Twycross R G
Churchill Hospital, Headington, Oxford.
Cancer Surv. 1988;7(1):29-53.
Pain is a complex somato psychic experience that requires a multimodality approach to treatment. Pharmacologically, pain in cancer can be divided into opioid non-responsive, opioid partially responsive, opioid responsive (but do not use opioids) and opioid responsive (do use opioids). Three concepts govern the use of analgesics in opioid responsive pains: 'by the mouth', 'by the clock' and 'by the ladder'. Adjuvant drugs may also be necessary. Morphine is the strong opioid of choice for cancer pain. In patients unable to take oral medication, morphine can be administered by suppository, by injection or peridurally. Useful alternative strong opioids include phenazocine, hydromorphone and buprenorphine. A number of controversial issues are discussed. These include the oral to parenteral potency ratio of morphine; the main site of metabolism of morphine; the relative merits of morphine and diamorphine; the risk of respiratory depression; the development of tolerance; and the risk of addiction.
疼痛是一种复杂的躯体-心理体验，需要采用多模式方法进行治疗。在药理学上，癌症疼痛可分为对阿片类药物无反应型、对阿片类药物部分反应型、对阿片类药物反应型（但不使用阿片类药物）和对阿片类药物反应型（使用阿片类药物）。有三个概念指导在对阿片类药物反应型疼痛中使用镇痛药：“口服”、“按时”和“按阶梯”。辅助药物可能也是必需的。吗啡是治疗癌症疼痛的首选强效阿片类药物。对于无法口服药物的患者，吗啡可通过栓剂、注射或硬膜外给药。有用的替代强效阿片类药物包括非那佐辛、氢吗啡酮和丁丙诺啡。讨论了一些有争议的问题。这些问题包括吗啡的口服与胃肠外效价比；吗啡的主要代谢部位；吗啡和二醋吗啡的相对优缺点；呼吸抑制的风险；耐受性的发展；以及成瘾的风险。
