CMAJ. 1998 Feb 10;158 Suppl 3:S71-81.
To help health professionals develop optimal strategies for controlling the chronic pain caused by breast cancer.
Pain control, absence of adverse effects.
Systematic review of the literature up to Dec. 30, 1996, with nonsystematic coverage to July 1997. Where experimental evidence is lacking, recommendations are based on expert opinion. The evidence was evaluated and graded in "levels" (page S2).
The nature and severity of pain should be carefully evaluated using the history and physical examination. Psychosocial and emotional factors must also be identified. Adequacy of pain control should be evaluated regularly. The first objective in the management of pain due to cancer is to identify the cause and treat it whenever feasible. The first priority of treatment is to control pain rapidly and completely, as judged by the patient. The second priority is to prevent recurrence of pain. The administration of analgesic medication should be based on a regular schedule, around the clock, with additional doses for breakthrough pain when necessary. When drug therapy is necessary, the World Health Organization (WHO) 3-step approach to the use of analgesics is recommended. The oral route should be the first choice for opioid administration. If the oral route fails, transdermal or rectal administration should be considered. When parenteral administration is necessary, the intravenous or subcutaneous routes can be used according to circumstances. Intramuscular administration of opioids is not recommended. Careful observation and titration are required when switching from 1 opioid to another, particularly when the patient is already receiving a high dosage. When converting a patient from long-term oral use of morphine or hydromorphone to parenteral use, a ratio of 3:1 should usually be employed. (This ratio increases to 6:1 for opioid-naive patients.) After initiating morphine or making any change of dose or route of administration, the dosage should be evaluated after approximately 24 hours. Tolerance to opioids must not be confused with physical dependence or psychological, dependence (so-called "addiction"). Patients should be made aware of possible side effects of medications and should be encouraged to maintain a diary for recording medications taken, dosages and adverse events. Adjuvant analgesics should be administered, when necessary, with an opioid or nonopioid analgesic. Noninvasive measures such as psychosocial interventions and physical modalities may bring significant relief. Neuroinvasive procedures are rarely required and should only be considered when other interventions have failed.
The guidelines were reviewed and revised by a writing committee, expert primary reviewers, secondary reviewers selected from all regions of Canada and by the Steering Committee. The present guidelines reflect a consensus of all of these contributors. They have been reviewed and endorsed by the Canadian Society of Palliative Care Physicians and the Canadian Association of Radiation Oncologists.
帮助医疗专业人员制定控制乳腺癌所致慢性疼痛的最佳策略。
疼痛得到控制，无不良反应。
对截至1996年12月30日的文献进行系统综述，并对1997年7月之前的文献进行非系统覆盖。在缺乏实验证据的情况下，建议基于专家意见。证据在“级别”（第S2页）中进行评估和分级。
应通过病史和体格检查仔细评估疼痛的性质和严重程度。还必须识别心理社会和情感因素。应定期评估疼痛控制的充分性。癌症疼痛管理的首要目标是识别病因并在可行时进行治疗。治疗的首要任务是根据患者判断迅速且完全地控制疼痛。其次是预防疼痛复发。镇痛药的给药应基于常规时间表，全天候给药，必要时额外给药以应对突破性疼痛。当需要药物治疗时，建议采用世界卫生组织（WHO）的镇痛药三步使用法。口服途径应是阿片类药物给药的首选。如果口服途径无效，应考虑经皮或直肠给药。当需要胃肠外给药时，可根据情况采用静脉或皮下途径。不建议肌内注射阿片类药物。从一种阿片类药物转换为另一种时，尤其是当患者已接受高剂量药物时，需要仔细观察和滴定。当将患者从长期口服吗啡或氢吗啡酮转换为胃肠外给药时，通常应采用3:1的比例。（对于未使用过阿片类药物的患者，该比例增至6:1。）开始使用吗啡或改变剂量或给药途径后，应在约24小时后评估剂量。对阿片类药物的耐受性绝不能与身体依赖或心理依赖（所谓的“成瘾”）相混淆。应让患者了解药物可能的副作用，并鼓励他们记录所服用的药物、剂量和不良事件，以保持日记。必要时，辅助镇痛药应与阿片类或非阿片类镇痛药一起使用。心理社会干预和物理治疗等非侵入性措施可能会带来显著缓解。很少需要进行神经侵入性手术，仅在其他干预措施均失败时才应考虑。
该指南由一个写作委员会、专家初审人员、从加拿大所有地区选出的二审人员以及指导委员会进行审查和修订。本指南反映了所有这些贡献者的共识。它们已得到加拿大姑息治疗医师协会和加拿大放射肿瘤学家协会的审查和认可。
