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2023/4/21EconomicConsiderationsinthePharmacologicManagementofPain(药物治疗疼痛中的经济因素考虑）LiuZhanXian-JanssenPha

rmaceuticalLtd.2023/4/21GeneralIntroductionofPain(疼痛概论）⚫Definition(疼痛的定义）–Physicalpainisacommon,subjectiveandcomplicatedprocessthati

sinitiatedbyanunpleasantsensoryexperience.Itoccursviaseveralmechanismsthatmayresultinimmobility,deconditioningandemotionalreactions.

(躯体疼痛是由于不愉快的感觉经验引起的一种常见的,主观的和复杂的过程.它是通过可引起行动受限,状态异常和情绪反应的一系列机制而发生的.2023/4/21⚫Epidemiology(流行病学资料)–>75millionpeopleinU.S.have

someformofpersistentorrecurrentpain*andpainisthemostcommonsymptomforwhichpatientsseekmedicalassistance**(在美国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;疼痛已成为患者求医的最常见的症状.–在中国,130万癌症死亡人群中,60%以上忍受着中到重度疼痛GeneralIntroductionofPain(疼痛概论）*CaudillM,HolmanG,TurkD.Pati

entCare.1996:154**FoleyK.CecilTextbookofMedicine.Philadelphia,1992:972023/4/21GreatestChallenge(伟大的挑战)Thegreatesthealthcarechallengefor

thenextdecadeistomakethebestuseoflimitedavailableresourcestoattainthehighestqualityofhealthcareforthelowestcost.Aspharmacoeco

nomicdatabecomeincreasinglyavailable,theiruseincost-effectivepainmanagementandinallhealthcaredecisions,willplayamajorrole.Thepharmacistisunique

lypoisedtoadapttothisshiftingparadigm.*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,利用最低的花费来得到最高的健康质量.由于药物经济学资料的增加,在疼痛控制健康项目决策中,其花费和结果的研

究将起主要作用.药剂师们在适应这场变更中起着独一无二的平衡作用.GeneralIntroductionofPain(疼痛概论）*MichaelRigas,EconomicConsiderationsinthePharmacologicManag

ementofPain.P&Ts1997:4542023/4/21⚫ClassificationofPain(疼痛的分类)–TemporalClassification(时间分类)•AcutePain•ChronicPain–usuallydefinedasthat

lasting6monthsorlonger•thetiming,localizationandcharacterofthepainareoftenmorevague(疼痛的时间,部位和性质经常是含糊

的)•Theremaybeindicationsofsleepdisturbances,lossofappetite,decreasedlibido,weightlossanddepression.(经常伴有睡眠干扰,食欲不振,性欲下降,体重降低及抑郁)–Physiol

ogicClassification(生理学分类)Somatic,Visceral,Neuropathic(躯体,内脏,神经性)GeneralIntroductionofPain(疼痛概论）2023/4/21⚫PainManagementPr

inciples(疼痛控制原则)*–AcutePain•patienteducationonpostoperativepain•theneedforregularlyscheduledanalgesicsasopposedtoas-neededanalgesicsforthefirst24hou

rsofmoreaftersurgery•theneedforfrequentassessmentandreassessmentofpainbynursingpersonnel•theneedforconsistentuseofatoolforpatientself-assessmento

fpain•thepossibilityofpreemptiveanalgesicstrategiesforsurgicalpatients•thespecificanalgesicstrategiesof

feredtopatientsGeneralIntroductionofPain(疼痛概论）*guidelinesandqualityassurancestandardsfromtheAgencyforHealthCarePolicyandResearch(AHCPR)2

023/4/21–ChronicPain•WHOanalgesicladder(WHO阶梯疗法)–Nonopioid±AdjuvantWeakopioid±Nonopioid±AdjuvantStrongopioid±N

onopioid±Adjuvant–canprovidesatisfactorypainreliefto70-90%ofthispatientpopulation*(可使70-90%的中到重度癌痛患者得到满意地缓解)

–Durogesicisthenoveladministrationwayinchronicpainrelief(多瑞吉的出现创新了慢性痛控制领域里的给药途径)GeneralIntroductionofPa

in(疼痛概论）*WHOcitedinPortenoyR.Issuesintheeconomicanalysisoftherapiesforcancerpain.Oncology.1995;9(11):S712023/4/21PharmacologicTherapies

ofPain(疼痛的药物治疗)Theappropriateandsuccessfulmanagementofpainentailsselectionoftherightanalgesic,administeredintherightway,dos

ageandontherightschedulesoastomaximizepainreliefandminimizeadverseeffects.*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,从而达到能最大缓解疼痛的同时将副作用降到最小

.Estimates*InturrisiC.Managementofcancerpain:pharmacologyandprinciplesofmanagement.Cancer,1989;63:23082023/4/21⚫NonnarcoticAna

lgesics(非麻醉性镇痛药)–Aspirin,AcetaminophenandNSAIDs(阿斯匹林,对乙酰氨基酚及非甾体抗炎药)•firstlineagentsforthetreatmentofmild-to-moderatepain(是轻到中度疼痛的一线用药)•ceiling

effect(天花板效应)anincreaseinthedosagebeyondtherecommendedmaximumdosenotresultinanincreaseinanalgesia,andpotentiallyincreasesside

effects•notsuitableuseforchronic,evolvingpain*(不适合用于慢性,进展性疼痛)PharmacologicTherapiesofPain(疼痛的药物治疗)*AshbyM.etal,Descriptionofamec

hanisticapproachtopainmanagementinadvancedcancer.Preliminaryreport.Pain.1992;(51):1532023/4/21⚫NarcoticAnalgesics(麻醉性镇痛药)Narco

ticmedicationshouldbeadministeredonaregularbasissoastomaintaintheplasmalevelofthedrugabovetheminimaleffectiveconcentrationforpai

nrelief.Itisnotrecommendedthatpatientswithchronicpaintakenarcoticsonanas-requiredbasis,becausewaitinguntilthepainordistressbecomesmoreseveremaya

ctuallyexacerbatethepain.*(麻醉性镇痛药物的使用应按时给药,而不是按需给药,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.同时,按需给药可使疼痛更加恶化)Pharmacologic

TherapiesofPain(疼痛的药物治疗)*RalphsJetal.Opiatereductioninchronicpainpatients:Pain.1994;56:2792023/4/21–Agonistcommonlyusedinthem

anagementofchronicpain(suchascancerpain)(激动剂通常用于慢性疼痛的治疗,如癌痛)–Agonist-antagonistoftenusedinacutepostopera

tivepainmanagement,butareoflimiteduseinchronicpain(激动剂-拮抗剂通常用于急性手术后疼痛控制上,而不用于慢性疼痛的治疗)PharmacologicTherapiesofPain(疼痛的药物治疗)2023/4/21–Adverseeffect

sofnarcotics•Despitetheprovenefficacyofnarcoticsinthemanagementofpain,thedevelopmentofadverseeffectsisalsotypicalwiththeseagents(尽管麻醉性镇痛药在疼痛控制上有确切疗效,

但这些药物的不良反应反应也是很典型的)•opioidsideeffectsdependonanumberoffactorsthatinclude:patientage,extentofdiseaseandorgandysfunction,concurrentadministrationofce

rtaindrugs,prioropioidexposureandtherouteofdrugadministration*(阿片类药物不良反应的影响因素有:年龄,疾病和器官功能受损程度,从前阿片类药物使用状况和给药途径)PharmacologicTherapies

ofPain(疼痛的药物治疗)*InturrisiC.Managementofcancerpain:pharmacologyandprinciplesofmanagement.Cancer,1989;63:23082023/4/2

1•Commonadverseeffects–sedation,nausea,vomiting,constipation,respiratorydepressionandtolerance(镇静;恶心;呕吐;便秘;呼吸抑制及耐药性)•Adverseeffectsevaluationisone

oftheimportantpartsofnarcoticpharmacoeconomicevaluation(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)PharmacologicTherapiesofPain(疼痛的药物治疗)202

3/4/21⚫AdjunctiveTherapies(辅助性治疗)–anticonvulsants,antidepressant,stimulants,antihistamine,phenothiazine

,steroids,miscellaneous,anxiolytics(抗惊厥药,抗抑郁药,兴奋剂,抗组胺药,酚噻嗪,类固醇类,杂环类,抗焦虑药)–mostoftheseagentsareveryinexpensiveandtheycanbever

ycost-effectivewhenappropriatelyco-prescribedtohelpcontrolpain.(大部分这类药物非常便宜,在疼痛控制上的适当应用,可有很好的“效/价”比)PharmacologicTherapiesofPain(疼痛的药物治疗)2023/4/21Va

riousRoutesofAdministration-AdvantagesandDisadvantages创伤性首过效应起效时间作用时间耐受性患者偏好度花费IV/IM++-+++++--++++CSC+-++++

+--++++Oral-+++++++++++++TTS--++++++++++++++不同给药途径的优缺点比较2023/4/21ProprietaryDrugsVersusGenerics(专利药物与仿

制药物)⚫Theobjectiveofmakingformulariesistomaximizecost-effectivenessbyexcludingorlimitingexpensivemedicationsaslongasthequalityofcar

eisnotcompromised.*(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使“效/价”比达到最大)*JohnsonJ,etal.Pharmacoeconomicanalysisinformularydecisions:aninternationa

lperspective.AmJHospPharm.1994;51:25932023/4/21NonpharmacologicApproachestoPainManagement(非药物治疗方法)⚫Fac

torstobeconsideredarewhethertheinterventioneffectivelymobilizesapatient,reducestheneedforanursinghomeorn

ursingathome,preventshospitalization,reducesideeffectsandoverallcost*(对这些治疗的考虑在于其是否可明显增加病人的活动,降低对护理的需求,减少住院,降低不良反应和能降低总支出)–Physi

calInterventions(物理疗法)–BehavioralInterventions(行为疗法)*PortenoyR.etal.Issuesintheeconomicanalysisoftherapiesforcancerpain.Oncology.1995;9(11):S7120

23/4/21EconomicIssuesintheManagementofPain(疼痛控制中的经济因素)Thecostofnotmanagingaswellasmanagingchronicpainarepotentiallyveryhigh.Th

emorbideffectsofunrelievedpainonmoodandimmobilitycanresultinnumerousmedicalinterventions.Pain-relatedcomplications,expensivediagnosticprocedures

,hospitalizationsforpaincontrolanddaysmissedfromworkcanbeextremelycostly.(不控制疼痛和对慢性疼痛的控制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)2023/4/21⚫PrimaryIssues(主要因素)–thecostof

pharmacotherapy--themostimportantanalgesicapproachforcancerpain(药物治疗费用--对于癌痛而言是最重要的止痛方法)•Incorporatingpharmacoeconomicdataintotheformularydecision-

makingprocess--helpsinselectingmedicationsthataresafe,effectiveandcost-efficient(将药物经济学数据放入药物目录的评审中--这将有助于选择出既安全有效又‘效/价’比合适的药物)•Toperformacomprehe

nsiveevaluationofanexistingorproposedpharmaceuticalservice(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)EconomicIssuesintheManagementofPain(疼痛控制中的经济因素)2023/4/2

1⚫OtherIssues(其它因素)–thedifferencesintreatmentsettings(治疗方案的差异)–theneedtojustifyservices(服务需求的调整)–reimbursementbiases(报销目录的倾斜)–thepot

entialforconflictofinterest(潜在的公私利益冲突)EconomicIssuesintheManagementofPain(疼痛控制中的经济因素)2023/4/21Pharmacoeconomics--MethodsandGuidelin

es(药物经济学的方法及指导原则)⚫Methods–Cost-minimizationAnalysis•Outcomesareconsideredtobeequalandcompareonlytheimputesor

costsofeachalternativewhenefficacyandsideeffectsaresimilar–Cost-benefitAnalysis•measuresoutcomesindollars,Theoutcomemaybeexpressedinrat

ioofbenefittocost,ortheratioofthedifference(netcosttobenefit),ornetcost(benefitminuscost)–Cost-effectivenessAnalysis•m

easuresoutcomesinnonmonetaryunits(e.g.thecostperunitofsuccessoreffect--thecostperhourofreducednursingca

retimeorpermmHgchangeinBPforantihypertensivetherapy)2023/4/21Pharmacoeconomics--MethodsandGuidelines(药物经济学的方法及指导原则)–Cost-utili

tyAnalysis•Outcomesexpressedinnonmonetaryunitsareadjustedforhealth-relatedqualityoflife.–Cost-of-illnessAnal

ysis•attemptstoidentifyalldirectandindirectcostsoftreatingacertaindiseaseorillness2023/4/21⚫BasicPrinciplestoGuidetheP

harmaco-economicProcess(指导原则)–Definetheproblem–Determinethestudy’sperspective–Determinethealternativesandoutcomes–Selecttheappropriatepha

rmacoeconomicmethod–Placemonetaryvaluesontheoutcomes–Identifystudyresources–Establishtheprobabilitiesoftheoutcomes–Applyd

ecisionanalysis–Performasensitivityorincrementalcostanalysis–PresenttheresultsPharmacoeconomics--MethodsandGuide

lines(药物经济学的方法及指导原则)2023/4/21⚫ImplicationsforPharmacyandTherapeuticsCommittees(P&T)SeveralimplicationsforP&Tcommitteesthatshouldbeconsidered–

Considerthelargerpicture–Determineiftheagentscomparedwiththenewdrugarerelevanttotheirinstitution–Considerthatthecost-effectivenessofdrugsvariesamon

gpatientgroupsandindications–Cautionagainstpotentialbiasinindustry-sponsoredeconomicresearchPharmacoeconomics--Methods

andGuidelines(药物经济学的方法及指导原则)2023/4/21TheRoleofPharmacistinPharmacoeconomicPharmcistsmustensurethattheirc

entralroleintheeconomicpharmacologicmanagementofpainisestablishedandmaintained.*(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)*MichaelRigas,EconomicConsid

erationsinthePharmacologicManagementofPain.P&Ts1997:454