Elander James, Lusher Joanne, Bevan David, Telfer Paul
Department of Psychology, London Metropolitan University, Calcutta House, Old Castle Street, E1 7NT London, UK.
Soc Sci Med. 2003 Nov;57(9):1683-96. doi: 10.1016/s0277-9536(02)00553-1.
Concerns about dependence on prescribed analgesia may compromise pain management, but there was previously little reliable evidence about substance dependence among patients with sickle cell disease (SCD). We conducted in-depth, semi-structured interviews with SCD patients in London, UK, to assess DSM-IV symptoms of substance dependence and abuse. Criteria were applied to differentiate between pain-related symptoms, which corresponded to the DSM-IV symptoms but involved analgesics used to control pain, and non-pain-related symptoms, which involved analgesic use beyond pain management. Pain-related symptoms are informative about how the pattern of recurrent acute pain in SCD may make patients vulnerable to perceptions of drug dependence. Non-pain-related symptoms are informative about more stringently defined dependence on analgesia in SCD. Inter-rater reliability was high, with mean Kappa coefficients of 0.67-0.88. The criteria could be used to assess analgesic dependence in other painful conditions. Pain-related symptoms were more frequent, accounting for 88% of all symptoms reported. When pain-related symptoms were included in the assessment, 31% of the sample met the DSM-IV criteria for substance dependence, compared with only 2% when the assessment was restricted to non-pain-related symptoms. Qualitative analysis of participants' descriptions of analgesic use showed that active coping attempts (attempts to anticipate pain and avoid hospital admissions) and awareness of dependence were themes in descriptions of both pain-related and non-pain-related symptoms. Seeking a more normal lifestyle and impaired activities were themes associated with pain-related symptoms. Psychological disturbance was a theme associated with non-pain-related symptoms. The implications are for more responsive treatment of pain in SCD and greater awareness of how patients' pain coping may be perceived as analgesic dependence. Further research could examine ways that pain-related and non-pain-related symptoms of dependence may be associated with other pain coping strategies and with the outcomes of treatment for painful episodes in hospital.
对处方镇痛药依赖的担忧可能会影响疼痛管理，但此前关于镰状细胞病（SCD）患者药物依赖的可靠证据很少。我们对英国伦敦的SCD患者进行了深入的半结构化访谈，以评估物质依赖和滥用的DSM-IV症状。应用标准来区分与疼痛相关的症状（与DSM-IV症状相对应，但涉及用于控制疼痛的镇痛药）和与疼痛无关的症状（涉及超出疼痛管理范围的镇痛药使用）。与疼痛相关的症状有助于了解SCD中复发性急性疼痛模式如何使患者容易产生药物依赖感。与疼痛无关的症状有助于更严格地界定SCD中对镇痛药的依赖。评分者间信度很高，平均Kappa系数为0.67 - 0.88。这些标准可用于评估其他疼痛性疾病中的镇痛药依赖情况。与疼痛相关的症状更为常见，占所有报告症状的88%。当评估中纳入与疼痛相关的症状时，31%的样本符合DSM-IV物质依赖标准，而当评估仅限于与疼痛无关的症状时，这一比例仅为2%。对参与者镇痛药使用描述的定性分析表明，积极应对尝试（预测疼痛并避免住院的尝试）和对依赖的认知是与疼痛相关和与疼痛无关症状描述中的主题。寻求更正常的生活方式和活动受限是与疼痛相关症状相关的主题。心理障碍是与疼痛无关症状相关的主题。这意味着要对SCD中的疼痛进行更有针对性的治疗，并提高对患者疼痛应对方式可能被视为镇痛药依赖的认识。进一步的研究可以探讨与疼痛相关和与疼痛无关的依赖症状可能如何与其他疼痛应对策略以及住院疼痛发作的治疗结果相关联。
