肿瘤内科的疼痛管理课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,肿瘤内科的疼痛管理现状和对策,肿瘤内科的疼痛管理现状和对策,1,癌症相关疼痛的全球性,Cancer-related pain is a major issue of healthcare systems worldwide.,The reported incidence, considering all stages of the disease, is 51%, which can increase to 90% in the advanced and terminal stages.,For advanced cancer, pain is moderate to severe in about 4050% and very severe or excruciating in 2530% of cases.,癌症相关疼痛的全球性Cancer-related pain,2,疼痛治疗的现状在欧洲,A recent European study that focused on the prevalence and treatment of cancer pain has been performed in,11 European countries and Israel in 20062007,.,A total of 5,084 cancer patients were contacted and 56% (573) of them suffered moderate to severe pain at least monthly.,The results of this survey challenge the belief that cancer pain is usually well managed.,The study found that pain was principally managed,by medical oncologists (42%,242/573).,Most patients (72%, 415/573) reported that their clinician asked them about their pain either at most consultations (16%, 95/573) or every consultation (55%, 320/573).,Only,15%,(88/573) of patients reported that their clinician measured their pain using a pain scale (55%, 320/573).,Of 441 patients, 437 reported that they used prescription medications to treat pain.,Among these, 24% were taking a step III opioid alone, 12% were taking a step II opioid alone, 7% were taking step II and step III opioids, either together or in combination with non-opioid drugs, and 8% received non-opioid analgesics alone,.,Eventually, pain was described as distressing by 67% of patients, as an intolerable aspect of their cancer by 36%, and,32% reported that the pain was so bad they wanted to die.,Breivik H, Cherny N, Collett B, et al. Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes.,Ann Oncol. 2009;26 Epub ahead of print,*The most recent study of the prevalence and management of cancer pain in Europe and I,srael that demonstrates that at the moment the treatment of cancer pain is suboptimal.,疼痛治疗的现状在欧洲A recent European st,3,WHO癌症疼痛三阶梯治疗指南的目前的评价,In 1986 the World Health Organization (WHO) published analgesic guidelines for the treatment of cancer pain based on a three-step ladder and practical recommendations.,The WHO analgesic ladder remains the clinical model for pain therapy.,These and similar data suggest that a direct move to the third step of the WHO analgesic ladder is feasible.,WHO癌症疼痛三阶梯治疗指南的目前的评价In 1986 th,4,WHO癌症疼痛三阶梯治疗指南的目前的评价,Opioids are the gold-standard treatment in moderate to severe pain.,The World Health Organization (WHO) in 1986 established a stepwise approach for the treatment of patients with cancer pain.,The goal was to provide treatment guidelines that health-care practitioners could easily follow.,Numerous studies have shown that when the WHO treatment guidelines are followed, 90% of patients are pain-free.,WHO癌症疼痛三阶梯治疗指南的目前的评价Opioids ar,5,WHO癌症疼痛三阶梯治疗指南的目前的评价,These pain management guidelines suggest that the choice of analgesic pharmacotherapy should be based on the intensity of pain reported by the patient, not simply on its specific etiology.,In the WHO guidelines,morphine,remains a cornerstone for the management of cancer pain.,A substantial minority of patients treated with oral morphine (1030%) do not have a successful outcome because of excessive adverse effects, inadequate analgesia, or a combination of both adverse effects together with inadequate analgesia.,It is now recognized that individual patients vary greatly in their response to different opioids. Patients who obtain poor analgesic efficacy or tolerability with one opioid will frequently tolerate another opioid.,Opioids, such as morphine, hydromorphone, oxycodone, fentanyl, and buprenorphine, have been shown to be highly effective in alleviating moderate to severe malignant pain.,WHO癌症疼痛三阶梯治疗指南的目前的评价 These pai,6,WHO癌症疼痛三阶梯治疗指南的目前的评价,Recently, the development of new drugs and formulations of different opioids has enlarged the available therapeutic arsenal and improved their administration, thus contributing to better tolerance of side effects.,This has modified the third step in analgesia, and morphine does not remain the first-choice drug.,WHO癌症疼痛三阶梯治疗指南的目前的评价Recently,7,WHO癌症疼痛三阶梯治疗指南的目前的评价,However, the role of the weak opioids in the treatment of moderate cancer pain has been questioned, and some experts speculate that this second step of the ladder could be omitted.,Marinangeli F, Ciccozzi A, Leonardis M,et al. Use of strong opioids in advanced cancer pain: a randomized trial. J Pain Symptom Manage. 2004;27:409,16.,*,This article speculates that second step of the ladder could be omitted.,WHO癌症疼痛三阶梯治疗指南的目前的评价However, t,8,弱阿片类药物在二阶梯治疗中的地位受到质疑,While the use of non-opioids for step I and “strong” opioids for step III is widely accepted, the clinical usefulness of the “weak” opioids in the management of cancer pain has been challenged. There are two systematic reviews comparing the efficacy of non steroidal anti-inflammatory drugs (NSAID) versus a weak opioid.,1，2,The results suggest that the transition from step I to step II drugs does not necessarily improve analgesia.,Furthermore, this transition may delay achieving optimal pain control, especially in patients with rapidly progressive pain or in those who need quick titration of analgesic therapy.,1.Eisenberg E, Berkey CS, Carr DB, Mosteller F, Chalmers TC. Efficacy and safety of nonsteroidal antiinflammatory drugs for cancer pain: a meta-analysis. J Clin Oncol. 1994;12:275665.,2.McNicol E, Strassels S, Goudas L, Lau J, Carr D. Nonsteroidal anti-inflammatory drugs, alone or combined with opioids, for cancer pain: a systematic review.,J Clin Oncol. 2004;22:1975,92.,弱阿片类药物在二阶梯治疗中的地位受到质疑While the,9,强阿片类药物一线治疗疼痛的临床试验,The efficacy and tolerability of strong opioids as first-line treatment compared with the recommended WHO regimen was analyzed in a phase III study performed in 100 terminal cancer patients who suffered from mild to moderate pain.,Patients who were started on strong opioids not only had significantly better pain relief, but they also required significantly fewer changes in therapy, had greater reductions in pain when therapeutic changes were initiated, and reported greater satisfaction with treatment. No differences were observed in quality of life or performance status between the two groups.,These data suggest the utility of strong opioids for first-line treatment of pain in patients with terminal cancer.,1,1.Marinangeli F, Ciccozzi A, Leonardis M, et al. Use of strong opioids in advanced cancer pain: a randomized trial. J Pain Symptom Manage. 2004;27:409,16.,强阿片类药物一线治疗疼痛的临床试验The efficacy,10,疼痛视觉量表评分5是治疗的关键,Experience reported since its application more than 20 years ago, as well as the deeper understanding of the different types of pain and the release of brand new therapeutic formulations, have currently led us to consider new changes in this unique analgesic treatment model, thus useful in choosing the best therapy according to the type of pain and not only its severity.,As a result, some experts suggest the ,analgesic elevator, model. In contrast to the ladder concept, this model leads us to the concept of immediate response, since the transport of analgesics inside a lift would be quicker than stepping up a ladder.,This highlights how important it is to perform a continuous evaluation for pain based on the Pain Visual Analog Severity Scale (PVASS).,In fact, a score 5 on this scale should make us be alert and provide the level of analgesia required immediately.,Torres L M, Caldern E, Pernia A, Martnez-Vzquez J. From the stairs to the escalator. Rev Soc Esp Dolor. 2002;9:28990.,疼痛视觉量表评分5是治疗的关键Experience rep,11,Morphine,Doses need to be individualized,bioavailability is variable (1565%),Serum levels have a peak at approximately one hour. Clearance is variable and medium elimination half-life ranges from 34 hours (17). This determines the way of administration.,Comparative clinical studies have shown no difference among the different types of opioids available in terms of symptom control and side effects. One retrospective cohort study including 12,000 patients compared efficacy and adverse events among transdermal fentanyl, controlled/extended-release morphine, and oxycodone, finding no difference either in pain control or in the gastrointestinal side-effect profile.,Weschules DJ, Bain KT, Reifsnyder J, et al. Toward evidence-based prescribing at end of life: a comparative analysis of sustained-release morphine, oxycodone,and transdermal fentanyl, with pain, constipation, and caregiver interaction outcomes in hospice patients. Pain Med. 2006;7:3209.,MorphineDoses need to be indiv,12,Fentanyl,Fentanyl is a selective -receptor agonist. Compared to morphine, it is approximately 100-times more potent, 1,000-times more lipophilic, and it features a lower molecular weight. Fentanyl is metabolized primarily in the liver. In humans,in vitro,experiments have demonstrated that fentanyl is metabolized mainly by cytochrome P450 3A4 (CYP3A4) to nor-fentanyl,via,oxidative N-dealkylation. Its clearance half-life is short and the effect of a single oral dose lasts for 30 minutes.,26,Oral (enteral) bioavailability of fentanyl is poor and hence the usual routes of administration are intravenous, subcutaneous, spinal, transdermal, and transmucosal.,FentanylFentanyl is a selectiv,13,Fentanyl,Fentanyl is recommended for patients whose opioid requirements are stable at a level corresponding to 60 mg/day of morphine.,Jost L, Roila F. ESMO Guidelines Working Group. Management of cancer pain: ESMO Clinical Recommendations. Ann Oncol. 2008;19(Suppl 2):ii11921.,FentanylFentanyl is recommende,14,Transdermal Fentanyl TTS,Once the patch is placed, fentanyl serum levels increase up to analgesic concentrations in 612 hours, remaining stable from 1224 hours and decreasing during the following 48 hours. One single administration every 72 hours reaches stable serum fentanyl levels. After removing the patch, serum levels of fentanyl progressively decrease until 50% in 17 hours.,Its bioavailability is 92%, and the released amount of the drug correlates with the size of the patch.,Transdermal Fentanyl TTSOnce t,15,Oral transmucosal fentanyl citrate,Fentanyl Iontophoretic Transdermal System,Fentanyl Sublingual Tablet,Oral transmucosal fentanyl cit,16,Fentanyl citrate nasal spray, TAIFUN.,Fentanyl citrate nasal spray,17,Oxycodone,first-step metabolization in liver, which explains its 6087% bioavailability.,Oxycodone serum half-life time is double that of morphine (35 hours) and reaches stationary concentrations in 2436 hours.,Oxycodone interacts with several medications, including selective serotonin reuptake inhibitors, cyclosporine, and rifampin.,Selective serotonin reuptake inhibitors inhibit oxycodone metabolism by CYP450, which leads to higher concentrations and increased toxicity.,Oxycodonefirst-step metaboliza,18,Oxycodone,comparison between oxycodone and morphine in combination versus morphine alone and proved that the concomitant administration exhibited a better analgesia profile and less incidence of emesis.,Lauretti GR, Oliveira GM, Pereira NL. Comparison of sustained-release morphine with sustained-release oxycodone in advanced cancer patients.,Br J Cancer. 2003;89:202730.,Oxycodonecomparison between ox,19,Oxycodone,On cancer chronic pain, five clinical trials have been published comparing controlled-release oxycodone versus controlled-release morphine (four trials) and versus hydromorphone (one study). The main efficacy endpoint was the perception of pain reported by patients themselves, measured as a score on PVASS or as the amount of rescue medication needed. No significant differences in efficacy were proven, but in a single study,56,results were more favorable to morphine. In general, the limited number of patients recruited makes these studies difficult to evaluate properly. Their importance, on the other hand, lies in the fact that these studies helped determine equianalgesic doses. Thus, in terms of equianalgesic efficacy, 1 mg oxycodone dose corresponds to 1.5 mg of morphine,5558,whereas one 1 mg oxycodone dose corresponds to 0.25 mg of hydromorphone.,59,OxycodoneOn cancer chronic pai,20,The match of oxycodone and naloxone,Agonist,Antagonist,Naloxone,Oxycodone,Targin,The match of oxycodone and nal,21,Oxycodone,Naloxone,Targin,The innovative principle,Achieving potent analgesia;,Treatment and/ or prophylaxis of opioid induced constipation;,Improved quality of life and compliance.,OxycodoneNaloxoneTargin The,22,innovative,innovative,23,肿瘤内科的疼痛管理课件,24,肿瘤内科的疼痛管理课件,25,肿瘤内科的疼痛管理课件,26,肿瘤内科的疼痛管理课件,27,肿瘤内科的疼痛管理课件,28,总结,Since 1986, the application of the WHO stepladder analgesic regimen has allowed a better control of pain and will achieve pain relief in the majority of patients with cancer. Between 7090% of patients with cancer pain treated according to the three-step ladder achieves effective analgesia.,Experience reported since its application more than 20 years ago suggests the utility of strong opioids for first-line treatment of pain in patients with terminal cancer could be better, especially for patients with moderate to severe cancer pain.,Recent updates about the prevalence and treatment of cancer pain in Europe have demonstrated that assessment is poor and treatment and outcomes are often suboptimal. It is necessary to improve pain management in moderate to severe cancer pain.,Opioids are the gold-standard treatment in moderate to severe pain and in the WHO guidelines; morphine remains a cornerstone for the management of cancer pain. Recently, the development of new drugs and formulations of different opioids has enlarged the available therapeutic arsenal, modifying the third-step in analgesia and morphine is not the only option.,总结Since 1986, the application,29,肿瘤内科的疼痛管理课件,30,我国肿瘤病人疼痛处理中问题现状,1.管理上较为严格，有需要的病人不能合理或及时的得到相应的符合标准的处理。,2.病人家属及病人自己的问题，不愿意及时使用强阿片类药物。,3.病人的经济问题。,4.药物品种的缺少。尤其在基层医院。,5.病人的教育。,6.医务人员对肿瘤病人疼痛的不作为。,7.药品企业对疼痛产品开发的不足。,8.缺少相应的符合国情的疼痛治疗指南。,9.对于难治性疼痛缺少共识。,10.缺少专业的队伍，包括心理，护士和专科医生。,我国肿瘤病人疼痛处理中问题现状1.管理上较为严格，有需要的病,31,管理上较为严格，有需要的病人不能合理或及时的得到相应的符合标准的处理。,1.由于国家政策的限制，现行的麻醉药品管理较为严格。,2.表现为：,1.病人用药量有限制,2.针剂控制,3.药品品种不全，剂量不全,4.地域差异明显,5.处方医生限制,管理上较为严格，有需要的病人不能合理或及时的得到相应的符合标,32,病人家属及病人自己的问题，不愿意及时使用强阿片类药物,1.由于历史原因，国人对于使用阿片类药物有一事实上的恐惧心理，不愿过早使用此类药物。,2.缺少相应的宣传教育机制。,3.缺少心理辅导机制。,4.对于阿片类药物的副作用的夸大。,5.对于使用针剂的误区，尤其在基层医院。,病人家属及病人自己的问题，不愿意及时使用强阿片类药物1.由于,33,病人的经济问题,1.由于药品的价格较高，病人往往需要长期使用，没有医保或就是有医保病人的经济负担仍然较重。,2.对于没有报销来源的病人，长期的治疗疼痛的药物根本负担不起。,3.这也是造成国内目前为止杜冷丁仍然有很多医院仍在使用的主要问题。,4.肿瘤病人的疼痛问题作为一个人道的问题解决方法可能是提供免费的药品。,病人的经济问题1.由于药品的价格较高，病人往往需要长期使用，,34,药物品种的缺少,1.止痛药品在国内和发达国家相比仍然稀少。,2.基层医院更为明显，是杜冷丁仍在使用的一个重要原因。,3.同一品种规格的不全，甚至造成不能正确的给病人合理的剂量。,4.不同的医院差异显著。,5.新药开发较少。,药物品种的缺少1.止痛药品在国内和发达国家相比仍然稀少。,35,病人的教育,1.病人对于晚期癌症疼痛存在误区，对于合理使用麻醉药品存在一定的恐惧感。,2.由于不愿意使用，使得相当大的一部分病人没有得到合理的治疗。,3.对于晚期癌症病人的心理疏导国内几近空白。,4.大部分肿瘤科医生缺少使用抗焦虑药物的经验。,病人的教育1.病人对于晚期癌症疼痛存在误区，对于合理使用麻醉,36,医务人员对肿瘤病人疼痛的不作为,1.对肿瘤治疗中往往忽视了肿瘤疼痛的治疗。,2.就是对肿瘤疼痛给予关注，但也不能给病人以理规范化的疼痛治疗。,3.临床上仍有给予病人短效制剂，针剂或杜冷丁的现象。,4.由于三阶梯止痛方案的影响，不能较早及时给病人强阿片类药物处理。,5.对于阿片类药物副作用处理不及时，不重视。,6.对于难治性疼痛缺少有效的方法。,7.过分依赖非甾体抗炎类药物。,8.对于疼痛评介原则不是很清楚。,医务人员对肿瘤病人疼痛的不作为1.对肿瘤治疗中往往忽视了肿瘤,37,药品企业对疼痛产品开发的不足,目前国内强阿片类药物品种和剂型均较少,相关的药品研发较为落后。,没有相应的管理机构保障。,对于现有的品种没有按照特殊药品处理。,相关的药品价格较高。,药品企业对疼痛产品开发的不足目前国内强阿片类药物品种和剂型均,38,缺少相应的符合国情的疼痛治疗指南,1.目前虽有NCCN疼痛指南，但是对于国情仍有一定的差异。,2.目前国内大部分医院没有专业的疼痛处理队伍或疼痛门诊。,3.没有治疗疼痛的小组，其成员包括肿瘤内科医师，外科医师，麻醉科医师，介入科医师，放射科医师，护士，心理医师。,4.国内晚期癌症病人以门诊处理为主，缺少社区医生的处理。,5.对于初诊病人的滴定多数医院没有开展。,6.没有一个统一的合理的疼痛处理规范。,7.比如目前已经将晚期癌症病人的疼痛处理中定义为只要有疼痛就可以用阿片类药物，但在国内仍不是共识。,8.受三阶梯疼痛治疗方案的影响较大， 但是政府部门仍然作为一个重要的原则，和目前的临床实践不符。,9.怎样制定一个简单易行符合国情的疼痛治疗指南是目前的一个重要问题。,缺少相应的符合国情的疼痛治疗指南1.目前虽有NCCN疼痛指南,39,国内目前临床上的疼痛处理流程,晚期癌症疼痛病人,初次使用治疗疼痛药物,即往使用过阿片类或复方制剂,疼痛评分以及疼痛原因的评估,疼痛评分以及做剂量换算,4,分以下,5-10,分,奥施康定，美施康定或芬太尼贴剂,弱阿片类或复方制剂,奥施康定，美施康定或芬太尼贴剂,一个处方周期后评估,5-10,分,国内目前临床上的疼痛处理流程晚期癌症疼痛病人初次使用治疗疼痛,40,对于难治性疼痛缺少共识,目前疼痛药物治疗大约可以控制80-90%的晚期癌症疼痛病人，其他的病人不能通过药物得到很好的疼痛控制，这部分病人的疼痛需要使用抗焦虑药物，介入治疗，包括神经阻滞，综合治疗。,由于这些技术不在肿瘤内科范畴，因此这部分病人的合理治疗得不到保障。,对于目前这部分病人我们目前处理的经验采用皮下泵吗啡的方法获得很好的效果。,对于难治性疼痛缺少共识目前疼痛药物治疗大约可以控制80-90,41,谢谢！,谢谢！,42,