University Medical Centre, St. Radboud, Nijmegen, The Netherlands.
Pain Pract. 2010 Mar-Apr;10(2):85-93. doi: 10.1111/j.1533-2500.2009.00335.x. Epub 2010 Jan 8.
The management of chronic pain remains a challenge because of its complexity and unpredictable response to pharmacological treatment. In addition, accurate pain management may be hindered by the prejudice of physicians and patients that strong opioids, classified as step 3 medications in the World Health Organization ladder for cancer pain management, are reserved for the end stage of life. Recent information indicates the potential value of strong opioids in the treatment of chronic nonmalignant pain. There are, up until now, insufficient data to provide indications about which opioid to use to initiate treatment or the dose to be used for any specific pain syndrome. The strong inter-patient variability in opioid receptor response and in the pharmacokinetic and pharmacodynamic behavior of strong opioids justifies an individual selection of the appropriate opioid and stepwise dose titration. Clinical experience shows that switching from one opioid to another may optimize pain control while maintaining an acceptable side effect profile or even improving the side effects. This treatment strategy, described as opioid rotation or switch, requires a dose calculation for the newly started opioid. Currently, conversion tables and equianalgesic doses are available. However, those recommendations are often based on data derived from studies designed to evaluate acute pain relief, and sometimes on single dose studies, which reduces this information to the level of an indication. In daily practice, the clinician needs to titrate the optimal dose during the opioid rotation from a reduced calculated dose, based on the clinical response of the patient. Further research and studies are needed to optimize the equianalgesic dosing tables.
慢性疼痛的管理仍然是一个挑战，因为它的复杂性和对药物治疗的不可预测反应。此外，由于医生和患者的偏见，即世界卫生组织癌症疼痛管理阶梯中列为第 3 步药物的强阿片类药物仅保留用于生命的终末期，可能会阻碍准确的疼痛管理。最近的信息表明，强阿片类药物在治疗慢性非恶性疼痛方面具有潜在价值。到目前为止，还没有足够的数据提供关于使用哪种阿片类药物开始治疗或任何特定疼痛综合征的剂量的指示。强阿片类药物在阿片受体反应和药代动力学和药效学行为方面存在个体间的强变异性，这证明了对合适的阿片类药物进行个体选择和逐步剂量滴定是合理的。临床经验表明，从一种阿片类药物转换到另一种阿片类药物可能会优化疼痛控制，同时保持可接受的副作用谱，甚至改善副作用。这种治疗策略，称为阿片类药物旋转或转换，需要为新开始的阿片类药物计算剂量。目前，有转换表和等效镇痛剂量可供使用。然而，这些建议通常基于源自旨在评估急性疼痛缓解的研究的数据，有时甚至基于单次剂量研究，这将这些信息降低到指示的水平。在日常实践中，临床医生需要根据患者的临床反应，从计算出的较低剂量开始，在阿片类药物旋转过程中滴定最佳剂量。需要进一步研究和研究来优化等效镇痛剂量表。
