Il dolore non necessario
Fonti
IRFMN- DOXA 1995. Cross sectional survey in 2.244 italians. In: Apolone G,
Hearn J et al. Cancer pain epidemiology: a systematic review. In: Bruera ED et al. Cancer Pain, assessment and management. Cambridge, Cambridge University Press, 2003.
Dal 2005 tutti i farmaci antidiolorifici, dai semplici antifiammatori alla morfina, saranno gratuiti e passeranno in fascia A, secondo quanto annunciato giorni fa dal ministro della salute Girolamo Sirchia e dal direttore generale dell'Agenzia italiana del farmaco (AIFA) Nello Martini. L'utilizzo corretto dei farmaci antidolorifici nel contesto di malattie croniche e gravi, come i tumori, è stato stabilito dall'Organizzazione mondiale della sanità, che ha definito una scala a tre gradini: al livello più basso ci sono i farmaci antinfiammatori non steroidei, da usare per i dolori più lievi (per esempio paracetamolo e acido acetilsalicilico). Il secondo livello prevede l'aggiunta di farmaci oppiacei deboli (come la codeina) ai farmaci di primo livello. Se questi non bastano si passa al terzo livello con gli oppioidi forti, come la morfina (vedi box: I farmaci contro il dolore).
Come si identifica e si misura il dolore?
La modalità più usata e codificata prevede di porre alla persona una serie di domande per identificare l'intensità del dolore su una scala da 0 a 10, chiedendo di indicare il livello di dolore provato nell'ultima settimana e al momento in cui viene sottoposto il questionario. A seconda dei livelli identificati dalla persona, il dolore viene classificato in lieve, moderato, forte.
Quanto è diffuso il dolore in Italia e in Europa
Il dolore è una condizione comune e molto diffusa, più frequente in alcune malattie e in alcune fasi della vita. Secondo una stima di Vittorio Ventafridda, direttore scientifico della fondazione Floriani di Milano, presentata in un articolo pubblicato sul Sole 24 ore,1 in Italia i pazienti che soffrono di dolori benigni (cioè non dovuti a una condizione terminale) ricorrenti, che intaccano la qualità della vita in modo profondo, sono circa 14 milioni.
Secondo altre statistiche su ampi campioni della popolazione italiana,2-3 quasi il 60% degli italiani riporta qualche forma di dolore nell'ultimo mese dal momento dell'intervista, il 28% degli italiani intervistati riporta che questo dolore era di intensità moderata-severa e il 12% racconta che questo dolore ha avuto un impatto importante sulla vita quotidiana. In alcune malattie croniche il dolore diventa più frequente e ancora più rilevante per la qualità della vita quotidiana.
Dai dati della Pain in Europe Survey, una vasta ricerca sulla diffusione del dolore cronico in Europa, presentati a Milano nel maggio 2004, risulta che, mentre in Europa 1 paziente su 5 soffre di dolore cronico, in Italia ne soffre 1 su 4. In metà delle famiglie italiane c'è almeno una persona affetta da dolore cronico, a fronte di una diffusione europea del sintomo pari al 19% (meno di un quinto della popolazione). Oltre il 40% delle persone in Italia che provano dolore afferma di avere una sofferenza grave, rispetto al 35% circa dei pazienti in Europa.
In particolare nelle persone malate di tumore, secondo revisioni recenti,(4) la prevalenza del dolore, pur variando molto per tipo di malattia e stadio del tumore, è stimabile attorno al 74% (in tutta Europa); il sintomo è più diffuso in caso di tumore della testa e del collo, dell'apparto genito urinario, dell'esofago e della prostata.
Il confronto con la situazione europea mostra come in Italia la prescrizione e l'uso di farmaci antidolorifici, in particolare di oppiacei, siano molto bassi rispetto alla diffusione del sintomo del dolore. Questo è dovuto anche a una serie di pregiudizi che i medici e i malati continuano ad avere, soprattutto sui farmaci come la morfina, che vanno smentiti.
La morfina, questa sconosciuta
La morfina è un derivato dall'oppio, una sostanza grezza, lattiginosa che è estratta dal papavero sonnifero (papaverum sonniferum album). L'oppio contiene più di 20 sostanze alcaloidi (tra cui la codeina) da cui si ricavano alcune sostanze psicoattive e stupefacenti (come l'eroina) e altre a uso sedativo-analgesico e terapeutico (come la morfina), isolata fin dal 1804.
La morfina e i suoi derivati, se introdotti nel nostro organismo, agiscono prevalentemente sul sistema nervoso centrale con meccanismi molto simili ad alcuni oppioidi endogeni, cioè prodotti autonomamente dall'organismo, come le endorfine, che hanno effetti inibenti (analgesici) e depressori sul nostro corpo, in stretta relazione con i centri del piacere. Pur essendo il meccanismo fisiologicamente simile, l'azione della morfina è più potente e duratura.
L'introduzione di morfina causa alcuni effetti fisiologici (alterazioni del respiro, rallentamento psicomotorio, rilassamento della muscolatura liscia, riduzione della secrezione dello stomaco e della forza contrattile della vescica), e psicologici (rallentamento della ideazione, disorganizzazione del pensiero, stato di sonnolenza, scarsa percezione della realtà) che nel loro insieme spiegano come, a dosi farmacologiche, sia un farmaco analgesico e sedativo utile; questi effetti anticipano anche i principali effetti collaterali indesiderati, che si verificano soprattutto nel caso di trattamento prolungato.
La somministrazione di morfina e di altri oppiacei causa essenzialmente due fenomeni principali, di cui si deve tener conto nell'impostare la cura: la tolleranza e la dipendenza.
Per tolleranza si intende l'adattamento fisiologico dell'organismo che, a fronte della somministrazione prolungata del farmaco, in un certo senso si abitua a quella dose e rende indispensabile un incremento del dosaggio per mantenere lo stesso effetto terapeutico desiderato a livello fisiologico e psicologico. La dipendenza alla morfina, abitudine all'assunzione che porta alla necessità di un uso continuativo, possiamo distinguerla in: fisica (astinenza da brusca sospensione del farmaco) e psicologica (desiderio fortissimo degli effetti psicologici indotti dal farmaco).
Vero e falso
Nel caso del trattamento del dolore con morfina la tolleranza, che determina una sorta di abitudine dell'organismo al farmaco e la necessità di aumentare la dose per ottenere gli stessi effetti terapeutici, non è di sviluppo rapido e si verifica solo dopo somministrazione prolungata nel tempo. Gli incrementi di dosaggio della morfina sono quindi legati solitamente più all'aumento del dolore causato dalla malattia che alla tolleranza farmacologica. La dipendenza da morfina nel contesto di un uso terapeutico è invece un fenomeno raro.
Tra i pregiudizi più comuni, bisogna smentire che la morfina sia riservata ai malati in fin di vita, come pensano spesso le persone a cui viene somministrata. La morfina si usa spesso infatti anche dopo comuni operazioni chirurgiche.
Può essere somministrata a bambini, a dosaggi stabiliti apposta per l'età pediatrica, e ad anziani, valutando l'eventuale interazione con altri farmaci.
Per quanto riguarda alcuni effetti collaterali, come sonnolenza o stato confusionale, qualora si verificassero scompaiono dopo alcuni giorni in cui si assume il farmaco (sonnolenza) o possono essere comunque controllati e contenuti (stato confusionale).
L'effetto meno temuto risulta invece il più importante e frequente ed è la stitichezza, che può però essere prevenuta con un'alimentazione opportuna, assunzione di molti liquidi ed eventualmente ricorrendo ai lassativi.
Alcune definizioni di dolore
Il dolore può essere suddiviso in base alla causa e alla tipologia in dolore fisiologico (come quello acuto, per esempio quello che deriva da una prolungata esposizione al calore, che ha un primo significato di allarme, avviso), patologico, quello più frequente, che è associato a malattie, sia acute sia croniche, e infine quello patogeno, così chiamato in quanto non sembra associato ad alcuna causa precisa, tanto da diventare esso stesso malattia.
Una possibile altra classificazione permette anche di classificare il dolore in base alla sua durata in acuto e cronico, e in base all'intensità da assente a molto severo.
Il dolore più comune, quello che chiunque ha sperimentato almeno una volta, è il dolore patologico, associato o dovuto a specifiche malattie o condizioni morbose che hanno indotto danneggiamenti dei tessuti, e accompagna la durata della malattia fino alla sua risoluzione, o naturale o indotta (accelerata) dalle cure e terapie.
I farmaci contro il dolore
Esistono oggi molti farmaci dotati di attività antidolorifica. La maggior parte dei farmaci analgesici ancora in uso sono stati identificati attraverso osservazioni empiriche o per caso, e solo recentemente si sono identificati i veri meccanismi biochimici alla base del loro effetto analgesico. In alcuni casi i farmaci analgesici in uso sono nati come antipiretici e per alcuni il vero meccanismo di azione non è ancora noto.
E' possibile definire una prima distinzione tra i farmaci che agiscono solamente o prevalentemente a livello periferico, cioè dove è presente lo stimolo originario, come tutti i farmaci antinfiammatori non steroidei (FANS) (per esempio: acido acetilsalicilico) e quelli che agiscono prevalentemente a livello del sistema nervoso centrale, cioè a livello di alcune aree cerebrali dove vi è l'interpretazione del dolore a livello emotivo e affettivo, come gli oppiacei, tra cui il farmaco di riferimento è considerato la morfina. Una distinzione tra non-oppiacei (FANS) e oppiacei permette di creare due categorie distinte che, nonostante la relativa diversità di prodotti in ciascuna di esse, aiuta a capire quale possa essere la migliore strategia terapeutica contro il dolore.
I FANS, in generale, sono farmaci dotati di una miscela di attività antinfiammatoria, antipiretica (agisce cioè contro la febbre) e analgesica che si prestano in modo particolare a essere adatti come prima terapia (e talvolta unica) nel caso di dolore acuto, associato a cause note di tipo meccanico o infiammatorio, di intensità lieve-moderata. La somministrazione di dosi adeguate di questi farmaci, per un periodo limitato, in associazione con una attento monitoraggio della efficacia (controllo del dolore) e degli effetti collaterali (di solito di tipo gastro-intestinale) è in grado di solito di controllare la maggior parte degli episodi saltuari o ricorrenti di dolore acuto. Questi farmaci, per altro, sono considerati dalla OMS il primo gradino della terapia nel caso anche di dolore cronico, associato a cancro, quando l'intensità del dolore è considerata lieve. Infatti, nel caso un paziente abbia dolore con questa intensità va trattato con i farmaci del primo gradino.
I farmaci oppiacei, invece, rappresentano il trattamento di scelta per il dolore più intenso o comunque non controllabile con i FANS. Gli oppiacei sono a loro volta classificati in due sotto-gruppi: quelli dotati di attività analgesica debole e quelli dotati di attività forte. In caso di dolore ancora più intenso (da moderato a severo e di mancato controllo con i trattamenti degli dei gradini 1 e 2) l'OMS raccomanda l'uso degli oppiacei più forti, come appunto la morfina, che rappresenta il prototipo del terzo gradino della scala dell'OMS.
Fonti
IRFMN- DOXA 1995. Cross sectional survey in 2.244 italians. In: Apolone G,
Hearn J et al. Cancer pain epidemiology: a systematic review. In: Bruera ED et al. Cancer Pain, assessment and management. Cambridge, Cambridge University Press, 2003.
fonte: www.partecipasalute.it
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