全身阿片类药物转换为鞘内吗啡时戒断反应的临床研究

Clinical study on withdrawal reactions during conversion of systemic opioid drugs to intrathecal morphine *

摘要:

目的：观察全身阿片类药物转换为鞘内吗啡镇痛时的戒断反应，探讨患者静脉自控给药治疗的可行性。方法：选取阿片类药物耐受的难治性癌痛患者30例，经吗啡静脉自控镇痛(patient controlled analgesia, PCA)剂量滴定24h后植入半植入式鞘内药物输注系统，外接PCA泵鞘内持续输注吗啡。采用临床阿片类药物戒断量表(Clinical Opiate Withdrawal Scale, COWS)评估静脉吗啡转换为鞘内吗啡期间患者阿片戒断反应(opioid withdrawal reaction, OWR)，记录OWR的发生次数、时间和程度；根据COWS评分将患者分为无OWR组(n=7)和OWR组(n=23)，依据OWR的程度分为轻(n=4)、中(n=17)、中重(n=2)和重度(n=0)四组。OWR患者根据需求，采用吗啡静脉PCA给药治疗。评估转换过程中患者疼痛强度、焦虑、抑郁、睡眠、患者满意度，以及阿片类药物不良反应等。结果：本文患者OWR发生率为76.7%(23/30)，轻度及中度占91.3%(21/23)，其中87.0%(20/23)的患者需要通过静脉吗啡PCA缓解OWR。中重度组的COWS平均评分高于轻度组(P＜0.05)，中度组的PCA给药次数高于轻度组(P＜0.05)。戒断反应组(n=23)的入院时每日口服吗啡毫克当量与OWR持续时间(r=0.490, P=0.018)、发生次数(r=0.488, P=0.018)和PCA给药次数(r=0.495, P=0.016)呈正相关。本文患者转换为鞘内吗啡镇痛后疼痛数字评分法评分、每日吗啡使用剂量均较入院时下降(P＜0.05)，焦虑、抑郁、睡眠均得到不同程度改善。出院时便秘发生率较术前明显降低(P＜0.01)。结论：全身阿片类药物转换为鞘内吗啡镇痛时戒断反应的发生率较高，静脉吗啡PCA治疗方便易行、效果确切。

Abstract:

Aims:To observe withdrawal reactions when systemic opioid medications are converted to intrathecal morphine for pain management and to explore the feasibility of patient-controlled intravenous treatment.Methods:Thirty patients suffering from intractable cancer pain who had developed opioid tolerance were selected. After a 24-hour titration of intravenous morphine using patient-controlled analgesia (PCA), a semi implantable intrathecal drug delivery system was implanted and connected to an intrathecal morphine infusion pump. The Clinical Opiate Withdrawal Scale (COWS) was employed to assess opioid withdrawal reactions (OWR) in patients during the transition from intravenous morphine to intrathecal , recording the frequency, duration, and severity of OWR. Patients were categorized based on COWS scores into two groups: those without OWR (n=7) and those with OWR (n=23), further classified by the severity of OWR as mild (n=4), moderate (n=17), moderate to severe (n=2), and severe (n=0). Patients with OWR received intravenous morphine via PCA as needed. Evaluation during the transition process included pain intensity, anxiety, depression, sleep quality, patient satisfaction, and adverse reactions to opioid medications.Results: The incidence of OWR in the patients was 76.7% (23/30), with mild and moderate cases comprising 91.3% (21/23). Among those with OWR, 87.0% (20/23) required relief via patient-controlled intravenous morphine. The moderate to severe OWR group had higher average COWS scores than the mild group (P<0.05), and the moderate OWR group required more PCA administrations than the mild group (P<0.05). The daily oral morphine milligram equivalent at admission of patients in the withdrawal reaction group (n=23) was positively correlated with the duration (r=0.490, P=0.018) and frequency (r=0.488, P=0.018) of OWR and the number of PCA administrations (r=0.495, P=0.016). After transition to intrathecal morphine for pain management, patients experienced a reduction in pain as measured by numerical rating scale scores and a decrease in daily morphine usage compared to admission (P<0.05). Patients' levels of anxiety, depression, and sleep quality improved to varying degrees. The occurrence of constipation at discharge was significantly reduced compared to pre-operation (P<0.01).Conclusion: The incidence of withdrawal reactions is relatively high when converting systemic opioid medications to intrathecal morphine for pain management. Patient-controlled intravenous morphine treatment is convenient and effective.