de Stoutz N D, Bruera E, Suarez-Almazor M
Palliative Care Program, Medizinische Klinik C, Kantonsspital, St. Gallen, Switzerland.
J Pain Symptom Manage. 1995 Jul;10(5):378-84. doi: 10.1016/0885-3924(95)90924-c.
Accumulation of active (toxic) metabolites of opioids might explain cases of opioid toxicity when high doses are used for long periods of time. Other mechanisms of late toxicity of opioids may be found at the receptor level. Whatever the cause, a change of opioids using equianalgesic doses can be expected to improve symptoms of toxicity in some patients, while maintaining pain control. We reviewed the experience with this technique in patients admitted to the Palliative Care Unit of the Edmonton General Hospital. Of 191 patients, 80 underwent opioid rotation (OR) for cognitive failure, hallucinations, myoclonus, nausea and vomiting, local toxicity, and persistent pain. These leading symptoms improved in 58/80 patients (73%, P < 0.01). Pain control, as measured on a 10-cm visual analogue scale (VAS), improved from 4.4 +/- 2.3 to 3.6 +/- 2.0 (P < 0.004) at a dose significantly lower than that predicted to be equianalgesic (577 +/- 1535 mg before OR versus 336 +/- 593 mg after OR, P < 0.04). We conclude that symptoms of opioid toxicity can be relieved by OR, and that a choice of two or three different opioids is necessary to obtain satisfactory long-term pain control.
当长期大剂量使用阿片类药物时，其活性（毒性）代谢产物的蓄积可能解释阿片类药物中毒的情况。阿片类药物迟发性毒性的其他机制可能存在于受体水平。无论原因如何，使用等效镇痛剂量更换阿片类药物有望改善部分患者的中毒症状，同时维持疼痛控制。我们回顾了埃德蒙顿总医院姑息治疗科收治患者采用该技术的经验。在191例患者中，80例因认知功能障碍、幻觉、肌阵挛、恶心呕吐、局部毒性反应及持续性疼痛而接受阿片类药物轮换（OR）。这些主要症状在58/80例患者中得到改善（73%，P<0.01）。以10厘米视觉模拟量表（VAS）衡量的疼痛控制情况，在剂量显著低于预计等效镇痛剂量时（OR前为577±1535毫克，OR后为336±593毫克，P<0.04），从4.4±2.3改善至3.6±2.0（P<0.004）。我们得出结论，OR可缓解阿片类药物中毒症状，且需要选择两种或三种不同的阿片类药物才能获得满意的长期疼痛控制。
