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.

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.

비암성 통증 환자에서 아편 유사제 약물의 만성적 사용 증례 및 가이드라인 제안

윤동욱,강웅구 한국중독정신의학회 2019 중독정신의학 Vol.23 No.2

Opioid analgesics have been increasingly prescribed in recent years. In Korea, chronic opioid prescription has not common practice among physicians not treating cancer patients, and the lack of experience sometimes results in inadequate prescription and various medical and social problems. The authors have some experience with patients chronically using opioids. We have submitted a review paper to the Journal of Korean Neuropsychiatric Association (JKNPA) pertaining to chronic pain, opioid drugs, addiction, and the use of opioid medication. This paper is a “practical” version addressing the same topics, presenting cases, and guidelines. Here we present five of our patients chronically using opioid medications. Treatments seem to be successful for some patients, while not for other patients. After the case review, based on the author’s experience and existing literature, a simple guideline on the use of opioids in the treatment of chronic noncancer pain is proposed. This guideline is by no means comprehensive, and we hope in the future, that related experts would exert joint efforts to create better guidelines.

중등도 이상의 암성통증을 호소하는 노인 환자에 대한 고용량의 마약성 진통제의 이용: 전향적 관찰 연구

김정은(Jung Eun Kim),최윤선(Youn Seon Choi),이경희(Kyung Hee Lee),김준석(Jun Suk Kim),고수진(Su Jin Koh),백선경(Sun Kyung Baek),김시영(Si Young Kim),송홍숙(Hong Suk Song),임보라미(Bo Rami Lim) 대한임상노인의학회 2016 대한임상노인의학회지 Vol.17 No.1

Background: Despite the large number of elderly individuals who are dying of cancer in Korea, the quality of pain management remains poor. Thus, in this study, the safety and efficacy of using high-dose opioids to treat has been evaluated pain in elderly patients with cancer. Methods: Data from cancer patients (N=94) aged ≥65 years who were administered high-doses of opioids (≥120 mg/day) were collected at 38 hospitals between February 2009 and March 2010. After 8 weeks, changes in pain severity were examined using a numeric rating scale; in addition, the opioid dosages, quality of life parameters, and opioid-based adverse events were investigated. Results: Ninety-two patients were prescribed opioids at the beginning of the study and followed for 8 weeks. The mean pain intensity changed from 5.61±1.56 at baseline to 4.02±2.17 (P<0.001) after 8 weeks. The mean opioid dosage, expressed as oral morphine equivalents, changed from 178.86±76.88 at baseline to 288.54±389.09 (P=0.0025) after 8 weeks. The quality of life parameters, including daily activities, ambulation, and sleep, improved significantly after 8 weeks (P<0.001). At baseline, 44 patients (47.8%) complained of adverse effects such as constipation, dizziness, and nausea; the frequency of adverse events did not increase after 8 weeks. Conclusion: The use of high-dose opioids for treating cancer pain is safe, effective, and tolerable in elderly patients.

Effects of high-frequency, high-intensity transcutaneous electrical nerve stimulation versus intravenous opioids for pain relief after hysteroscopy: a randomized controlled study

( Birgitta Platon ),( Sven-egron Thörn ),( Clas Mannheimer ),( Paulin Andréll ) 대한산부인과학회 2020 Obstetrics & Gynecology Science Vol.63 No.5

Objective To compare the time spent in the Post-Anesthesia Care Unit (PACU) and the pain-relieving effects of treatment with high-frequency, high-intensity transcutaneous electrical nerve stimulation (TENS) or intravenous (IV) opioids after hysteroscopy. Methods All patients who postoperatively reported a visual analogue scale (VAS) pain score of ≥3 were included in the study. TENS treatment was given with a stimulus intensity between 40 and 60 mA for 1 minute and repeated once if there was insufficient pain relief. In the opioid group, a fractionated dose of 5 mg morphine was administered. If the patient reported insufficient pain relief after the assigned treatment, the patient was reassigned to the other treatment group. Results Seventy-four women were randomized to TENS (n=38) or IV opioids (n=36) for treatment. Both groups reported significant pain relief after discharge from the PACU, with a decrease of VAS scores from 5.6 to 1.4 in the TENS group (P<0.001) and 5.1 to 1.3 in the opioid group (P<0.001). There were no significant differences between the groups. When only the responders in both groups, i.e., patients with VAS scores of <3 on respectively assigned treatments, were compared, the TENS responders (n=22) were found to have spent a significantly shorter time in the PACU (91 vs. 69 minutes, P=0.013) compared to the opioid responders (n=20). Conclusion Using TENS as first line of pain relief may reduce the need for postoperative opioids. In addition, TENS appears preferable as the first line of treatment due to its association with a shorter time spent in the PACU if the patient responds to the treatment. Trial Registration Vastra Gotalandsregionen Identifier: 211261

Recovery from minimally invasive vs. open surgery in kidney cancer patients: Opioid use and workplace absenteeism

Marieke J. Krimphove,Stephen W. Reese,Xi Chen,Maya Marchese,Daniel Pucheril,Eugene Cone,Wesley Chou,Karl H. Tully,Adam S. Kibel,Richard D. Urman,Steven L. Chang,Luis A. Kluth,Prokar Dasgupta,Quoc-Dien 대한비뇨의학회 2021 Investigative and Clinical Urology Vol.62 No.1

Purpose: Does surgical approach (minimally invasive vs. open) and type (radical vs. partial nephrectomy) affects opioid use and workplace absenteeism. Materials and Methods: Retrospective multivariable regression analysis of 2,646 opioid-naïve patients between 18 and 64 undergoing radical or partial nephrectomy via either a minimally invasive vs. open approach for kidney cancer in the United States between 2012 and 2017 drawn from the IBM Watson Health Database was performed. Outcomes included: (1) opioid use in opioid-naïve patients as measured by opioid prescriptions in the post-operative setting at early, intermediate and prolonged time periods and (2) workplace absenteeism after surgery. Results: Patients undergoing minimally invasive surgery had a lower odds of opioid use in the early and intermediate post-operative periods (early: odds ratio [OR], 0.77; 95% confidence interval [CI], 0.62–0.97; p=0.02, intermediate: OR, 0.60; 95% CI, 0.48–0.75; p<0.01), but not in the prolonged setting (prolonged: OR, 1.00; 95% CI, 0.75–1.34; p=0.98) and had earlier return to work (minimally invasive vs. open: −10.53 days; 95% CI, −17.79 to −3.26; p<0.01). Controlling for approach, patient undergoing partial nephrectomy had lower rates of opioid use across all time periods examined and returned to work earlier than patients undergoing radical nephrectomy (partial vs. radical: −14.41 days; 95% CI, −21.22 to −7.60; p<0.01). Conclusions: Patients undergoing various forms of surgery for kidney cancer had lower rates of peri-operative opioid use, fewer days of workplace absenteeism, but no difference in long-term rates of opioid use in patients undergoing minimally invasive as compared to open surgery.

Effect of continuous post-operative lidocaine infusion in an enhanced recovery program on opioid use following gynecologic oncology surgery

Deanna Taiym,Matthew Cowan,Brad Nakamura,Hooman Azad,Anna Strohl,Emma Barber 대한부인종양학회 2023 Journal of Gynecologic Oncology Vol.34 No.5

Objective: To determine the effectiveness of implementing an Enhanced Recovery After Surgery (ERAS) program, including continuous intraoperative and postoperative intravenous (IV) lidocaine infusion, on perioperative opioid use. Methods: This was a single-institution retrospective pre- post- cohort study. Consecutive patients undergoing planned laparotomy for known or potential gynecologic malignancy were identified after implementation of an ERAS program and compared to a historical cohort. Opioid use was calculated as morphine milligram equivalents (MMEs). Cohorts were compared using bivariate tests. Results: A total of 215 patients were included in the final analysis, 101 patients received surgery before ERAS implementation and 114 received surgery after. A reduction in total opioid use was observed in ERAS patients compared with historical controls (MME 26.5 [9.6–60.8] versus 194.5 [123.8–266.8], p<0.001). Length of stay (LOS) was reduced by 25% in the ERAS cohort (median 3 days, range 2–26, versus 4 days, range 2–18; p<0.001). Within the ERAS cohort, 64.9% received IV lidocaine for the planned 48 hours, and 5.6% had the infusion discontinued early. Within the ERAS cohort, patients who received IV lidocaine infusion used less opioids compared to those who did not (median 16.9, range 5.6–55.1, versus 46.2, range 23.2–76.1; p<0.002). Conclusion: An ERAS program including a continuous IV lidocaine infusion as the opioid-sparing analgesic strategy was noted to be safe and effective, leading to decreased opioid consumption and LOS compared with a historic cohort. Additionally, lidocaine infusion was noted to decrease opioid consumption even among patients already receiving other ERAS interventions.

The Effect of Nefopam on Postoperative Fentanyl Consumption: A Randomized, Double-blind Study

( Jee Youn Moon ),( Sang Sik Choi ),( Shin Young Lee ),( Mi Kyung Lee ),( Jung Eun Kim ),( Ji Eun Lee ),( So Hyun Lee ) 대한통증학회 2016 The Korean Journal of Pain Vol.29 No.2

Background: Nefopam is a non-opioid, non-steroidal, centrally acting analgesic drug. The concomitant use of opioids and nefopam is believed to have many advantages over the administration of opioids alone for postoperative pain management. We conducted a randomized, double-blind study to determine the fentanylsparing effect of co-administration of nefopam with fentanyl for postoperative pain management via patient controlled analgesia (PCA). Methods: Ninety female patients who underwent laparoscopic total hysterectomy under general anesthesia were randomized into 3 groups, Group A, fentanyl 1,000 ug; Group B, fentanyl 500 ug + nefopam 200 mg; and Group C, fentanyl 500 ug + nefopam 400 mg, in a total volume of 100 ml PCA to be administered over the first 48 h postoperatively without basal infusion. The primary outcome was total fentanyl consumption during 48 h; secondary outcomes included pain scores and incidence of side effects. Results: Eighty-one patients were included in the analysis. The overall fentanyl-sparing effects of PCA with concomitant administration of nefopam during the first 48 h postoperatively were 54.5% in Group B and 48.9% group C. Fentanyl use was not significantly different between Groups B and C despite the difference in the nefopam dose. There were no differences among the three groups in terms of PCA-related side effects, although the overall sedation score of Group B was significantly lower than that of Group A. Conclusions: The concomitant administration of nefopam with fentanyl for postoperative pain management may allow reduction of fentanyl dose, thereby reducing the risk of opioid-related adverse effects. (Korean J Pain 2016; 29: 110-8)

The Effect of Nefopam on Postoperative Fentanyl Consumption: A Randomized, Double-blind Study

문지연,최상식,이신영,이미경,김정은,이지은,이소현 대한통증학회 2016 The Korean Journal of Pain Vol.29 No.2

Background: Nefopam is a non-opioid, non-steroidal, centrally acting analgesic drug. The concomitant use of opioids and nefopam is believed to have many advantages over the administration of opioids alone for postoperative pain management. We conducted a randomized, double-blind study to determine the fentanyl- sparing effect of co-administration of nefopam with fentanyl for postoperative pain management via patient controlled analgesia (PCA). Methods: Ninety female patients who underwent laparoscopic total hysterectomy under general anesthesia were randomized into 3 groups, Group A, fentanyl 1,000 g; Group B, fentanyl 500 g + nefopam 200 mg; and Group C, fentanyl 500 g + nefopam 400 mg, in a total volume of 100 ml PCA to be administered over the first 48 h postoperatively without basal infusion. The primary outcome was total fentanyl consumption during 48 h; secondary outcomes included pain scores and incidence of side effects. Results: Eighty-one patients were included in the analysis. The overall fentanyl-sparing effects of PCA with concomitant administration of nefopam during the first 48 h postoperatively were 54.5% in Group B and 48.9% group C. Fentanyl use was not significantly different between Groups B and C despite the difference in the nefopam dose. There were no differences among the three groups in terms of PCA-related side effects, although the overall sedation score of Group B was significantly lower than that of Group A.Conclusions: The concomitant administration of nefopam with fentanyl for postoperative pain management may allow reduction of fentanyl dose, thereby reducing the risk of opioid-related adverse effects. (Korean J Pain 2016; 29: 110-8)

The Effect of Nefopam on Postoperative Fentanyl Consumption: A Randomized, Double-blind Study

Moon, Jee Youn,Choi, Sang Sik,Lee, Shin Young,Lee, Mi Kyung,Kim, Jung Eun,Lee, Ji Eun,Lee, So Hyun The Korean Pain Society 2016 The Korean Journal of Pain Vol.29 No.2

Background: Nefopam is a non-opioid, non-steroidal, centrally acting analgesic drug. The concomitant use of opioids and nefopam is believed to have many advantages over the administration of opioids alone for postoperative pain management. We conducted a randomized, double-blind study to determine the fentanyl-sparing effect of co-administration of nefopam with fentanyl for postoperative pain management via patient controlled analgesia (PCA). Methods: Ninety female patients who underwent laparoscopic total hysterectomy under general anesthesia were randomized into 3 groups, Group A, fentanyl $1,000{\mu}g$; Group B, fentanyl $500{\mu}g$ + nefopam 200 mg; and Group C, fentanyl $500{\mu}g$ + nefopam 400 mg, in a total volume of 100 ml PCA to be administered over the first 48 h postoperatively without basal infusion. The primary outcome was total fentanyl consumption during 48 h; secondary outcomes included pain scores and incidence of side effects. Results: Eighty-one patients were included in the analysis. The overall fentanyl-sparing effects of PCA with concomitant administration of nefopam during the first 48 h postoperatively were 54.5% in Group B and 48.9% group C. Fentanyl use was not significantly different between Groups B and C despite the difference in the nefopam dose. There were no differences among the three groups in terms of PCA-related side effects, although the overall sedation score of Group B was significantly lower than that of Group A. Conclusions: The concomitant administration of nefopam with fentanyl for postoperative pain management may allow reduction of fentanyl dose, thereby reducing the risk of opioid-related adverse effects.