아편유사제를 사용한 암환자에서 발생한 통각과민 2례

홍석철,권정혜,한수정 한국호스피스완화의료학회 2019 한국호스피스.완화의료학회지 Vol.22 No.2

아편유사제는 중증의 암성통증 조절의 중요한 약제이며 천장효과가 없다. 그러나 의식저하, 인지기능 저하, 환각, 섬망, 호흡저하, 근간대경련, 발작, OIH 등의 합병증으로 인해 용량증량에 제한이 있다.아편유사제 유발 OIH증은 아편유사제에 노출된 환자에서 역설적으로 통증이 증가하는 현상이다.이 경우 아편유사제의 용량을 줄이거나, 중단하거나 다른 종류의 아편유사제로 변경하거나 NMDA 길항제를 추가하는 것이 조절에 도움이 된다. 아편 주사제에 노출된이후 발생한 OIH를 조절한 증례를 보고하고자 한다. Opioids are important drugs for the management of severe cancer pain without a ceiling effect. However, opioid administration leads to dose-limiting complications including drowsiness, hallucinations, delirium, respiratory depression, cognitive impairment, seizure, myoclonus, and hyperalgesia. Opioid-induced hyperalgesia (OIH) is a paradoxical phenomenon as opioid exposure increases pain sensitivity. Reducing or stopping opioids, opioid rotation, or co-administration of N-methyl-D-aspartate (NMDA) antagonists have been suggested for the management of OIH. In this study, we report two clinical cases of successful management of OIH in cancer pain patients that were treated with opioids.

질식전자궁적출술 후 통증에 대한 Gabapentin의 효과

김현미 ( Hyun Mi Kim ),김은옥 ( Eun Ok Kim ),송지은 ( Ji Eun Song ),박성호 ( Sung Ho Park ),전현아 ( Hyun Ah Jun ),김홍배 ( Hongbae Kim ),이근영 ( Keun Young Lee ) 대한산부인과학회 2008 Obstetrics & Gynecology Science Vol.51 No.3

목적: Gabapentin은 새로이 개발된 항전간제이다. 수술 전 Gabapentin의 투여가 수술 후 환자에서 제통 효과와 항오심 효과를 나타내기도 한다고 한다. 이번 연구 목적은 수술 전 Gabapentin 복용 후 질식전자궁적출술을 경험하는 환자에서 아편유사제 사용량 감소와 제통 효과를 알아보기 위한 것이다. 방법: 무작위추출, 이중 맹검, 실험-대조군 연구로, 선택적 질식전자궁적축술을 시행받은 환자 40명이 연구대상으로 선출되었다. 환자들은 무작위 방법으로 세 군으로 나누어 수술 전날 저녁과 수술 2시간 전에 gabapentin 1,200 mg을 경구 투여한 GABA 2군 (n=17), 900 mg을 경구 투여한 GABA 1군 (n=13), 아무것도 투여하지 않은 대조군 (n=10)으로 나뉘었다. 모든 환자들은 수술 후 통증치료를 위한 IV-PCA를 사용하였다. 결과는 수술 후 1, 2, 4, 8시간과 20시간에 측정한 PCA 소모량과 VAS로 통증정도와 아편제재의 부작용 (오심, 구토, 어지럼증)을 측정하였다. 결과: 대조군과 실험군 사이에 fentanyl 소모량에는 통계적으로 유의한 차이가 있었다 (GABA 2 group, 57.51±8.95 mg, GABA 1 group, 52.21±5.78 mg, Control group, 50.63±2.55 mg)(P<0.05)) 각 군 간의 부작용에서는 유의한 차이를 보이고 있지 않았다. 결론: 수술 전 gabnapentin의 투여가 좋은 진통 효과와 수술 후 아편유사제 소모량을 줄여줄 수 있다. Gabapentin을 질식전자궁적출술 전 사용함으로써 수술 후 진통제 필요량을 효과적으로 줄여줄 수 있을 것으로 사료된다. Objective: Gabapentin is a new generation anticonvulsant drug. Preemptive gabapentin may produce analgesic effect in postoperative patient and have antiemetic effect. The aim of the present study was to investigate the opioid-sparing and analgesic effect of preemptive gabapentin on postoperative pain in patient undergoing vaginal hysterectomy. Methods: In a randomized, double-blind, controlled study, 40 patients scheduled for an elective vaginal total hysterectomy were investigated/-. The patients were randomized to receive either oral gabapentin 1200mg (GABA group 2, n=17) or 900mg (GABA group 1, n=13) with premedication the night before and again 2hours before surgery. The other group (control group, n=10) had only routine premedication without gabapentin. All patients received patient-controlled analgesia (PCA). Postoperatively, pain was assessed using a visual analogue scale (VAS, 0-10) at time 1, 2, 4, 8, and 20 hours. Cumulative PCA consumption and opioid-related adverse events (nausea, vomiting, dizziness) was recorded. Results: There was significant decrease of fentanly consumption in gabapentin group (GABA 2 group : 57.51±8.95 mg, GABA 1 group : 52.21±5.78 mg) compared to control group (50.63±2.55 mg)(p<0.05). There was no significant difference in side-effect (nausea, vomiting, dizziness) were observed between case and control group. Conclusions: Preemptive gabapentin has a good analgesic effect and reduce postoperative fentanyl consumption on postoperative pain after vaginal hysterectomy. Gabapentin effectively rescue analgesic requirement in post-operative patients with vaginal total hysterectomy.

아편유사제의 안전한 사용

고세일,원영웅,강정훈 대한의사협회 2022 대한의사협회지 Vol.65 No.1

Background: Opioids are effective analgesics for cancer pain and refractory non-cancer pain. Although they are essential medication, problematic issues on aberrant behavior and adverse events have rapidly emerged as social problems in Korea. This study aimed to describe the mechanisms, efficacy, and adverse events, especially how to deal with opioid dependency. Current Concepts: Opioid-induced aberrant behavior includes physical and psychological dependences (addiction), abuse, and diversion (giving prescribed opioids to another person). Most physicians are unfamiliar with how to handle patients presenting these problematic issues. Physical and psychological dependences develop through different pathophysiologic mechanisms, i.e., noradrenergic and dopaminergic pathways, respectively. Motivational enhancement therapy, psychosocial support, substitution therapy with buprenorphine, and adjunctive medications, including alpha-2 adrenergic agonist, antidepressants, and non-steroidal antiinflammatory drugs, are the mainstay of treatment for opioid dependency. Constipation, nausea/vomiting, drowsiness/sedation, delirium, itching sensation, voiding difficulty, dry mouth, opioid-induced hyperalgesia, and respiratory depression are well-known physical side effects of opioid consumption. Discussion and Conclusion: Research on the development history, epidemiology of opioid dependency, and its treatment are warranted to avoid an opioid crisis in Korea. Above all, thorough knowledge for physicians and patients is urgently needed.

아편유사제 복용 중인 암성 통증 환자들에서 경구 Oxycodone/Naloxone으로 전환 후 발생한 금단증상

김정훈,송하나,이경원,강정훈,Kim, Jung Hoon,Song, Haana,Lee, Gyeong-Won,Kang, Jung Hun 한국호스피스완화의료학회 2017 한국호스피스.완화의료학회지 Vol.20 No.2

목적: 경구 oxycodone/naloxone 복합제는 아편유사제에 의해 유발되는 변비를 완화시키거나 예방하는 목적으로 사용되고 있다. Naloxone에 의해 oxycodone의 진통 효과가 상쇄되거나 금단증상이 나타난다는 보고는 거의 없었으나 저자는 실제 임상에서 몇몇 금단증상 예를 경험하였기에 이 환자들에 대한 조사 연구를 수행하였다. 방법: 2012년 1월 1일부터 2016년 12월 31일까지 경남 지역 암센터에 방문했던 진행성 암환자들로 oxycodone/naloxone extended-release tablets를 투약 받고 마약 금단증상이 나타났던 환자들의 의무기록을 후향적으로 조사하였다. 결과: 연구 기간 중 경구 oxycodone/naloxone을 처방 받은 1,641명의 암 환자 중, 총 10예(0.6%) 에서 마약 금단 증상을 겪었다. 금단증상 관련 통증 강도의 변화는 oxycodone/naloxone 투여 전 NRS 3에서 평균 NRS 6점으로 증가하였다. 금단증상 중 오한이 10예 중 7예에서 나타나 가장 많이 나타난 증상이었으며 그 외에 식은땀, 전신 쇠약감, 근육경련, 복부경련(각 5예), 불안(4예), 열, 어지럼증, 의식혼란, 하품(각 2예)의 순으로 빈번하게 관찰되었다. 결론: Oxycodone/naloxone extended-release 복합제에 의한 마약 금단증상은 흔하지는 않아도 적은 수의 환자에서라도 나타날 수 있다. 향후 이에 대한 다기관, 전향적 연구가 필요하다. Purpose: Oral naloxone is combined with oxycodone to alleviate or prevent opioid-induced constipation in cancer pain patients. However, there is still concern that oral naloxone may precipitate opioid withdrawal symptoms in patients on opioids. We retrospectively investigated clinical characteristics of cancer patients who experienced opioid withdrawal symptoms. Methods: We reviewed medical records of all patients who were prescribed with oral oxycodone/naloxone at a tertiary cancer center from January 1, 2012 through December 31, 2016. Eligible patients were screened based on demographics, opioid and naloxone dosages, clinical manifestation and pain intensity. Results: Among a total of 1,641 patients, 10 patients were selected. Seven patients were male, and the average age was 68.1 years. The median dose of naloxone that induced withdrawal symptoms was 20 mg. Most common withdrawal symptom was shivering (seven patients) followed by cold sweating (five), and muscle twitching (five). Other symptoms included restlessness, fever, dizziness, and yawning. Pain was exacerbated from the median intensity of numeric rating scale (NRS) 3 to NRS 6. Conclusion: Opioid withdrawal symptoms may occur when switching to oral oxycodone/naloxone for cancer patients who have been treated with other strong opioids. A prospective, multicenter study on this issue should be conducted in future.

아편유사제에 의한 통각과민

이희승 대한의사협회 2014 대한의사협회지 Vol.57 No.1

Perioperative opioid-induced hyperalgesia (OIH) can be defined as the “increased perception of pain after opioid-based anesthesia and surgery” since hyperalgesia is defined as “increased pain from a stimulus that normally provokes pain.” OIH has been identified mainly after remifentanil-based anesthesia in surgical patients given the high dose and rapid withdrawal used. The mechanisms of OIH have been postulated mainly by the cellular-level adaptation in internalization of the receptors and downregulation of intracellular coupling, upregulation of spinal dynorphins, and activation of N-methyl-D-aspartate receptors have been postulated as well. The clinical aspects of OIH with various causes, especially remifentanil, have been investigated. Pros and cons related to remifentanil-induced hyperalgesia have been suggested. The dose and duration of remifentanil used in surgery and anesthesia can be the appropriate factors for OIH, including the way of setting for the control groups of those studies, and the methods for evaluating the pain. Opioids remain one of the most powerful pain killers for acute pain management. Opioids are sometimes necessary for perioperative analgesia, but OIH can be an unavoidable risk. Ongoing interest in OIH and the development of anesthesia optimized for its prevention will increase the quality of perioperative life.

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.

약물요법/암성 통증 관리-비아편유사진통제

김동희 대한의사협회 2010 대한의사협회지 Vol.53 No.2

Cancer pain patients have various diagnosis, stage of disease, response to pain, and treatments and individualized treatment methods are thus needed. Use of Nonopioid analgesics is the first step treatment (according to WHO ladder) for mild to moderate pain, and may be useful for second or third step treatments when combined with weak or strong opioids to reduce side effects of opioids and to create synergy between the two drugs. Acetaminophen and nonsteroidal antiinflammatory drugs(NSAIDs) are also nonopioid analgesics. NSAIDs have a ceiling effect, along with antipyretic, analgesic and antiinflammatory effects, while not producing physical and psychological dependence. Adverse effects of NSAIDs include gastrointestinal hemorrhage, coagulopathy, and deterioration of renal function

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.

무통분만

이해진,전진영 대한의사협회 2010 대한의사협회지 Vol.53 No.1

We discuss recent advances in the administration of labor analgesia aimed at a more effective birthing experience for parturient women. Patient-controlled epidural analgesia (PCEA) is the most effective method of labor pain relief in medical practice. It also provides more consistent and predictable labor analgesia. When a parturient women has a contraindication to epidural analgesia, systemic analgesia techniques are provided as a guide to effective analgesia. PCEA of “low-dose” or “light mixtures” of local anesthetics and lipophilic opioids has allowed anesthesiologists to provide reasonable pain relief for most parturient women while decreasing the total dose of local anesthetics and opioids, thus minimizing the side effects of each agent. Fentanyl analgesia utilizing patient -controlled intravenous analgesia (PCIA), may provide effective self-titrated pain relief, although they are not as effective as the epidural method. Recently, remifentanil was suggested as the opioid of choice for labor analgesia. Potential advantages of remifentanil include better titration of analgesia and neonatal outcome. However,all systemic opioids rapidly cross the placenta. These drugs may cause neonatal respiratory and neurobehavioral depression. In order to reduce the incidence of breakthrough pain, more research on computer-integrated patient-controlled analgesia technology may be necessary. The study of a new local anesthetic drug that has less motor blockade and cardiotoxicity than ropivacaine is desirable, while PCEA is the most effective form of labor analgesia currently available. If epidural analgesia is contraindicated, PCI remifentanil bolus alone may be a suitable systemic analgesia for labor pain.

수술 후 고용량의 펜타닐 투여 후 발생한 마비성 장폐색

김수진, 김희영, 박진욱, 박상희, 박지현, 문연진, 윤미정, 권미영 충북대학교 의학연구소 2021 忠北醫大學術誌 Vol.31 No.1

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