癌症性疼痛患者的物質濫用風險


  【24drs.com】一篇新研究認為,基於物質濫用風險,建議對使用鴉片類製劑治療疼痛的癌症病患進行更嚴格的篩選和監控。
  
  研究者報告指出,在某些癌症病患中,發現有成癮性的證據,包括使用非法藥物、重複就醫、藥物轉讓等。
  
  沙烏地阿拉伯Dhahran健康中心神經麻醉科醫師Osama Alabdulhadi表示,傳統上,因為壽命有限,並不會考慮癌症病患的鴉片類製劑或其他物質濫用風險。
  
  不過,這些病患的餘命延長,因此出現了更大的物質濫用風險;雖然這是少部分患者,我們的建議是謹慎仔細的評估心理社會歷史和家族史,並且加上尿液測試。
  
  Alabdulhadi醫師指出,最佳方式或許是轉診給疼痛心理師,我們最近開始讓病患先接受疼痛心理師看診,這對我們確實相當有幫助;我可以說,預估至少有70%-80%的病患有成癮的風險。
  
  他們的研究結果發表於國際疼痛研究協會第14屆全球疼痛研討會。
  
  與加拿大西安大略大學倫敦區癌症計畫疼痛與症狀門診的合作下,Alabdulhadi醫師等人在2004至2010年間前瞻追蹤了516名癌症病患(平均年紀62歲),紀錄成癮和異常藥物相關行為的風險因素,平均追蹤32個月,約半數(53%)是女性病患,平均每日最大鴉片劑量為426 mg(相當於口服嗎啡量)。
  
  病患的腫瘤類型包括乳癌(n = 83)、胃腸道(n = 80)、肺(n = 79)、泌尿生殖道(n = 79)、其他(n = 69)、淋巴瘤(n = 45)、多發性骨髓瘤(n = 31)、耳/鼻/喉(n = 31)、皮膚(n = 19)。
  
  53%病患的主要疼痛診斷為腫瘤浸潤,34%是治療相關疼痛,13%是與癌症無關之疼痛。
  
  整個追蹤期間,監測病患的尿液毒性檢測並且訪視,開始時也篩檢家族和個人的物質濫用史。
  
  該研究確認46名病患(8.9%)出現至少1種物質濫用風險因素,21名有1種以上之強烈成癮意義的行為,包括使用非法藥物(n = 13)、酒精濫用(n = 9)、非法重複就醫(n = 9)、藥物轉讓(n = 2)。
  
  例如,2名病患並未處方有benzodiazepines,但卻檢測陽性;至於酒精濫用案例,則是從病患或家族獲得相關資料。
  
  Mark Sullivan博士受邀發表評論時表示,隨著癌症存活率增加,癌症疼痛處置越來越像非癌症疼痛處置;治療期間越久,需要的保障也越多。
  
  在另一個探討非癌症性疼痛之長期鴉片類藥物治療的議題中,華盛頓大學精神病學和行為科學教授、人文和生物倫理學兼職教授Sullivan博士表示,長期鴉片類藥物治療的醫源性超乎於醫療範圍、涉入社會與文化領域,包括降低我們用非醫療方式處理疼痛的能力、以及不切實際的期待緩解。
  
  加拿大安大略多倫多Rouge Valley健康體系緩和照護與疼痛處置開業醫師Erica Weinberg同意,鴉片類誤用和物質濫用問題在癌症病患越來越多,我們做的還不夠;醫師治療癌症病患的方法各有不同—他們很有同理心,他們不認為有可能是個問題,但是,「我的孫子偷了我的藥」、「我的處方箋不見了」等等「情況」越來越多時,這不再沒有問題。
  
  Weinberg醫師在最近發表的主題中寫道,癌症病患和他們的家人必須篩檢鴉片誤用/濫用的可能性;即使是臨終病患也很重要;親友轉讓鴉片類藥物的狀況一定要加以考量。篩檢化學因應和情緒壓力/心智健康議題;適當以非藥物和/或適當藥物治療(刊載於Hot Spot,Odette癌症中心快速反應放療計畫新聞報,2012年8月)。
  
  Weinberg醫師在訪問中表示,我會對每個就醫的癌症病患都加以篩檢嗎?不會。如果他們得要住院,我不會擔心,但是,如果他們要返家,他們的藥物在哪?這是環境因素;要篩檢的是這些病患週遭的環境因素。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6933&x_classno=0&x_chkdelpoint=Y
  

Risk for Substance Abuse in Patients With Cancer Pain

By Kate Johnson
Medscape Medical News

August 30, 2012 (Milan, Italy) — More stringent screening and monitoring is recommended for cancer patients receiving opioid therapy for pain because of their risk for substance abuse, a new study suggests.

Researchers report finding evidence of addiction, including illicit drug use, double doctoring, and drug diversion, among a group of cancer patients.

Traditionally, cancer patients were not considered at risk for opioid or other substance abuse, given their short life expectancies, said the study's lead investigator Osama Alabdulhadi, MD, a neuroanesthetist at Dhahran Health Center in Dhahran, Saudi Arabia.

However, extended life expectancies in these patients have opened a window for greater risk for substance abuse, he told Medscape Medical News. "Although it's a small proportion of people, our recommendation is a careful psychosocial history and a careful family history, plus the urine test," he said.

Referral to a pain psychologist is perhaps the "best tool," Dr. Alabdulhadi added. "We recently started having our patients seen first by a pain psychologist, and this is very, very helpful to us. I would say it predicts at least 70% to 80% of patients at risk of becoming addicted."

Their findings were presented here at the International Association for the Study of Pain 14th World Congress on Pain.

Evidence of Addiction

In collaboration with the Pain and Symptom Clinic of the London Regional Cancer Program at the University of Western Ontario in London, Ontario, Canada, Dr. Alabdulhadi and his group prospectively followed 516 consecutive cancer patients (mean age, 62 years) between 2004 and 2010.

Risk factors for addiction and aberrant drug-related activities were documented, with a mean follow-up of 32 months.

Roughly half (53%) of the patients were female, and the mean maximal daily opioid dose was 426 mg in oral morphine equivalents.

Patients' tumor types included breast (n = 83), gastrointestinal (n = 80), lung (n = 79), urogenital (n = 79), other (n = 69), lymphoma (n = 45), multiple myeloma (n = 31), ear/nose/throat (n = 31), and skin (n = 19).

The primary pain diagnosis was tumor infiltration in 53% of patients, treatment-related pain in 34%, and pain unrelated to cancer in 13%.

Over the course of follow-up, patients were monitored with urine toxicology tests and interviews and were screened at baseline for family and personal history of substance abuse.

The study identified 46 patients (8.9%) who manifested at least 1 risk factor for substance abuse and 21 patients who manifested 1 or more behaviors "strongly suggestive of addiction," including illicit drug use (n = 13), ethanol abuse (n = 9), illicit double doctoring (n = 9), and drug diversion (n = 2).

For example, 2 patients tested positive for benzodiazepines when they had not been prescribed this medication, he said. In the case of ethanol abuse, this information was obtained from the patient or from the family.

Safeguards Needed

Asked to comment on the findings, Mark Sullivan, MD, PhD, said, "With increasing cancer survival, cancer pain management is becoming more like noncancer pain management. Treatment duration is longer, so more safeguards are needed."

In a separate plenary address on the subject of chronic opioid therapy in noncancer pain, Dr. Sullivan, who is professor of psychiatry and behavioral sciences and adjunct professor of bioethics and humanities at the University of Washington, in Seattle, acknowledged that the iatrogenesis of chronic opioid therapy has spread beyond medical boundaries into both social and cultural arenas, including "an erosion of our ability to handle pain in nonmedical ways, along with perhaps unrealistic expectations of relief."

Erica Weinberg, MD, a general practitioner in palliative care and pain management at Rouge Valley Health System, Toronto, Ontario, Canada, agreed that opioid misuse and substance abuse are growing problems among cancer patients.

"We're not doing enough," she told Medscape Medical News. "Clinicians treat cancer patients differently — they're very empathetic, they don't think there could be a problem, but I can't tell you the number of times I've had grandchildren stealing people's pills, and prescriptions getting 'lost,' and so forth — it's happening more and more. And patients are living that much longer."

In a recent publication on the subject, Dr. Weinberg writes, "Cancer patients and their families need to be screened for opioid misuse/abuse potential. This is important even in the end-of-life setting; diversion of opioids by families and friends is always a concern. Screen for chemical coping and emotional distress/mental health issues; treat appropriately with nonpharmacological and/or appropriate pharmacological means" (Hot Spot, the newsletter of the Rapid Response Radiotherapy Program of the Odette Cancer Center, August 2012).

"Do I screen every cancer patient that comes into the hospital? No," Dr. Weinberg said in an interview. "If they're going to stay in the hospital, I don't worry, but if they're going home again, where are their pills? It's the environment; it's screening the environment around them."

Neither speaker has disclosed any relevant financial relationships.

International Association for the Study of Pain 14th World Congress on Pain. Abstract PT 389. Presented August 28, 2012.

    
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