Rouveix B, Bauwens M C, Giroud J P
Département de Pharmacologie Clinique, CNRS Unité UPRES-A 8068, UFR Cochin-Port-Royal, Hôpital Cochin, Paris.
Bull Acad Natl Med. 1999;183(5):889-901; discussion 901-3.
Accurate assessment of pain is the key to appropriate analgesia. This necessitates not only an understanding of the organic component, but also a comprehension of the role played by the mental, social and spiritual dimensions in the individual patient's suffering. It implies that the entire care team must be involved in pain management. The nature of a patient's pain is one predictor of the response to treatment. It is mainly characterized by its location, intensity, extent, timing and type (excessive nociception, neurogenic, or mixed), the circumstances in which it appears, and any accompanying signs. The choice of analgesic for treating pain due to excessive nociception was greatly facilitated by the introduction of the WHO three-step approach. Better knowledge of the pharmacological and pharmacokinetic properties of the different analgesics has contributed to increase their efficacy and tolerability. Certain types of pain of neurogenic origin respond poorly to both opiate and non opiate analgesics. They can be treated with other drugs whose mechanisms of action in pain relief are not fully understood. They include the following; antidepressants (amitriptyline, nortriptyline, desipramine and doxepine); anticonvulsants (carbamazepine, phenytoin, valporic acid and clonazepam); antiarrhythmic agents (lidocaine, mexiletine, flecainide and tocainide). The unwanted effects of these different treatments, together with psychological disturbances induced by the underlying disease, can call for the use of antiemetics, laxatives, spasmolytics, glucocorticoids and psychotropic agents (anxiolytics, neuroleptics and antidepressants). Finally, in many cases, better pain relief is obtained by combining drug-based therapy with other interventions such as radiation therapy, neurosurgery, and psychological/behavioral approaches. All these means must be chosen and used according to each individual patient's needs. Pain must be considered as a disease that can and must be eliminated or at least attenuated.
准确评估疼痛是恰当镇痛的关键。这不仅需要了解疼痛的器质性成分，还需要理解心理、社会和精神层面在个体患者痛苦中所起的作用。这意味着整个护理团队都必须参与疼痛管理。患者疼痛的性质是治疗反应的一个预测指标。它主要由疼痛的部位、强度、范围、时间和类型（过度伤害性感受、神经源性或混合型）、出现的情况以及任何伴随症状来表征。世界卫生组织的三阶梯止痛法的引入极大地促进了对因过度伤害性感受引起的疼痛的镇痛药选择。对不同镇痛药的药理和药代动力学特性有更深入的了解有助于提高其疗效和耐受性。某些神经源性疼痛对阿片类和非阿片类镇痛药的反应都很差。它们可以用其他药物治疗，但其缓解疼痛的作用机制尚未完全明了。这些药物包括：抗抑郁药（阿米替林、去甲替林、地昔帕明和多塞平）；抗惊厥药（卡马西平、苯妥英、丙戊酸和氯硝西泮）；抗心律失常药（利多卡因、美西律、氟卡尼和妥卡尼）。这些不同治疗方法的不良反应，连同基础疾病引起的心理障碍，可能需要使用止吐药、泻药、解痉药、糖皮质激素和精神药物（抗焦虑药、抗精神病药和抗抑郁药）。最后，在许多情况下，通过将药物治疗与其他干预措施如放射治疗、神经外科手术以及心理/行为方法相结合，可以获得更好的疼痛缓解效果。所有这些方法都必须根据每个患者的需求来选择和使用。必须将疼痛视为一种能够且必须消除或至少减轻的疾病。
