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

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

complicatedprocessthatisinitiatedbyanunpleasantsensoryexperience.Itoccursviaseveralmechanismsthatmayresultinimmobili

ty,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)–>7

5millionpeopleinU.S.havesomeformofpersistentorrecurrentpain*andpainisthemostcommonsymptomforwhichpatientsseekmedicalassistan

ce**(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.

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

Thegreatesthealthcarechallengeforthenextdecadeistomakethebestuseoflimitedavailableresourcestoattaintheh

ighestqualityofhealthcareforthelowestcost.Aspharmacoeconomicdatabecomeincreasinglyavailable,theiruseincost-effectivepai

nmanagementandinallhealthcaredecisions,willplayamajorrole.Thepharmacistisuniquelypoisedtoadapttothisshiftingparadigm.*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）*MichaelRig

as,EconomicConsiderationsinthePharmacologicManagementofPain.P&Ts1997:4542023/4/21⚫ClassificationofPain(疼痛的分

类)–TemporalClassification(时间分类)•AcutePain•ChronicPain–usuallydefinedasthatlasting6monthsorlonger•thetiming,loc

alizationandcharacterofthepainareoftenmorevague(疼痛的时间,部位和性质经常是含糊的)•Theremaybeindicationsofsleepdisturbances,lossofappetite,decreasedlibido,we

ightlossanddepression.(经常伴有睡眠干扰,食欲不振,性欲下降,体重降低及抑郁)–PhysiologicClassification(生理学分类)Somatic,Visceral,Neuropathic(躯体,内脏,神经性)GeneralIntrod

uctionofPain(疼痛概论）2023/4/21⚫PainManagementPrinciples(疼痛控制原则)*–AcutePain•patienteducationonpostoperativepain•theneed

forregularlyscheduledanalgesicsasopposedtoas-neededanalgesicsforthefirst24hoursofmoreaftersurgery•theneedforfrequentassessm

entandreassessmentofpainbynursingpersonnel•theneedforconsistentuseofatoolforpatientself-assessmentofpain•thepossibili

tyofpreemptiveanalgesicstrategiesforsurgicalpatients•thespecificanalgesicstrategiesofferedtopatientsGeneralIntroductionofPain(疼痛概论）*guide

linesandqualityassurancestandardsfromtheAgencyforHealthCarePolicyandResearch(AHCPR)2023/4/21–ChronicPain•WHOanalgesicladder(WHO阶梯疗法)–N

onopioid±AdjuvantWeakopioid±Nonopioid±AdjuvantStrongopioid±Nonopioid±Adjuvant–canprovidesatisfactorypainreliefto70-90%ofthispatientpopulation*(可使7

0-90%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)GeneralIntroductionofPain(疼痛概论）*

WHOcitedinPortenoyR.Issuesintheeconomicanalysisoftherapiesforcancerpain.Oncology.1995;9(11):S712023/4/21Pharmacologi

cTherapiesofPain(疼痛的药物治疗)Theappropriateandsuccessfulmanagementofpainentailsselectionoftherightanalgesic,administeredintherightway,dosageandon

therightschedulesoastomaximizepainreliefandminimizeadverseeffects.*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⚫Nonn

arcoticAnalgesics(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)•firstlineagentsforthet

reatmentofmild-to-moderatepain(是轻到中度疼痛的一线用药)•ceilingeffect(天花板效应)anincreaseinthedosagebeyondtherecommendedmaximumdosenotresultinani

ncreaseinanalgesia,andpotentiallyincreasessideeffects•notsuitableuseforchronic,evolvingpain*(不适合用于慢性,进展性疼痛

)PharmacologicTherapiesofPain(疼痛的药物治疗)*AshbyM.etal,Descriptionofamechanisticapproachtopainmanagementinadvancedcancer.Preli

minaryreport.Pain.1992;(51):1532023/4/21⚫NarcoticAnalgesics(麻醉性镇痛药)Narcoticmedicationshouldbeadministe

redonaregularbasissoastomaintaintheplasmalevelofthedrugabovetheminimaleffectiveconcentrationforpainrelief.Itisnotrecommend

edthatpatientswithchronicpaintakenarcoticsonanas-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)PharmacologicThera

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

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

iteduseinchronicpain(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–Advers

eeffectsofnarcotics•Despitetheprovenefficacyofnarcoticsinthemanagementofpain,thedevelopmentofadversee

ffectsisalsotypicalwiththeseagents(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)•opioidsideeffectsdependon

anumberoffactorsthatinclude:patientage,extentofdiseaseandorgandysfunction,concurrentadministrationofcert

aindrugs,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)PharmacologicTherapiesofPain(疼痛的药物治疗)*InturrisiC.Managementofcancerpain:pharmacologyandprinciplesofmanagement.Cancer,1989;63:23082023/4/21•Co

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

portantpartsofnarcoticpharmacoeconomicevaluation(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)2023/4/21⚫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)–mostoftheseagentsareveryinexpensiveandtheycanbeverycost-effectivewhenappropriatelyco-prescri

bedtohelpcontrolpain.(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)2023/4/21VariousRoutesofAdministration-Advantage

sandDisadvantages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2023/4/21Proprietary

DrugsVersusGenerics(专利药物与仿制药物)⚫Theobjectiveofmakingformulariesistomaximizecost-effectivenessbyexcludingorlim

itingexpensivemedicationsaslongasthequalityofcareisnotcompromised.*(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:aninternationalperspective.AmJHospPharm.1994;51:25932023/4/21Nonp

harmacologicApproachestoPainManagement(非药物治疗方法)⚫Factorstobeconsideredarewhethertheinterventioneffectivelymobilizesapatien

t,reducestheneedforanursinghomeornursingathome,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)–PhysicalInterventions(物理疗法)–BehavioralInterventions(行为疗法)*PortenoyR

.etal.Issuesintheeconomicanalysisoftherapiesforcancerpain.Oncology.1995;9(11):S712023/4/21EconomicIssuesintheManagementofPain(疼痛控制中

的经济因素)Thecostofnotmanagingaswellasmanagingchronicpainarepotentiallyveryhigh.Themorbideffectsofunrelievedpainonmoodandimmobilitycanresultinnumerousme

dicalinterventions.Pain-relatedcomplications,expensivediagnosticprocedures,hospitalizationsforpaincontrolanddaysmissedfromworkcanbeextremel

ycostly.(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⚫Prima

ryIssues(主要因素)–thecostofpharmacotherapy--themostimportantanalgesicapproachforcancerpain(药物治疗费用--对于癌痛而言是最重要的止痛方法)•Incorporatingp

harmacoeconomicdataintotheformularydecision-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)•Toperformacomprehensiveevaluationofanexistingorproposedpharmaceuti

calservice(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)2023/4/21⚫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)–thepotentialforconflictofinterest(潜在的公私利益冲突

)EconomicIssuesintheManagementofPain(疼痛控制中的经济因素)2023/4/21Pharmacoeconomics--MethodsandGuidelines(药物经济学的方法及指

导原则)⚫Methods–Cost-minimizationAnalysis•Outcomesareconsideredtobeequalandcompareonlytheimputesorcostsofeachalternativewhenefficacyandsideeffectsar

esimilar–Cost-benefitAnalysis•measuresoutcomesindollars,Theoutcomemaybeexpressedinratioofbenefittocost,ortheratiooft

hedifference(netcosttobenefit),ornetcost(benefitminuscost)–Cost-effectivenessAnalysis•measuresoutcomesinno

nmonetaryunits(e.g.thecostperunitofsuccessoreffect--thecostperhourofreducednursingcaretimeorpermmHgchangeinBPforantihypertensivetherapy)

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

adjustedforhealth-relatedqualityoflife.–Cost-of-illnessAnalysis•attemptstoidentifyalldirectandindirectcostsoftreatingacertaindiseaseorillne

ss2023/4/21⚫BasicPrinciplestoGuidethePharmaco-economicProcess(指导原则)–Definetheproblem–Determinethestudy’sperspective–Determinet

healternativesandoutcomes–Selecttheappropriatepharmacoeconomicmethod–Placemonetaryvaluesontheoutcomes–Identifystudyresources–Est

ablishtheprobabilitiesoftheoutcomes–Applydecisionanalysis–Performasensitivityorincrementalcostanalysis–

PresenttheresultsPharmacoeconomics--MethodsandGuidelines(药物经济学的方法及指导原则)2023/4/21⚫ImplicationsforPharmacyandTherapeuticsCommittees

(P&T)SeveralimplicationsforP&Tcommitteesthatshouldbeconsidered–Considerthelargerpicture–Determineiftheagentscomparedwiththenewdru

garerelevanttotheirinstitution–Considerthatthecost-effectivenessofdrugsvariesamongpatientgroupsandindications–Cautionagainstpotentialbiasinindust

ry-sponsoredeconomicresearchPharmacoeconomics--MethodsandGuidelines(药物经济学的方法及指导原则)2023/4/21TheRoleofPharmacistinPharmacoec

onomicPharmcistsmustensurethattheircentralroleintheeconomicpharmacologicmanagementofpainisestablishedandmaintained.*(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,EconomicConsiderationsinthePharmacologicManagementofPain.P&Ts1997:454