癌痛治疗时机及合理用药分析解析.ppt

1、 P3-EPIC翻译为欧洲癌症与营养前瞻性调查研究与原文不符；=这样的表示方式请修（已解决）改；参考文献1标注方法有误；WHO和我国数据来源；卫生部1997年的提法有误；EPIC RESULTSAvailable at： http:/.hk/url?sa=t18(9):1437-1449.Prevalence of pain in patients with cancer: a systematic review of the past 40 years.van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, Schouten HC

2、, van Kleef M, Patijn J.SourcePain Management and Research Centre, University Hospital Maastricht, Masstricht, The Netherlands. mvdbadcc.azm.nlChin Med Sci J. 2001 Sep;16(3):175-8.National survey on prevalence of cancer pain.Liu Z, et al. Chin Med Sci J. 2001 Sep;16(3):175-178.Liu Z, Lian Z, Zhou W,

3、 Mu Y, L X, Zhao D, Cai Z, Cao J, Ren Z.SourceNational Institute on Drug Dependence, Peking University, Beijing 100083. AbstractOBJECTIVE: To collect nationwide basic data about cancer related pain.METHODS: Sixty cancer patients in each province were randomly selected to participate in this survey.

4、The subjects represented all stages of cancer, tumor sites, and different demographic characteristics. Two self-designed structured questionnaires including reasons, types of pain and pain management were used by patients and physicians respectively. Subjects were asked to report whether he/she had

5、experienced any type of cancer related pain and filled out the equivalent questionnaire. The severity of pain was assessed by using “visual analogue scale“. Original data input and analysis were using EPI-INFO software package.RESULTS: The result showed that 61.6% (958/1555) of patients had differen

6、t types of cancer related pain. Majority of pain (85.1%) were caused by advanced cancer. The major reasons (64.4%) for poor management or impedimental factors of pain care are due to patient including over-concern on opioid analgesic addiction, reluctance to report pain or refused to use opioid anal

7、gesic until at times when pain is intolerable; 26.8% belonged to physicians reasons including fear to cause addiction on opioid and lack of knowledge about cancer pain management; 16.2% are due to lack of different kinds of opioid analgesic for use and 16.1% belonged to drug regulation.CONCLUSIONS:

8、The results showed that majority of patients (61.6%) had different types of cancer relatad pain. In most of patients, cancer pain was relieved when they were treated. The major reason for under-treatment or impeded factors for effective relief of cancer pain was fear of opioid addiction by both medi

9、cal professionals and patients.PMID: 12899334 PubMed - indexed for MEDLINE Int J Tissue React. 1985;7(1):93-6.WHO guidelines for the use of analgesics in cancer pain.Ventafridda V, Saita L, Ripamonti C, De Conno F.AbstractThe growing incidence of cancer pathology all over the world implies not only

10、problems of prevention and cure, but also of pain control. Pain appears in more than 50% of cancer patients, mainly because analgesic opioids are not available or adequately administered. For this reason, the World Health Organization (WHO) has created a Collaborating Centre for Cancer Pain Relief a

11、t the Division of Pain Therapy of the National Cancer Institute, Milan. Experts in pain therapy have drafted guidelines on the sequential use of analgesic drugs by identifying three steps: non-narcotics, weak narcotics, narcotics, all in association with adjuvant drugs. After a positive pilot trial,

12、 field testing will be conducted in developed and developing countries. The first step of the analgesic ladder is represented by the use of non-narcotics; the adequate use of these substances in advanced cancer patients does not exceed 6 months of treatment. Treatment is then either discontinued or

13、changed to a following step because of side-effects (40%) or inefficacy (44%). The reduction in the use of non-narcotics corresponds to a successive increase in the use of opioids, particularly direct agonists. Through an adequate use of the analgesic ladder, pain can be relieved in the great majori

14、ty of cancer patients.PMID: 2409039 PubMed - indexed for MEDLINE 神经敏化表现为：痛阈降低，痛觉反应增强(痛觉过敏) 和非伤害性刺激引发伤害性反应(触诱发痛) 1。痛觉过敏：正常疼痛刺激诱发更加强烈的疼痛感觉。 诱发触痛：正常非疼痛刺激诱发的疼痛感觉。 疼痛不仅是一种主观体验也是一种多重体验包括生理的感觉的行为的认知的情感的及社会文化六个方面.因此疼痛评估工具还可被划分为 一 是 评估 表, 疼痛体验的一个方面 一 是多评估 表, 来 疼痛体验的 方面 评估 表因 , 为 常 觉 评 分 法 ;文 评 分 法 数 评分法 评 估

15、表 多 评估 表的 currency1“fi fl 性疼痛的评估因为性疼痛常 的体情感社会方面”生 疼痛调查表 疼痛表 多 评估 表 应 据 表应的 和 的情 的 表 有一个 表 有的疼痛评估这个 示：12， 性 的 现 症 的currency1 更低生currency1，标标长2.7个月。10. McNicol E, et al. J Clin Oncol 2004; 22:1975-1992.11. Marinangeli F, et al. J Pain Symptom Manage 2004; 27:409-416. systematic review10 of six trials

16、compared the efficacy of an NSAID versus a “weak” opioid (three were single-dose trials and two were multiple-dose trials, and the duration of one trial was unclear). Again, the results failed to show the superiority of “weak” opioids over NSAIDs, although adverse events were either comparable or mo

17、re frequent in the opioid-treated patients. An additional eight trials were con- ducted in 833 patients to compare an NSAID with the combina- tion of an NSAID and an opioid. The results showed that the difference in the analgesic outcome measure for each trial was less than 25%. The new algorithm pr

18、oposes the following three stages of treatment for cancer pain. (1) For mild pain, non-opioid analge- sic treatment should be initiated. If pain is not adequately con- trolled, then low doses of “strong” opioids should be added and titrated according to the individual patients needs. (2) For mod- er

19、ate pain, low doses of “strong” opioids should be initiated and titrated, with or without non-opioids. (3) The treatment of se vere pain obviously requires the immediate use of “strong” opioids, with or without non-opioids. Invasive procedures such as neurolytic blocks, if available, should be consi

20、dered as an alternative or adjunct to pharmacotherapy at any stage of dis- ease in patients with moderate or severe cancer pain. Adjuvant drugs should be used for all stages when indicated. As a rule,“weak” opioids should be dropped in the treatment of cancer, other than in countries where “strong”

21、opioids are not readily available or physicians are not well trained in using them. In such cases, clinicians must bear in mind that the efficacy of “weak” opioids is limited. Finally, although a number of controlled trials provide data to support the efficacy and safety of this suggested algorithm,

22、 further validation should be provided by prospective studies in broad populations of patients with cancer pain. 100例晚期癌症(轻中度癌痛)患者，随机分为WHO阶段法治疗组和强效阿片类药物治疗组。强阿片治疗组VAS评分平均变化优于WHO阶段法治疗组。Fig. 1. Percent of cumulative weeks that the patient defined treatment as “satisfactory” *P 0.041, and percent of cumulative weeks with no changes in ther- apy. *P 0.001 Group B versus Group A.