pharmaecono-藥物治療疼痛的經(jīng)濟(jì)因素考慮課件

1、Economic Considerations in the Pharmacologic Management of Pain(藥物治療疼痛中的經(jīng)濟(jì)因素考慮）Liu ZhanXian-Janssen Pharmaceutical Ltd.2022/10/12Economic Considerations in theGeneral Introduction of Pain (疼痛概論）Definition (疼痛的定義）Physical pain is a common, subjective and complicated process that is initiated by an un

2、pleasant sensory experience. It occurs via several mechanisms that may result in immobility, deconditioning and emotional reactions.(軀體疼痛是由于不愉快的感覺(jué)經(jīng)驗(yàn)引起的一種常見(jiàn)的,主觀的和復(fù)雜的過(guò)程.它是通過(guò)可引起行動(dòng)受限, 狀態(tài)異常和情緒反應(yīng)的一系列機(jī)制而發(fā)生的.2022/10/12General Introduction of Pain Epidemiology (流行病學(xué)資料)75 million people in U.S. have some form

3、 of persistent or recurrent pain* and pain is the most common symptom for which patients seek medical assistance* (在美國(guó)有超過(guò)七千五百萬(wàn)人患有不同程度的持續(xù)性或反復(fù)發(fā)生的疼痛;疼痛已成為患者求醫(yī)的最常見(jiàn)的癥狀.在中國(guó),130萬(wàn)癌癥死亡人群中,60%以上忍受著中到重度疼痛General Introduction of Pain (疼痛概論）*Caudill M, Holman G,Turk D. Patient Care. 1996:154*Foley K. Cecil Textb

4、ook of Medicine. Philadelphia,1992:972022/10/12Epidemiology (流行病學(xué)資料)General IGreatest Challenge (偉大的挑戰(zhàn))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 pharmacoeconomic d

5、ata 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.*在下一個(gè)十年中,對(duì)健康領(lǐng)域里的最大的挑戰(zhàn)是充分利用可得到的有限資源,利用最低的花費(fèi)來(lái)得到最高的健康質(zhì)量.由于藥物經(jīng)濟(jì)學(xué)資料的增加,在疼痛控制健康項(xiàng)目決策中,其花費(fèi)和結(jié)果的研究將起主要作用.

6、藥劑師們?cè)谶m應(yīng)這場(chǎng)變更中起著獨(dú)一無(wú)二的平衡作用.General Introduction of Pain (疼痛概論）*Michael Rigas, Economic Considerations in the Pharmacologic Management of Pain. P&Ts 1997:4542022/10/12Greatest Challenge (偉大的挑戰(zhàn))GeneClassification of Pain (疼痛的分類(lèi))Temporal Classification(時(shí)間分類(lèi))Acute PainChronic Painusually defined as that la

7、sting 6 months or longer the timing,localization and character of the pain are often more vague(疼痛的時(shí)間,部位和性質(zhì)經(jīng)常是含糊的)There may be indications of sleep disturbances, loss of appetite,decreased libido,weight loss and depression. (經(jīng)常伴有睡眠干擾,食欲不振,性欲下降, 體重降低及抑郁)Physiologic Classification(生理學(xué)分類(lèi))Somatic, Visce

8、ral, Neuropathic(軀體,內(nèi)臟,神經(jīng)性)General Introduction of Pain (疼痛概論）2022/10/12Classification of Pain (疼痛的分類(lèi))Pain Management Principles(疼痛控制原則)*Acute Painpatient education on postoperative painthe need for regularly scheduled analgesics as opposed to as-needed analgesics for the first 24 hours of more afte

9、r surgerythe need for frequent assessment and reassessment of pain by nursing personnelthe need for consistent use of a tool for patient self-assessment of painthe possibility of preemptive analgesic strategies for surgical patientsthe specific analgesic strategies offered to patientsGeneral Introdu

10、ction of Pain (疼痛概論）* guidelines and quality assurance standards from the Agency for Health Care Policy and Research (AHCPR)2022/10/12Pain Management Principles(疼痛控Chronic PainWHO analgesic ladder (WHO階梯療法)NonopioidAdjuvant Weak opioid Nonopioid Adjuvant Strong opioid NonopioidAdjuvant can provide s

11、atisfactory pain relief to 70-90% of this patient population* (可使70-90%的中到重度癌痛患者得到滿意地緩解)Durogesic is the novel administration way in chronic pain relief(多瑞吉的出現(xiàn)創(chuàng)新了慢性痛控制領(lǐng)域里的給藥途徑)General Introduction of Pain (疼痛概論）*WHO cited in Portenoy R. Issues in the economic analysis of therapies for cancer pain. O

12、ncology. 1995;9(11):S712022/10/12Chronic PainGeneral IntroductiPharmacologic Therapies of Pain(疼痛的藥物治療)The appropriate and successful management of pain entails selection of the right analgesic, administered in the right way, dosage and on the right schedule so as to maximize pain relief and minimiz

13、e adverse effects.*適當(dāng)和成功的疼痛控制必需選擇正確的止痛藥物, 正確的途徑和劑量以正確的時(shí)間間隔給藥, 從而達(dá)到能最大緩解疼痛的同時(shí)將副作用降到最小.Estimates*Inturrisi C. Management of cancer pain:pharmacology and principles of management. Cancer, 1989;63:23082022/10/12Pharmacologic Therapies of PaiNonnarcotic Analgesics(非麻醉性鎮(zhèn)痛藥)Aspirin, Acetaminophen and NSAID

14、s (阿斯匹林,對(duì)乙酰氨基酚及非甾體抗炎藥)first line agents for the treatment of mild-to-moderate pain(是輕到中度疼痛的一線用藥)ceiling effect (天花板效應(yīng))an increase in the dosage beyond the recommended maximum dose not result in an increase in analgesia, and potentially increases side effectsnot suitable use for chronic,evolving pain

15、* (不適合用于慢性,進(jìn)展性疼痛)Pharmacologic Therapies of Pain(疼痛的藥物治療)*Ashby M. et al, Description of a mechanistic approach to pain management in advanced cancer. Preliminary report. Pain. 1992;(51):1532022/10/12Nonnarcotic Analgesics(非麻醉性鎮(zhèn)痛藥Narcotic Analgesics (麻醉性鎮(zhèn)痛藥)Narcotic medication should be administered

16、 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 with chronic pain take narcotics on an as-required basis, because waiting until the pain or distress becomes more severe may actually exac

17、erbate the pain.*(麻醉性鎮(zhèn)痛藥物的使用應(yīng)按時(shí)給藥,而不是按需給藥,這樣才能使藥物的血漿濃度維持在最低有效的疼痛緩解濃度之上.同時(shí),按需給藥可使疼痛更加惡化)Pharmacologic Therapies of Pain(疼痛的藥物治療)*Ralphs J et al. Opiate reduction in chronic pain patients: Pain. 1994;56:2792022/10/12Narcotic Analgesics (麻醉性鎮(zhèn)痛藥)PhAgonistcommonly used in the management of chronic pain (

18、such as cancer pain)(激動(dòng)劑通常用于慢性疼痛的治療,如癌痛)Agonist-antagonistoften used in acute postoperative pain management, but are of limited use in chronic pain(激動(dòng)劑-拮抗劑通常用于急性手術(shù)后疼痛控制上,而不用于慢性疼痛的治療)Pharmacologic Therapies of Pain(疼痛的藥物治療)2022/10/12AgonistPharmacologic TherapiesAdverse effects of narcoticsDespite th

19、e proven efficacy of narcotics in the management of pain, the development of adverse effects is also typical with these agents (盡管麻醉性鎮(zhèn)痛藥在疼痛控制上有確切療效, 但這些藥物的不良反應(yīng)反應(yīng)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 admi

20、nistration of certain drugs,prior opioid exposure and the route of drug administration* (阿片類(lèi)藥物不良反應(yīng)的影響因素有:年齡,疾病和器官功能受損程度,從前阿片類(lèi)藥物使用狀況和給藥途徑)Pharmacologic Therapies of Pain(疼痛的藥物治療)*Inturrisi C. Management of cancer pain:pharmacology and principles of management. Cancer, 1989;63:23082022/10/12Adverse ef

21、fects of narcoticsPhCommon adverse effectssedation, nausea, vomiting, constipation, respiratory depression and tolerance (鎮(zhèn)靜;惡心;嘔吐;便秘;呼吸抑制及耐藥性)Adverse effects evaluation is one of the important parts of narcotic pharmacoeconomic evaluation (對(duì)不良反應(yīng)的評(píng)價(jià)是麻醉性鎮(zhèn)痛藥物進(jìn)行藥物經(jīng)濟(jì)學(xué)評(píng)價(jià)的重要部分之一) Pharmacologic Therapies o

22、f Pain(疼痛的藥物治療)2022/10/12Common adverse effectsPharmacoAdjunctive Therapies(輔助性治療)anticonvulsants, antidepressant, stimulants, antihistamine, phenothiazine, steroids, miscellaneous, anxiolytics (抗驚厥藥,抗抑郁藥,興奮劑,抗組胺藥,酚噻嗪,類(lèi)固醇類(lèi),雜環(huán)類(lèi),抗焦慮藥)most of these agents are very inexpensive and they can be very cost-

23、effective when appropriately co-prescribed to help control pain.(大部分這類(lèi)藥物非常便宜,在疼痛控制上的適當(dāng)應(yīng)用,可有很好的“效/價(jià)”比)Pharmacologic Therapies of Pain(疼痛的藥物治療)2022/10/12Adjunctive Therapies(輔助性治療)PhaVarious Routes of Administration-Advantages and Disadvantages不 同 給 藥 途 徑 的 優(yōu) 缺 點(diǎn) 比較2022/10/12Various Routes of Administ

24、ratiProprietary Drugs Versus Generics(專(zhuān)利藥物與仿制藥物)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.* (制定藥物目錄的目的是在提供的健康服務(wù)質(zhì)量不受損害的情況下通過(guò)不用或限制使用昂貴藥物以使“效/價(jià)”比達(dá)到最大)*Johnson J, et al. Pharmacoe

25、conomic analysis in formulary decisions:an international perspective. Am J Hosp Pharm. 1994;51:25932022/10/12Proprietary Drugs Versus GenerNonpharmacologic Approaches to Pain Management (非藥物治療方法)Factors to be considered are whether the intervention effectively mobilizes a patient, reduces the need f

26、or a nursing home or nursing at home, prevents hospitalization, reduce side effects and overall cost*(對(duì)這些治療的考慮在于其是否可明顯增加病人的活動(dòng),降低對(duì)護(hù)理的需求,減少住院,降低不良反應(yīng)和能降低總支出)Physical Interventions(物理療法)Behavioral Interventions(行為療法)*Portenoy R. et al. Issues in the economic analysis of therapies for cancer pain. Oncolo

27、gy. 1995;9(11):S712022/10/12Nonpharmacologic Approaches toEconomic Issues in the Management of Pain (疼痛控制中的經(jīng)濟(jì)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 numerous medical interventio

28、ns. Pain-related complications, expensive diagnostic procedures, hospitalizations for pain control and days missed from work can be extremely costly.(不控制疼痛和對(duì)慢性疼痛的控制的花費(fèi)可能是很高的。疼痛不緩解在人的情緒和行動(dòng)上的病態(tài)可導(dǎo)致相當(dāng)多的醫(yī)療問(wèn)題出現(xiàn)。與疼痛有關(guān)的并發(fā)癥，昂貴的診斷手段，為控制疼痛而住院治療以及為此耽誤工作的代價(jià)都是非常高的)2022/10/12Economic Issues in the ManagemPrimary I

29、ssues(主要因素)the cost of pharmacotherapy -the most important analgesic approach for cancer pain (藥物治療費(fèi)用-對(duì)于癌痛而言是最重要的止痛方法)Incorporating pharmacoeconomic data into the formulary decision-making process-helps in selecting medications that are safe,effective and cost-efficient (將藥物經(jīng)濟(jì)學(xué)數(shù)據(jù)放入藥物目錄的評(píng)審中-這將有助于選擇出既

30、安全有效又效/價(jià)比合適的藥物)To perform a comprehensive evaluation of an existing or proposed pharmaceutical service (對(duì)現(xiàn)有的或提議中的藥事服務(wù)進(jìn)行深入的評(píng)估是很有必要的)Economic Issues in the Management of Pain (疼痛控制中的經(jīng)濟(jì)因素)2022/10/12Primary Issues(主要因素)Economic IOther Issues(其它因素)the differences in treatment settings (治療方案的差異)the need t

31、o justify services (服務(wù)需求的調(diào)整)reimbursement biases (報(bào)銷(xiāo)目錄的傾斜)the potential for conflict of interest (潛在的公私利益沖突)Economic Issues in the Management of Pain (疼痛控制中的經(jīng)濟(jì)因素)2022/10/12Other Issues(其它因素)Economic IssPharmacoeconomics-Methods and Guidelines (藥物經(jīng)濟(jì)學(xué)的方法及指導(dǎo)原則)MethodsCost-minimization AnalysisOutcomes

32、are considered to be equal and compare only the imputes or costs of each alternative when efficacy and side effects are similarCost-benefit Analysismeasures 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(

33、benefit minus cost)Cost-effectiveness Analysismeasures outcomes in nonmonetary units(e.g. the cost per unit of success or effect-the cost per hour of reduced nursing care time or per mm Hg change in BP for antihypertensive therapy)2022/10/12Pharmacoeconomics-Methods andPharmacoeconomics-Methods and

34、Guidelines (藥物經(jīng)濟(jì)學(xué)的方法及指導(dǎo)原則)Cost-utility AnalysisOutcomes expressed in nonmonetary units are adjusted for health-related quality of life.Cost-of-illness Analysisattempts to identify all direct and indirect costs of treating a certain disease or illness2022/10/12Pharmacoeconomics-Methods andBasic Principles to Guide the Pharmaco-economic Process(指導(dǎo)原則)Define the problemDetermine the studys perspectiveDetermine the alternatives and outcomesSelect the