1、2023-1-12Economic Considerations in the Pharmacologic Management of Pain(药物治疗疼痛中的经济因素考虑）2023-1-12General Introduction of Pain(疼痛概论）lDefinition(疼痛的定义）疼痛的定义）Physical pain is a common,subjective and complicated process that is initiated by an unpleasant sensory experience.It occurs via several mechanis
2、ms that may result in immobility,deconditioning and emotional reactions.(躯体疼痛是由于不愉快的感觉经验躯体疼痛是由于不愉快的感觉经验引起的一种常见的引起的一种常见的,主观的和复杂的过程主观的和复杂的过程.它是它是通过可引起行动受限通过可引起行动受限,状态异常和情绪反应的状态异常和情绪反应的一系列机制而发生的一系列机制而发生的.2023-1-12lEpidemiology(流行病学资料流行病学资料)75 million people in U.S.have some form of persistent or recurr
3、ent pain*and pain is the most common symptom for which patients seek medical assistance*(在美国在美国有超过七千五百万人患有不同程度的持续性或有超过七千五百万人患有不同程度的持续性或反复发生的疼痛反复发生的疼痛;疼痛已成为患者求医的最常见疼痛已成为患者求医的最常见的症状的症状.在中国在中国,130万癌症死亡人群中万癌症死亡人群中,60%以上忍受着以上忍受着中到重度疼痛中到重度疼痛General Introduction of Pain(疼痛概论）*Caudill M,Holman G,Turk D.Pati
4、ent Care.1996:154*Foley K.Cecil Textbook of Medicine.Philadelphia,1992:972023-1-12Greatest Challenge(伟大的挑战伟大的挑战)The greatest health care challenge for the next decade is to make the best use of limited available resources to attain the highest quality of health care for the lowest cost.As pharmacoec
5、onomic data become increasingly available,their use in cost-effective pain management and in all health care decisions,will play a major role.The pharmacist is uniquely poised to adapt to this shifting paradigm.*在下一个十年中在下一个十年中,对健康领域里的最大的挑战是充分利用可得到的有限资源对健康领域里的最大的挑战是充分利用可得到的有限资源,利用最低的花费来得到最高的健康质量利用最低的
6、花费来得到最高的健康质量.由于药物经济学资料的增加由于药物经济学资料的增加,在疼痛在疼痛控制健康项目决策中控制健康项目决策中,其花费和结果的研究将起主要作用其花费和结果的研究将起主要作用.药剂师药剂师们在适应这们在适应这场变更中起着独一无二的平衡作用场变更中起着独一无二的平衡作用.General Introduction of Pain(疼痛概论）*Michael Rigas,Economic Considerations in the Pharmacologic Management of Pain.P&Ts 1997:4542023-1-12lClassification of Pain(
7、疼痛的分类疼痛的分类)Temporal Classification(时间分类时间分类)Acute Pain Chronic Pain usually defined as that lasting 6 months or longer the timing,localization and character of the pain are often more vague(疼痛的时间疼痛的时间,部位和性质经常部位和性质经常是含糊的是含糊的)There may be indications of sleep disturbances,loss of appetite,decreased li
8、bido,weight loss and depression.(经常伴有睡眠干扰经常伴有睡眠干扰,食欲不振食欲不振,性欲下降性欲下降,体重降低及抑郁体重降低及抑郁)Physiologic Classification(生理学分类生理学分类)Somatic,Visceral,Neuropathic(躯体躯体,内脏内脏,神经性神经性)General Introduction of Pain(疼痛概论）2023-1-12lPain Management Principles(疼痛控制原则疼痛控制原则)*Acute Pain patient education on postoperative pa
9、in the need for regularly scheduled analgesics as opposed to as-needed analgesics for the first 24 hours of more after surgery the need for frequent assessment and reassessment of pain by nursing personnel the need for consistent use of a tool for patient self-assessment of pain the possibility of p
10、reemptive analgesic strategies for surgical patients the specific analgesic strategies offered to patientsGeneral Introduction of Pain(疼痛概论）*guidelines and quality assurance standards from the Agency for Health Care Policy and Research(AHCPR)2023-1-12 Chronic Pain WHO analgesic ladder(WHO阶梯疗法阶梯疗法)No
11、nopioidAdjuvant Weak opioid Nonopioid Adjuvant Strong opioid NonopioidAdjuvant can provide satisfactory pain relief to 70-90%of this patient population*(可使可使70-90%的中到重度癌痛患者得到的中到重度癌痛患者得到满意地缓解满意地缓解)Durogesic is the novel administration way in chronic pain relief(多瑞吉的出现创新了慢性痛控制领域里的给药途多瑞吉的出现创新了慢性痛控制领域里的
12、给药途径径)General Introduction of Pain(疼痛概论）*WHO cited in Portenoy R.Issues in the economic analysis of therapies for cancer pain.Oncology.1995;9(11):S712023-1-12Pharmacologic Therapies of Pain(疼痛的药物治疗)The appropriate and successful management of pain entails selection of the right analgesic,administere
13、d in the right way,dosage and on the right schedule so as to maximize pain relief and minimize adverse effects.*适当和成功的疼痛控制必需选择正确的止痛药物适当和成功的疼痛控制必需选择正确的止痛药物,正确的途径和剂量以正确的时间间隔给药正确的途径和剂量以正确的时间间隔给药,从而达从而达到能最大缓解疼痛的同时将副作用降到最小到能最大缓解疼痛的同时将副作用降到最小.Estimates*Inturrisi C.Management of cancer pain:pharmacology an
14、d principles of management.Cancer,1989;63:23082023-1-12lNonnarcotic Analgesics(非麻醉性镇痛药非麻醉性镇痛药)Aspirin,Acetaminophen and NSAIDs(阿斯阿斯匹林匹林,对乙酰氨基酚及非甾体抗炎药对乙酰氨基酚及非甾体抗炎药)first line agents for the treatment of mild-to-moderate pain(是轻到中度疼痛的一线用药是轻到中度疼痛的一线用药)ceiling effect(天花板效应天花板效应)an increase in the dosage
15、 beyond the recommended maximum dose not result in an increase in analgesia,and potentially increases side effects not suitable use for chronic,evolving pain*(不适不适合用于慢性合用于慢性,进展性疼痛进展性疼痛)Pharmacologic Therapies of Pain(疼痛的药物治疗)*Ashby M.et al,Description of a mechanistic approach to pain management in
16、advanced cancer.Preliminary report.Pain.1992;(51):1532023-1-12lNarcotic Analgesics(麻醉性镇痛药麻醉性镇痛药)Narcotic medication should be administered on a regular basis so as to maintain the plasma level of the drug above the minimal effective concentration for pain relief.It is not recommended that patients w
17、ith chronic pain take narcotics on an as-required basis,because waiting until the pain or distress becomes more severe may actually exacerbate the pain.*(麻醉性镇痛药物的使用应按时给药麻醉性镇痛药物的使用应按时给药,而不是按需给药而不是按需给药,这样才能使药物这样才能使药物的血浆浓度维持在最低有效的疼痛缓解浓度之上的血浆浓度维持在最低有效的疼痛缓解浓度之上.同时同时,按需给药可使按需给药可使疼痛更加恶化疼痛更加恶化)Pharmacologic
18、 Therapies of Pain(疼痛的药物治疗)*Ralphs J et al.Opiate reduction in chronic pain patients:Pain.1994;56:2792023-1-12 Agonistcommonly used in the management of chronic pain(such as cancer pain)(激动剂通常用于慢性疼痛的治疗激动剂通常用于慢性疼痛的治疗,如癌痛如癌痛)Agonist-antagonistoften used in acute postoperative pain management,but are o
19、f limited use in chronic pain(激动剂激动剂-拮抗剂通常用于急性手术后疼痛控制上拮抗剂通常用于急性手术后疼痛控制上,而不而不用于慢性疼痛的治疗用于慢性疼痛的治疗)Pharmacologic Therapies of Pain(疼痛的药物治疗)2023-1-12 Adverse effects of narcotics Despite the proven efficacy of narcotics in the management of pain,the development of adverse effects is also typical with the
20、se agents(尽管麻醉性镇痛药在疼痛控制上有确切疗效尽管麻醉性镇痛药在疼痛控制上有确切疗效,但这些但这些药物的不良反应反应也是很典型的药物的不良反应反应也是很典型的)opioid side effects depend on a number of factors that include:patient age,extent of disease and organ dysfunction,concurrent administration of certain drugs,prior opioid exposure and the route of drug administrati
21、on*(阿片类药物不良反应的影响因素有阿片类药物不良反应的影响因素有:年龄年龄,疾病和器疾病和器官功能受损程度官功能受损程度,从前阿片类药物使用状况和给药途从前阿片类药物使用状况和给药途径径)Pharmacologic Therapies of Pain(疼痛的药物治疗)*Inturrisi C.Management of cancer pain:pharmacology and principles of management.Cancer,1989;63:23082023-1-12 Common adverse effects sedation,nausea,vomiting,consti
22、pation,respiratory depression and tolerance(镇静镇静;恶心恶心;呕吐呕吐;便秘便秘;呼吸抑呼吸抑制及耐药性制及耐药性)Adverse effects evaluation is one of the important parts of narcotic pharmacoeconomic evaluation(对不良反应的评价是麻醉性镇痛药物进对不良反应的评价是麻醉性镇痛药物进行药物经济学评价的重要部分之一行药物经济学评价的重要部分之一)Pharmacologic Therapies of Pain(疼痛的药物治疗)2023-1-12lAdjunct
23、ive Therapies(辅助性治疗辅助性治疗)anticonvulsants,antidepressant,stimulants,antihistamine,phenothiazine,steroids,miscellaneous,anxiolytics(抗惊抗惊厥药厥药,抗抑郁药抗抑郁药,兴奋剂兴奋剂,抗组胺药抗组胺药,酚噻嗪酚噻嗪,类固醇类固醇类类,杂环类杂环类,抗焦虑药抗焦虑药)most of these agents are very inexpensive and they can be very cost-effective when appropriately co-pres
24、cribed to help control pain.(大部分这类药物非常便宜大部分这类药物非常便宜,在疼痛控制上在疼痛控制上的适当应用的适当应用,可有很好的可有很好的“效效/价价”比比)Pharmacologic Therapies of Pain(疼痛的药物治疗)2023-1-12Various Routes of Administration-Advantages and Disadvantages创伤性创伤性 首过效应首过效应 起效时间起效时间 作用时间作用时间 耐受性耐受性 患者偏好度患者偏好度花费花费IV/IM+-+-+CSC+-+-+Oral-+TTS-+2023-1-12Pr
25、oprietary Drugs Versus Generics(专利药物与仿制药物)l The objective of making formularies is to maximize cost-effectiveness by excluding or limiting expensive medications as long as the quality of care is not compromised.*(制定药物目录的目的是在提供的健康服务质量不制定药物目录的目的是在提供的健康服务质量不受损害的情况下通过不用或限制使用昂贵药物以受损害的情况下通过不用或限制使用昂贵药物以使使“
26、效效/价价”比达到最大比达到最大)*Johnson J,et al.Pharmacoeconomic analysis in formulary decisions:an international perspective.Am J Hosp Pharm.1994;51:25932023-1-12Nonpharmacologic Approaches to Pain Management(非药物治疗方法)l Factors to be considered are whether the intervention effectively mobilizes a patient,reduces
27、the need for a nursing home or nursing at home,prevents hospitalization,reduce side effects and overall cost*(对这些治疗的考虑在于其是否可明显增加对这些治疗的考虑在于其是否可明显增加病人的活动病人的活动,降低对护理的需求降低对护理的需求,减少住院减少住院,降低不良反应和降低不良反应和能降低总支出能降低总支出)Physical Interventions(物理疗法物理疗法)Behavioral Interventions(行为疗法行为疗法)*Portenoy R.et al.Issues
28、 in the economic analysis of therapies for cancer pain.Oncology.1995;9(11):S712023-1-12Economic Issues in the Management of Pain(疼痛控制中的经济因素)The cost of not managing as well as managing chronic pain are potentially very high.The morbid effects of unrelieved pain on mood and immobility can result in n
29、umerous medical interventions.Pain-related complications,expensive diagnostic procedures,hospitalizations for pain control and days missed from work can be extremely costly.(不控制疼痛和对慢性疼痛的控制不控制疼痛和对慢性疼痛的控制的花费可能是很高的。疼的花费可能是很高的。疼痛不缓解在人的情绪和行动上的病态可导致相当多的医疗问痛不缓解在人的情绪和行动上的病态可导致相当多的医疗问题出现。与疼痛有关的并发症，昂贵的诊断手段，为控
30、制疼题出现。与疼痛有关的并发症，昂贵的诊断手段，为控制疼痛而住院治疗以及为此耽误工作的代价都是非常高的痛而住院治疗以及为此耽误工作的代价都是非常高的)2023-1-12lPrimary Issues(主要因素主要因素)the cost of pharmacotherapy-the most important analgesic approach for cancer pain (药物治疗费用药物治疗费用-对于癌痛而言是最重要的止痛方法对于癌痛而言是最重要的止痛方法)Incorporating pharmacoeconomic data into the formulary decision-
31、making process-helps in selecting medications that are safe,effective and cost-efficient (将药物经济学数据放入药物目录的评审中将药物经济学数据放入药物目录的评审中-这将有助于选择出这将有助于选择出既安全有效又既安全有效又效效/价价比合适的药物比合适的药物)To perform a comprehensive evaluation of an existing or proposed pharmaceutical service (对现有的或提议中的药事服务进行深入的评估是很有必要的对现有的或提议中的药事服
32、务进行深入的评估是很有必要的)Economic Issues in the Management of Pain(疼痛控制中的经济因素)2023-1-12lOther Issues(其它因素其它因素)the differences in treatment settings (治疗方案的差异治疗方案的差异)the need to justify services (服务需求的调整服务需求的调整)reimbursement biases (报销目录的倾斜报销目录的倾斜)the potential for conflict of interest (潜在的公私利益冲突潜在的公私利益冲突)Econo
33、mic Issues in the Management of Pain(疼痛控制中的经济因素)2023-1-12Pharmacoeconomics-Methods and Guidelines (药物经济学的方法及指导原则)lMethods Cost-minimization Analysis Outcomes are considered to be equal and compare only the imputes or costs of each alternative when efficacy and side effects are similar Cost-benefit A
34、nalysis measures outcomes in dollars,The outcome may be expressed in ratio of benefit to cost,or the ratio of the difference(net cost to benefit),or net cost(benefit minus cost)Cost-effectiveness Analysis measures outcomes in nonmonetary units(e.g.the cost per unit of success or effect-the cost per
35、hour of reduced nursing care time or per mm Hg change in BP for antihypertensive therapy)2023-1-12Pharmacoeconomics-Methods and Guidelines (药物经济学的方法及指导原则)Cost-utility Analysis Outcomes expressed in nonmonetary units are adjusted for health-related quality of life.Cost-of-illness Analysis attempts to
36、 identify all direct and indirect costs of treating a certain disease or illness2023-1-12lBasic Principles to Guide the Pharmaco-economic Process(指导原则指导原则)Define the problem Determine the studys perspective Determine the alternatives and outcomes Select the appropriate pharmacoeconomic method Place
37、monetary values on the outcomes Identify study resources Establish the probabilities of the outcomes Apply decision analysis Perform a sensitivity or incremental cost analysis Present the resultsPharmacoeconomics-Methods and Guidelines (药物经济学的方法及指导原则)2023-1-12lImplications for Pharmacy and Therapeut
38、ics Committees(P&T)Several implications for P&T committees that should be consideredConsider the larger pictureDetermine if the agents compared with the new drug are relevant to their institutionConsider that the cost-effectiveness of drugs varies among patient groups and indicationsCaution against
39、potential bias in industry-sponsored economic researchPharmacoeconomics-Methods and Guidelines (药物经济学的方法及指导原则)2023-1-12The Role of Pharmacist in PharmacoeconomicPharmcists must ensure that their central role in the economic pharmacologic management of pain is established and maintained.*(药剂师应在疼痛的药物治疗经济学中建立和药剂师应在疼痛的药物治疗经济学中建立和巩固他们的中心作用巩固他们的中心作用)*Michael Rigas,Economic Considerations in the Pharmacologic Management of Pain.P&Ts 1997:454
