약물요법/암성 통증 관리-아편유사제

박수석 대한의사협회 2010 대한의사협회지 Vol.53 No.3

Opioids are the most effective analgesics for cancer pain treatments. But the ineffective treatment of cancer pain is often related to insufficient knowledge of opioids and fear of the addiction along with the side effects. To achieve effective treatment of cancer pain with opioids,we need a careful assessment of pain, proper use of opioids and regular review of the effectiveness of prescribed opioids. Basic principles of opioids therapy in cancer pain are ① Oral opioids (or transdermal) if possible; ② Combination of long-acting opioids for constant pain with short-acting opioids for breakthrough pain; ③“Opioids rotation”in poor analgesia and significant side effects with the calculations of the morphine equivalent daily dose (MEDD) ④ Initiation of prophylactic treatment for constipation and nausea. In this review, I will describe the essential aspects of opioids therapy, pharmacology, rotation, properties of the individual opioids, and management of common side effects.

Patients’ perception about opioids and addiction in South Korea

( Cho Long Kim ),( Sung Jun Hong ),( Yun Hee Lim ),( Jae Hun Jeong ),( Ho Sik Moon ),( Hey Ran Choi ),( Sun Kyung Park ),( Jung Eun Kim ),( Hakjong You ),( Jae Hun Kim ) 대한통증학회 2020 The Korean Journal of Pain Vol.33 No.3

Background: Chronic pain affects approximately 22% of the world’s population. Opioids can be useful in chronic pain management. However, some patients have negative perception of opioids. The purpose of this research was to evaluate patients’ perception about opioids and investigate problems associated with prescribing and taking opioids in South Korea. Methods: Patients who visited a pain clinic in 14 university hospitals of South Korea from September through October 2018 were asked to complete anonymous questionnaires about taking opioids. Results: Of the 368 patients that were surveyed (female 53.3%, male 46.7%), 56.8% were prescribed opioids. In the opioid group, 92.8% patients had heard of opioids from their doctor and 72.6% of them had a positive perception about opioids. The side effects associated with opioid use were constipation (35.4%), dizziness (24.6%), nausea and vomiting (17.4%), dysuria (6.2%), and addiction (2.0%). In the no opioid group, the primary sources of information about opioids were doctors (49.2%), mass media (30.8%), and the internet (16.2%). The main reasons why 39.0% patients did not take opioids were fear of addiction (57.7%) and side effects (38.5%). There were 71.5% and 60.9% patients in the opioid and no opioid group, respectively, who wished to take opioids when their numeric rating scale pain score was ≥ 7. Conclusions: Perception of opioids among patients who take them was either neutral or positive. However, 39.0% patients who have not been prescribed opioids did not want an opioid prescription, citing fear of addiction and side effects as the primary reasons.

Prevention, diagnosis, and treatment of opioid use disorder under the supervision of opioid stewardship programs: it's time to act now

Kim, Eun-Ji,Hwang, Eun-Jung,Yoo, Yeong-Min,Kim, Kyung-Hoon The Korean Pain Society 2022 The Korean Journal of Pain Vol.35 No.4

The third opium war may have already started, not only due to illicit opioid trafficking from the Golden Crescent and Golden Triangle on the international front but also through indiscriminate opioid prescription and opioid diversion at home. Opioid use disorder (OUD), among unintentional injuries, has become one of the top 4 causes of death in the United States (U.S.). An OUD is defined as a problematic pattern of opioid use resulting in clinically significant impairment or distress, consisting of 2 or more of 11 problems within 1 year, as described by the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition. Observation of aberrant behaviors of OUD is also helpful for overworked clinicians. For the prevention of OUD, the Opioid Risk Tool and the Current Opioid Misuse Measure are appropriate screening tests before and during opioid administration, respectively. Treatment of OUD consists of 3 opioid-based U.S. Food and Drug Administration-approved medications, including methadone, buprenorphine, and naltrexone, and non-opioid-based symptomatic medications for reducing opioid withdrawal syndromes, such as α₂ agonists, β-blockers, antidiarrheals, antiemetics, non-steroidal anti-inflammatory drugs, and benzodiazepines. There are at least 6 recommendable guidelines and essential terms related to OUD. Opioid stewardship programs are now critical to promoting appropriate use of opioid medications, improving patient outcomes, and reducing misuse of opioids, influenced by the successful implementation of antimicrobial stewardship programs. Despite the lack of previous motivation, now is the critical time for trying to reduce the risk of OUD.

반복적 스트레스가 흰쥐의 Opioid성 신경전달에 미치는 영향

사공정규,이광헌,김진성,구본훈,이종범,하정희 大韓神經精神醫學會 1999 신경정신의학 Vol.38 No.3

연구목적: 반복적인 스트레스에 노출된 실험동물에서 opioid성 신경전달의 변화양상을 검색하고 내인성 opioid peptide의 변화양상을 알아보기 위하여 본 연구를 시행하였다. 방 법: 본 연구에서는 웅성 흰쥐에게 하루 2시간, 2주간의 반복적인 부동화 스트레스를 가한 후 뇌의 각 부위에서 opioid 수용체의 mu-, delta- 및 kappa- 아형의 최대결합력 및 친화력의 변화 양상을 관찰하였다. 결 과: 반복적 부동화 스트레스 노출군에서는 대조군에 비하여 delta-아형 수용체의 수가 시상하부(hypo-thalamus) 및 선조체(striatum)에서 증가하였다. 본 연구결과 관찰된 선조체에서의 delta-아형 수용체의 상향조절과 관련지어 delta-아형 수용체의 내인성 효현제인 enkephalin의 뇌조직 내에서의 활성도를 검색하였을 때, 반복적 스트레스 노출군에서는 대조군에 비하여 그 함량이 감소하였다. 이러한 뇌조직내 enkephalin 활성도 감소 현상은 수용체 변화와 상응하게 시상하부 및 선조체에서 관찰되었으며, 이러한 수용체의 조절 현상은 내인성 수용체 효현제인 enkephalin의 활성도의 감소에 따른 생체의 적응 현상으로 해석되었다. 결 론: 이상의 결과로부터 반복적인 스트레스는 opioid 수용체 delta-아형을 상향조절하였으며, opioid 수용체 delta-아형의 내인성 효현제의 활성도를 감소시킴을 관찰하였다. Objectives : Research into emotional or behavioral stress typically focuses upon the hypothalamic-pituitary-adrenal axis. It is well established that the hypothalamic-pituitary-adrenocortical axis is subject to inhibitory control by opioids in a variety of animal species including pigs. Exposure to acute stress induces the upregulation of opioid receptors and the release of endogenous peptides which mediate the stress-induced analgesia. There is some literature substantiating that repeated stress can lead to changes in opioidergic neurotransmission. However, the changes are highly variable. This study was designed to observe the modulatory effect of repeated immobilization stress on opioidergic neurotransmission. Methods : Male Sprague-Dawley rats weighing 150-200g were forced to suffer immobilization stress for 2 hours on each of 14 successive days. Then we examined the maximum binding capacity and affinity of each opioid subtypes(mu, delta, kappa). Results : Repeated immobilization stress increased the binding of [³H]DPDPE on the delta-subtype opioid receptor in the striatum and hypothalamus. Saturation experiments followed by scatchard analyses of the results showed an increase in the density of delta-subtype opioid receptors, but the affinity of the delta-subtype opioid receptor remained unchanged. Repeated immobilization stress reduced enkephalin activity of striatum and hypothalamus. Conclusions : From these results, it could be concluded that repeated immobilization stress up-regulated the delta-subtype opioid receptors and reduced the activity of enkephalin, an endogenous ligand for the delta-subtype opioid receptor.

만성 비암성 통증 환자의 아편유사제 사용

윤동욱,강웅구 대한신경정신의학회 2019 신경정신의학 Vol.58 No.3

Opioids are effective analgesics, but they are often difficult to use properly, due mainly to adverse events, such as constipation, respiratory depression, addiction, tolerance, and opioid induced hyperalgesia. In the past, the problem of opioids around the world was usually caused by drugs traded illegally, so there was no need for medical and social attention in Korea. On the other hand, with the dramatic increase in the therapeutic use of opioids, which commenced more than a decade ago, problems caused by legally prescribed drugs have emerged, and now a more serious opioid crisis is being experienced than in the days of illegal drugs. A growing number of patients are chronically prescribed opioids, and a growing number of health care providers and hospitals suffer from problems related to chronic prescription. Currently, in Korea, it is the time to pay serious attention to achieve the safe and effective use of prescribed opioids. This paper consists of the following parts. 1) A summary of the issues related to chronic pain, opioids, and problems associated with the use of opioids. 2) Some case examples the authors’ experienced. 3) Simple guidelines on the use of opioids in the treatment of chronic non-cancer pain are proposed based on the author’s experience and existing literature. These guidelines are by no means comprehensive, and hopefully in the future, related experts will join forces to develop better guidelines.

마약성 진통제를 이용한 암성 통증의 효율적 관리에 대한 약사의 임상업무 개발

양사미,김민선,김재연,신혜영 한국병원약사회 2006 병원약사회지 Vol.23 No.4

Patients with cancer have diverse symptoms, impairments in physical and psychological functioning, and other difficulties that can undermine their quality of life. Generally, oral and transdermal morphine has been recognized as the analgesic of first choice in the management of increasing or persisting cancer pain. In this study, we evaluated the adequacy of pain control using opioid analgesics in terminal cancer patients in this hospital, and considered the pharmacist's role in the cancer pain management process. From August to October 2005, we conducted medication counseling of opioid analgesics in cancer patients, and gave them questionnaires to evaluate the efficacy of the opioid analgesics and occurring complications. Also, we investigated the ratio of pharmacist's intervention in using opioid analgesics. On the cancer pain intensity, 83 percent of patients experienced moderate to severe pain. 60 percent of patients satisfied opioid's analgesic effects, but 28.5 percents complained inadequate pain management. 62.8% of patients experienced adverse effects by opioid analgesics, and the list of common adverse effects includes constipation (40.6%), drowsiness (27.5%), dry mouth (20.3%), nausea and vomiting (8.7%). The rationale of the clinical pharmacist's intervention in using opioid analgesics was 35.7 percent, including alteration of the prescription about opioid analgesics (35.2%), relief from the adverse effects (26.5%), improvement of the patient's recognition about using opioids (26.5%). The results showed most patients administrated opioid analgesics had severe pain, and some of them experienced inadequate pain control or adverse effects. In conclusion, the pharmacists should be clinically well experienced and evaluate administrating opioid analgesic's efficacy. In addition, they should induce modification of the inappropriate prescription as the communication mediators between the doctor and the patients. Then, cancer pain management service could be more effective and patient's quality of life would be more improved.

마약성 진통제를 이용한 암성 통증의 효율적 관리에 대한 약사의 임상업무 개발

양사미,김민선,김재연,신혜영 한국병원약사회 2006 병원약사회지 Vol.23 No.3

Patients with cancer have diverse symptoms, impairments in physical and psychological functioning, and other difficulties that can undermine their quality of life. Generally, oral and transdermal morphine has been recognized as the analgesic of first choice in the management of increasing or persisting cancer pain. In this study, we evaluated the adequacy of pain control using opioid analgesics in terminal cancer patients in this hospital, and considered the pharmacist's role in the cancer pain management process. From August to October 2005, we conducted medication counseling of opioid analgesics in cancer patients, and gave them questionnaires to evaluate the efficacy of the opioid analgesics and occurring complications. Also, we investigated the ratio of pharmacist's intervention in using opioid analgesics. On the cancer pain intensity, 83 percent of patients experienced moderate to severe pain. 60 percent of patients satisfied opioid's analgesic effects, but 28.5 percents complained inadequate pain management. 62.8% of patients experienced adverse effects by opioid analgesics, and the list of common adverse effects includes constipation (40.6%), drowsiness (27.5%), dry mouth (20.3%), nausea and vomiting (8.7%). The rationale of the clinical pharmacist's intervention in using opioid analgesics was 35.7 percent, including alteration of the prescription about opioid analgesics (35.2%), relief from the adverse effects (26.5%), improvement of the patient's recognition about using opioids (26.5%). The results showed most patients administrated opioid analgesics had severe pain, and some of them experienced inadequate pain control or adverse effects. In conclusion, the pharmacists should be clinically well experienced and evaluate administrating opioid analgesic's efficacy. In addition, they should induce modification of the inappropriate prescription as the communication mediators between the doctor and the patients. Then, cancer pain management service could be more effective and patient's quality of life would be more improved.

통증완화를 위한 오피오이드 사용의 교훈: 경제협력개발기구 회원국의 경험을 중심으로

임지혜 ( Jeehye Im ),조재영 ( Jae Young Cho ) 한국보건행정학회 2021 보건행정학회지 Vol.31 No.4

The growing use of prescription analgesic opioids has rapidly escalated the treatment of chronic pain since the 1990s; however, it is also highly needed to control opioid-related issues, including opioids misuse, abuse, and addiction. In 2018, Organization for Economic Cooperation and Development (OECD) secretariat administered the survey on opioids use and policies to OECD countries and presented it at the Health Committee meeting of December 2018. This study aimed to review the opioids use in OECD countries and their policies to prevent and reduce associated harms, also seek the available policy lessons from OECD countries. More recently, opioids prescribing rate have been increased 14.7% between 2011-2013 and 2014-2016 and steadily focused on the main substance misused and abused in Korea. In addition, policy efforts have contributed to developing a guideline for prescribing opioids to steer the appropriate use of prescription analgesic opioids since 2000 in Korea, so it is not enough to control opioids compared with other OECD countries. Therefore, taking a people-centered and public health perspective, it will consider the health system policies and interventions at a national level to improve their preparation and approach to control opioid-related issues.

Expectations of Lumbar Surgery Outcomes among Opioid Users Compared with Non-Users

Reisener Marie-Jacqueline,Hughes Alexander P.,Schadler Paul,Forman Alexa,Sax Oliver C.,Shue Jennifer,Cammisa Frank P.,Sama Andrew A.,Girardi Federico P.,Mancuso Carol A. 대한척추외과학회 2020 Asian Spine Journal Vol.14 No.5

Study Design: Matched cohort study. Purpose: To compare and describe the effect of opioid usage on the expectations of lumbar surgery outcomes among patients taking opioids and patients not taking opioids. Overview of Literature: Chronic opioid use is common among lumbar-spine surgery patients. The decision to undergo elective lumbar surgery is influenced by the expected surgery outcomes. However, the effects of opioids on patients’ expectations of lumbar surgery outcomes remain to be rigorously assessed. Methods: A total of 77 opioid users grouped according to dose and duration (54 “higher users,” 30 “lower users”) were matched 2:1 to 154 non-opioid users based on age, sex, marital status, chiropractic care, disability, and diagnosis. All patients completed a validated 20-item Expectations Survey measuring expected improvement with regard to symptoms, function, psychological well-being, and anticipated future spine condition. “Greater expectations” was defined as a higher survey score (possible range, 0–100) based on the number of items expected and degree of improvement expected. Results: The mean Expectations Survey scores for all opioid users and all non-users were similar (73 vs. 70, p=0.18). Scores were different, however, for lower users (79) compared with matched non-users (69, p=0.01) and compared with higher users (70, p=0.01). In multivariable analysis, “reater expectations” was independently associated with having had chiropractic care (p=0.03), being more disabled (p=0.002), and being a lower-dose opioid user (p=0.03). Compared with higher users, lower users were also more likely to expect not to need pain medications 2 years after surgery (47% vs. 83%, p=0.003). Conclusions: Patient expectations of lumbar surgery are associated with diverse demographic and clinical variables. A lower dose and shorter duration of opioid use were associated with expecting more items and expecting more complete improvement compared with non-users. In addition, lower opioid users had greater overall expectations compared with higher users.

Opioid-induced constipation: a narrative review of therapeutic options in clinical management

Kordula Lang-Illievich,Helmar Bornemann-Cimenti 대한통증학회 2019 The Korean Journal of Pain Vol.32 No.2

Pain therapy often entails gastrointestinal adverse events. While opioids are effective drugs for pain relief, the incidence of opioid-induced constipation (OIC) varies greatly from 15% to as high as 81%. This can lead to a significant impairment in quality of life, often resulting in discontinuation of opioid therapy. In this regard, a good doctor-patient relationship is especially pivotal when initiating opioid therapy. In addition to a detailed history of bowel habits, patient education regarding the possible gastrointestinal side effects of the drugs is crucial. In addition, the bowel function must be regularly evaluated for the entire duration of treatment with opioids. Furthermore, if the patient has preexisting constipation that is well under control, continuation of that treatment is important. In the absence of such history, general recommendations should include sufficient fluid intake, physical activity, and regular intake of dietary fiber. In patients of OIC with ongoing opioid therapy, the necessity of opioid use should be critically reevaluated in terms of an with acceptable quality of life, particularly in cases of non-cancer pain. If opioids must be continued, lowering the dose may help, as well as changing the type of opioid. If these measures do not suffice, the next step for persistent OIC is the administration of laxatives. If these are ineffective as well, treatment with peripherally active -opioid receptor antagonists should be considered. Enemas and irrigation are emergency measures, often used as a last resort.