吗啡、酮咯酸及两者联用治疗术后疼痛的比较

据荟萃分析报道，治疗所需的非甾体类抗炎药（NSAID）和阿片类药物的数量相似。得出以上治疗所需数量的研究在基础疼痛强度方面存在的差异可能会影响这些结果。NSAID具有节省阿片类药物用量的作用，但这一效应的重要性尚不明确。因此，哥伦比亚Javeriana大学医学院的Cepeda博士及其同事比较了术后应用酮咯酸和吗啡达到止痛效果的患者比例，并对NSAID节省阿片类药物用量的作用是否可减少阿片类药物的副作用进行了分析。在这项双盲、随机对照试验中，1,003名成年患者被随机分组，分别接受30mg酮咯酸或0.1mg/kg吗啡静注治疗。研究人员计算应用止痛剂后30分钟疼痛强度至少降低50%的患者比例。此外，只要应用止痛剂后30分钟疼痛强度超过5分（满分为10），患者即开始每隔10分钟接受2.5mg吗啡，直至疼痛强度降至4分以下。研究中还评估了与阿片类药物相关的副作用。结果显示，分别有500名和503名患者接受吗啡或酮咯酸治疗。吗啡组有50%的患者疼痛得到缓解，而酮咯酸组该比例仅为31%（差异：19%；95%可信区间：13～25%）。酮咯酸－吗啡组所需的吗啡用量较少（差异：6.5mg；95%可信区间：-5.8至-7.2），且副作用的发生率也低于吗啡组（差异：11%；95%可信区间：5～16%）。Cepeda博士等总结认为，尽管先前的资料显示治疗所需的阿片类药物和NSAID的数量相似，但阿片类药物的止痛效果确实优于NSAID。术后早期在阿片类药物治疗中加入NSAID可降低吗啡的用量，并减少与阿片类药物相关的副作用。

Anesthesiology. 2005 Dec;103(6):1225-1232.

Comparison of Morphine, Ketorolac, and Their Combination for Postoperative Pain: Results from a Large, Randomized, Double-blind Trial.

Cepeda MS, Carr DB, Miranda N, Diaz A, Silva C, Morales O.

* Professor, double dagger Pain Research Coordinator, section sign Anesthesia Resident, parallel Pain Fellow, Department of Anesthesia and Clinical Epidemiology Unit, Javeriana University School of Medicine. dagger Saltonstall Professor of Pain Research, Departments of Anesthesia and Medicine, Tufts-New England Medical Center, and Innovative Drug Delivery Systems, Inc., Boston, Massachusetts.

BACKGROUND: Meta-analyses report similar numbers needed to treat for nonsteroidal antiinflammatory drugs (NSAIDs) and opioids. Differences in baseline pain intensity among the studies from which these numbers needed to treat were derived may have confounded the results. NSAIDs have an opioid-sparing effect, but the importance of this effect is unclear. Therefore, the authors sought to compare the proportions of subjects who obtain pain relief with ketorolac versus morphine after surgery and to determine whether the opioid-sparing effect of an NSAID reduces the magnitude of opioid side effects. METHODS: The study was a double-blind, randomized controlled trial. The authors randomly assigned 1,003 adult patients to receive 30 mg ketorolac or 0.1 mg/kg morphine intravenously. They calculated the proportion of subjects who achieved at least 50% reduction in pain intensity 30 min after analgesic administration. Further, so long as pain intensity 30 min after analgesic administration was 5 or more out of 10, patients received 2.5 mg morphine every 10 min until pain intensity was 4 or less out of 10. The authors assessed the presence of opioid-related side effects. RESULTS: Five hundred patients received morphine and 503 received ketorolac. Fifty percent of patients in the morphine group achieved pain relief, compared with 31% in the ketorolac group (difference, 19%; 95% confidence interval, 13-25%). The ketorolac-morphine group required less morphine (difference, 6.5 mg; 95% confidence interval, -5.8 to -7.2) and had a lower incidence of side effects (difference, 11%; 95% confidence interval, 5-16%) than the morphine group. CONCLUSIONS: Opioids are more efficacious analgesics than NSAIDs, although historic data for these two drugs yield similar numbers needed to treat. Adding NSAIDs to the opioid treatment reduces morphine requirements and opioid-related side effects in the early postoperative period.