Zech Detlev F J, Grond Stefan, Lynch John, Hertel Dagmar, Lehmann Klaus A
Pain Clinic, Department of Anaesthesiology and Operative Intensive Care, University of Cologne, Joseph-Stelzmannstrasse 9, D-50924 Köln, Germany.
Pain. 1995 Oct;63(1):65-76. doi: 10.1016/0304-3959(95)00017-M.
This paper reports on the experience gained using World Health Organization Guidelines for cancer pain relief over a 10-year period in an anaesthesiology-based pain service associated with a palliative care programme. The course of treatment of 2118 patients was assessed prospectively over a period of 140,478 treatment days. Non-opioid analgesics (WHO step I) were used on 11%, weak opioids (WHO step II) on 31% and strong opioids (WHO step III) on 49% of treatment days. Administration was via the enteral route on 82% and parenterally on 9% of treatment days. On the remaining days, either spinally applied opioids (2%) or other treatments (6%) were utilised. Fifty-six percent of the patients were treated with morphine. Morphine dose escalation was observed in about one-half of the patients being cared for until death, whereas the other half had stable or decreasing doses over the course of treatment. Co-analgesics were administered on 37% of days, most often antidepressants (15%), anticonvulsants (13%) and corticosteroids (13%). Adjuvants to treat symptoms other than pain were prescribed on 79% of days, most commonly laxatives (42%), histamine-2-receptor antagonists (39%) and antiemetics (35%). In addition, palliative antineoplastic treatment was performed in 42%, nerve blocks in 8%, physiotherapy in 5%, psychotherapy in 3% and TENS in 3% of patients. A highly significant pain reduction was achieved within the 1st week of treatment (P < 0.001). Over the whole treatment period, good pain relief was reported in 76%, satisfactory efficacy in 12% and inadequate efficacy in 12% of patients. In the final days of life, 84% rated their pain as moderate or less, while 10% were unable to give a rating. Analgesics remained constantly effective in all 3 steps of the WHO ladder. Other clinical symptoms were likewise significantly reduced at 1 week after initial assessment, with the exception of neuropsychiatric symptoms. During the course of treatment, the latter were the major symptoms on 23% of days, followed by nausea (23%), constipation (23%) and anorexia (20%). Our results emphasise once again the marked efficacy and low rate of complications associated with oral and parenteral analgesic therapy as the mainstay of pain treatment in the palliative care of patients with advanced cancer. Wide dissemination of WHO guidelines among doctors and healthcare workers is thus necessary to effect a clear improvement in the treatment of the many patients suffering from cancer pain in the clinical and home setting.
本文报告了在一个与姑息治疗项目相关的以麻醉学为基础的疼痛服务机构中，在10年期间使用世界卫生组织癌症疼痛缓解指南所获得的经验。对2118例患者的治疗过程进行了前瞻性评估，为期140478个治疗日。在11%的治疗日使用了非阿片类镇痛药（世界卫生组织第一步），31%使用了弱阿片类药物（世界卫生组织第二步），49%使用了强阿片类药物（世界卫生组织第三步）。82%的治疗日通过肠内途径给药，9%通过胃肠外途径给药。在其余的日子里，使用了脊髓给药的阿片类药物（2%）或其他治疗方法（6%）。56%的患者接受了吗啡治疗。在约一半直至死亡的接受护理的患者中观察到吗啡剂量增加，而另一半患者在治疗过程中剂量稳定或减少。在37%的日子里使用了辅助镇痛药，最常用的是抗抑郁药（15%）、抗惊厥药（13%）和皮质类固醇（13%）。在79%的日子里开了用于治疗疼痛以外症状的佐剂，最常见的是泻药（42%）、组胺-2受体拮抗剂（39%）和止吐药（35%）。此外，42%的患者接受了姑息性抗肿瘤治疗，8%接受了神经阻滞，5%接受了物理治疗，3%接受了心理治疗，3%接受了经皮电刺激神经疗法。在治疗的第一周内疼痛显著减轻（P<0.001）。在整个治疗期间，76%的患者报告疼痛缓解良好，12%疗效满意，12%疗效不佳。在生命的最后几天，84%的患者将疼痛评为中度或以下，而10%的患者无法给出评分。镇痛药在世界卫生组织阶梯的所有三个步骤中均持续有效。除神经精神症状外，其他临床症状在初次评估后1周也同样显著减轻。在治疗过程中，后者在23%的日子里是主要症状，其次是恶心（23%）、便秘（23%）和厌食（20%）。我们的结果再次强调了口服和胃肠外镇痛治疗作为晚期癌症患者姑息治疗中疼痛治疗的主要手段具有显著疗效和低并发症发生率。因此，有必要在医生和医护人员中广泛传播世界卫生组织指南，以切实改善在临床和家庭环境中众多癌症疼痛患者的治疗。
