全身阿片类药物转换为鞘内吗啡时戒断反应的临床研究  

Clinical study on withdrawal reactions during conversion of systemic opioid drugs to intrathecal morphine

作　　者：刘越 杜美慧 曾永芬 周晓艳 刘红军 金毅 LIU Yue;DU Mei-hui;ZENG Yong-fen;ZHOU Xiao-yan;LIU Hong-jun;JIN Yi(School of Anesthesiology,Xuzhou Medical University,Xuzhou 221004,China;Department of Pain Medicine,General Hospital of Eastern Theater Command,Nanjing 210002,China)

机构地区：[1]徐州医科大学麻醉学院,徐州221004 [2]中国人民解放军东部战区总医院疼痛科,南京210002

出　　处：《中国疼痛医学杂志》2024年第4期282-289,共8页Chinese Journal of Pain Medicine

基　　金：江苏省社会发展医药项目(竞争性)(BE2021728)。

摘　　要：目的:观察全身阿片类药物转换为鞘内吗啡镇痛时的戒断反应,探讨病人静脉自控给药治疗的可行性。方法:选取2022年11月至2023年9月就诊于东部战区总医院的阿片类药物耐受的难治性癌痛病人30例,经吗啡静脉病人自控镇痛(patient controlled analgesia,PCA)剂量滴定24 h后植入半植入式鞘内药物输注系统,外接PCA泵鞘内持续输注吗啡。采用临床阿片类药物戒断量表(clinical opiate withdrawal scale,COWS)评估静脉吗啡转换为鞘内吗啡期间病人阿片戒断反应(opioid withdrawal reaction,OWR),记录OWR的发生次数、时间和程度;根据COWS评分将病人分为无OWR组(n=7)和OWR组(n=23),依据OWR的程度分为轻(n=4)、中(n=17)、中重(n=2)和重度(n=0)四组。OWR病人根据需求,采用吗啡静脉PCA给药治疗。评估转换过程中病人疼痛强度、焦虑、抑郁、睡眠、病人满意度,以及阿片类药物不良反应等。结果:本研究中OWR发生率为76.7%(23/30),轻度及中度占91.3%(21/23),其中87.0%(20/23)的病人需要通过静脉吗啡PCA缓解OWR。中重度组的COWS平均评分高于轻度组(P<0.05),中度组的PCA给药次数高于轻度组(P<0.05)。OWR组(n=23)入院时每日口服吗啡毫克当量与OWR持续时间(r=0.490,P=0.018)、发生次数(r=0.488,P=0.018)和PCA给药次数(r=0.495,P=0.016)呈正相关。病人转换为鞘内吗啡镇痛后疼痛数字分级评分法(numerical rating scale,NRS)评分、每日吗啡使用剂量均较入院时下降(P<0.05),焦虑、抑郁、睡眠均得到不同程度改善。出院时便秘发生率较术前明显降低(P<0.01)。结论:全身阿片类药物转换为鞘内吗啡镇痛时戒断反应的发生率较高,静脉吗啡PCA治疗方便易行、效果确切。Objective:To observe withdrawal reactions when systemic opioid medications are converted to intrathecal morphine for pain management and to explore the feasibility of patient-controlled intravenous treatment.Methods:Thirty patients who had suffering from intractable cancer pain and developed opioid tolerance in General Hospital of Eastern Theater Command from November 2022 to September 2023 were selected.After a 24-hour titration of intravenous morphine using patient controlled analgesia(PCA),a semi implantable intrathecal drug delivery system was implanted and connected to an intrathecal morphine infusion pump.The clinical opiate withdrawal scale(COWS)was employed to assess opioid withdrawal reactions(OWR)in patients during the transition from intravenous morphine to intrathecal,and the frequency,duration,and severity of OWR were recorded.Patients were categorized based on COWS scores into two groups:those without OWR(n=7)and those with OWR(n=23),further classified by the severity of OWR as mild(n=4),moderate(n=17),moderate to severe(n=2),and severe(n=0).Patients with OWR received intravenous morphine via PCA as needed.Evaluate the pain intensity,anxiety,depression,sleep,patient satisfaction and adverse opioid reactions of patients during the conversion process.Results:The incidence of OWR in patients in this study was 76.7%(23/30),with mild and moderate cases comprising 91.3%(21/23).Among them,87.0%(20/23)required relief via patient-controlled intravenous morphine.The moderate to severe OWR group had higher average COWS scores than the mild group(P<0.05),and the moderate OWR group required more PCA administrations than the mild group(P<0.05).The daily oral morphine milligram equivalents at admission of patients in the OWR group(n=23)was positively correlated with the duration(r=0.490,P=0.018)and frequency(r=0.488,P=0.018)of OWR and the number of PCA administrations(r=0.495,P=0.016).After transition to intrathecal morphine,pain numerical rating scale(NRS)scores and daily morphine usage were significantly decreas

关 键 词：难治性癌痛 阿片类药物耐受 吗啡 半植入式鞘内药物输注系统 戒断反应 

分 类 号：R730.5[医药卫生—肿瘤]