other respondents included back pain (33%), osteoarthritis (22%), osteoporosis (17%), and neuropathic pain (10%, multiple entries). Before being switched to the buprenorphine patch, most patients had been pretreated with World Health Organization (WHO) Step II opioids (47%) or WHO Step III opioids (18%), including tramadol (in 35% of patients) and a tilidin/naloxone combination (15%); 9% had not been prescribed any opioids in advance of receiving transdermal buprenorphine. Most patients (77%) in the survey had been started on the lowest dose of the buprenorphine patch (35 microg/h), and nearly half (49%) were placed on adjuvant analgesics, including tramadol or tilidin/naloxone. Pain relief was rated as good or very good by 81% of the respondents. Adverse effects were similar to those seen on other opioids, although their intensity was mild in most cases. Local side effects, including erythema (4% of cases) and pruritus (1%), were transitory. Based on the survey results, transdermal buprenorphine is considered an effective opioid treatment for patients with stable cancer and non-cancer pain; it may prove particularly useful in patients who have experienced side effects taking oral analgesic preparations, as well as in those who are taking extensive co-medications.     

Use of strong opioids in advanced cancer pain: a randomized trial

The World Health Organization (WHO) guidelines for the treatment of cancer pain recommend nonopioid analgesics as first-line therapy, so-called "weak" analgesics combined with nonopioid analgesics as second-line therapy, and so-called "strong" opioids (with nonopioid analgesics) only as third-line therapy. However, these guidelines can be questioned with regard to the extent of efficacy as well as the rationale for not using strong opioids as first-line treatment, especially in terminal cancer patients. The purpose of this randomized study was to prospectively compare the efficacy and tolerability of strong opioids as first-line agents with the recommendations of the WHO in terminal cancer patients. One hundred patients with mild-moderate pain were randomized to treatment according to WHO guidelines or to treatment with strong opioids. Evaluated outcomes included pain intensity, need for change in therapy, quality of life, Karnofsky Performance Status, general condition of the patient, and adverse events. No between-treatment differences were observed for changes in quality of life or performance status, but patients started on strong opioids had significantly better pain relief than patients treated according to WHO guidelines (P=0.041). Additionally, patients started on strong opioids required significantly fewer changes in therapy, had greater reduction in pain when a change was initiated, and reported greater satisfaction with treatment than the comparator group (P=0.041). Strong opioids were safe and well-tolerated, with no development of tolerance or serious adverse events. These data suggest the utility of strong opioids for first-line treatment of pain in patients with terminal cancer.     

Slow-release tramadol for treatment of chronic malignant pain – an open multicenter trial

 Patients with moderate to severe cancer pain and insufficient pain relief from nonopioid analgesics were treated with slow-release tramadol for initial dose finding and as a long-term treatment. Immediate-release tramadol was provided for the treatment of breakthrough pain and a standard nonopioid analgesic (1000 mg naproxen daily) was given as suggested for step 2 of the WHO analgesic ladder. Ninety of 146 patients (62%) completed the 6-week trial period. Drop-outs were due to adverse events (20%), inadequate pain relief (9%), or both (2.5%), death due to the underlying disease (4%), low patient compliance (2%) or other reasons. Average and maximal pain intensity decreased from day 1 to day 4. The number of patients with good and complete pain relief increased from 43% after week 1 to 71% after week 6 with maximum daily doses of tramadol up to 650 mg. However, 70% of the patients still needed less than 400 mg tramadol per day in week 6. Most patients (86%) experienced adverse events during the study period. Some common side effects of opioids, such as fatigue, dizziness, and constipation, decreased in frequency over the 6 weeks. The frequency of other adverse events such as nausea, vomiting and sweating did not change. Slow-release tramadol provided fast and efficient pain relief in almost two-thirds of patients both during initial dose finding and during long-term treatment, improving treatment options in step 2 of the WHO analgesic ladder. Published online: 31 May 2000     

Pain and pain treatments in European palliative care units. A cross sectional survey from the European Association for Palliative Care Research Network

The Research Network of the European Association for Palliative Care (EAPC) performed a survey of 3030 cancer patients from 143 palliative care centres in 21 European countries. The survey addressed pain intensity and the use of non-opioid analgesics, adjuvant analgesics and opioids. Patients were treated with analgesics corresponding to the WHO pain ladder step I (n = 855), step II (n = 509) and step III (n = 1589). The investigators assessed 32% of the patients as having moderate or severe pain. In general there were small differences between pain intensities across different countries. Cancer primary sites and the presence of metastasis had only minor influences on pain intensity. The most frequently used non-opioid analgesics were NSAIDs (26%) and paracetamol (23%). Adjuvant analgesics or co-analgesics used by >1% of the patients were corticosteroids (39%), tricylic antidepressants (11%), gabapentin (5%), bisphosphonates (4%), clonazepam (2%), carbamazepine (4%) and phenytoin (2%). The use of non-opioid analgesics and co-analgesics varied widely between countries. Opioids administered for mild to moderate pain were codeine (8%), tramadol (8%), dextropropoxyphene (5%) and dihydrocodeine (2%). Morphine was the most frequently used opioid for moderate to severe pain (oral normal release morphine: 21%; oral sustained-release morphine: 19%; i.v. or s.c. morphine: 10%). Other opioids for moderate to severe pain were transdermal fentanyl (14%), oxycodone (4%), methadone (2%), diamorphine (2%) and hydromorphone (1%). We observed large variations in the use of opioids across countries. Finally, we observed that only a minority of the patients who used morphine needed very high doses.     

Cancer pain: knowledge and attitudes of physicians in Israel

The effectiveness of cancer pain therapy is influenced by the attitudes and knowledge of the treating physicians. As part of a quality improvement project in the management of cancer pain, a survey of 236 medical practitioners was conducted. One hundred seventy-six respondents (74.5%) completed the survey. Fifty-two percent treated patients with cancer pain several times a week or more. Whereas 57.7% of physicians stated that 76-100% of patients could achieve a satisfactory outcome from analgesic therapy, only 17.2% of respondents reported that > 75% actually achieve a satisfactory outcome in their own experience. Unsatisfactory outcome was ascribed to inadequate pain relief (59.7%), or excessive central nervous system (CNS) side effects (43.3%). According to the responding physicians, the major barriers to effective relief include inadequate assessment of the pain and pain relief (65.3%), inadequate knowledge of pain therapy (57.9%), and physician reluctance to prescribe opioids (49.1%). Questions evaluating physician knowledge identified widely prevalent knowledge deficits in pain physiology, risk of addiction, use of adjuvant analgesics, opioid dosing, and treatment of side effects. Specialists in oncology tended to evaluate their knowledge more highly than others (P < 0.05). Despite this, there was no significant knowledge difference between oncologists and noncancer specialists. The data highlight some of the barriers to the successful management of cancer pain in Israel, the prevalence of knowledge deficits, and the common disparity between clinicians' self-assessment of clinical competence and their ability to respond correctly to questions on the management of cancer pain.     

中国癌症疼痛现状调查中国医务人员对癌痛治疗态度、知识、实践情况的调查

采用“医务人员对癌症疼痛认知及临床治疗情况调查表”,对全国２９个省、区、市各级医疗卫生机构的医药卫生专业人员进行了调查。结果表明：在癌痛治疗基本知识、态度方面,２７３名参加过癌痛治疗培训的专业人员癌痛基本知识平均得分分值为９．２７±１．６７,显著高于未参加过培训人员６．８４±２．５４的平均分值（ｔ＝１４．２３,Ｐ＜０．０５）;在癌痛治疗现状上,分别有３５．６％、３７．０％和２６．８％的人认为目前癌痛患者中的７０％以上、约５０％和３０％以下得到了必要的止痛药治疗,而认为基本达到ＷＨＯ三级止痛治疗阶梯目标的仅占所有应答者的１７．１％;在有效癌痛治疗的障碍因素上,医务人员、患者的“恐瘾”心理和麻醉性镇痛药管理过严是主要障碍因素。     

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.     

2005年7月至2006年7月沈阳地区多中心急诊镇痛药使用情况分析

目的 分析中国医科大学附属第一、第二、笫四医院2005年7月至2006年7月急诊镇痛药使用情况,旨在为临床合理用药提供有益参考.方法 对1年中资料完整的急诊镇痛药处方2312张进行描述性分析,项目包括处方的一般情况、药品的使用病因及频度、麻醉药品的用药频率(DDDs)以及药物利用指数(DUI),其中200例患者接受治疗效果的问卷调查.调查以进入和离开急诊作为时间点.疼痛程度评估采用0～10数字量表(NRS).患者对镇痛效果满意程度进行选择.未选人聋哑者、囚犯、家庭暴力受害者及精神异常者,亦不包括14岁以下的患者.分类资料统计发生率和构成比,治疗前后疼痛评分采用配对t检验.结果 镇痛药以注射液剂型为主,山莨菪碱和布桂嗪注射液应用最多,口服片剂较少.外伤痛是最多应用镇痛药的病因.麻醉性镇痛药中,DDDs及DUI均小于世界卫生组织限定值.哌替啶注射液应用最多.接受调查的患者中,71.5%对治疗的效果满意或基本满意;用药前NRS评分7.47±2.21,用药后评分5.00±3.16,评分显著降低(统计量t值23.38,P<0.01);但评分4分及4分以上患者仍占57.5%.结论 三所医院急诊能对疼痛患者进行初步处理.麻醉性镇痛药的使用较为谨慎.急诊镇痛效果仍有待进一步提高.     

Management of pain in patients with myocardial infarction

A survey of analgesics used for pain relief in patients suffering with myocardial infarction was carried out for a duration of one month. Forty-eight patients were studied regarding pain relief prior to transfer to hospital and on admission to the Coronary Care Unit (CCU), out of 48, only three patients did not require any analgesic. It was found that the management of pain in the community and the CCU was variable. Intravenous diamorphine 5 mgs was found to be most effective practice for pain relief. Out of twenty-six patients who received IV diamorphine 5 mgs initially 16 patients (62%) had adequate pain relief, in contrast to 21% (3) of those who received only 2.5 mgs. In 14 patients who received this lower dose it was found only to be effective in three patients.     

Predictive factors in advanced cancer pain treated only by analgesics.

Analgesic response, incidental pain and pain mechanism were evaluated in order to predict the chances of pain relief in advanced cancer patients. In an observation period of about 2 months, 130 patients were followed at home until death using only a pharmacological approach to control pain according to the WHO ladders. Ninety-eight patients were considered. Pain relief was considered good if less than moderate. Pain was assessed during the course of examinations (2-3 a week) by independent observers. If other techniques were needed the result was considered negative. The patients were tested with an NSAID (Diclofenac) and assigned to group 1 if the pain became slight in 3 days. If the response was negative, a 4-day trial with opioids was started. If the pain was slight the patient was included in group 3, otherwise in group 5. Every patient belonging to these groups but with incidentical pain was included in groups 2, 4 and 6, respectively. For each group a subdivision was made according to the pain characteristics. There was a progressive worsening in pain relief in groups 4, 5 and 6, suggesting a good correlation between response to the drugs and future chances of pain control in a period of 2 months. This study demonstrates that incidental pain reduces the possibility of pain control (50%) with the exclusive administration of analgesics in patients with a mean life expectation of about 2 months. This negative influence is counterbalanced by the possible individual response to analgesics administered sequentially during a 1-week period (85.8% good pain relief with NSAID, 74% with opioids).(ABSTRACT TRUNCATED AT 250 WORDS)