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1、2019/1/21,General Introduction of Pain (疼痛概论）,Definition (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 mechanisms that may result in immobility, deconditioning and emotional reactions.(躯体疼痛是由于不愉快的感觉经
2、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.,2019/1/21,Epidemiology (流行病学资料) 75 million people in U.S. have some form of persistent or recurrent pain* and pain is the most common symptom for which patients seek medical assistance* (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
3、死亡人群中,60%以上忍受着中到重度疼痛,General Introduction of Pain (疼痛概论）,*Caudill M, Holman G,Turk D. Patient Care. 1996:154 *Foley K. Cecil Textbook of Medicine. Philadelphia,1992:97,2019/1/21,Greatest Challenge (伟大的挑战) The greatest health care challenge for the next decade is to make the best use of limited avail
4、able resources to attain the highest quality of health care for the lowest cost. As pharmacoeconomic 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 pa
5、radigm.* 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.,General Introduction of Pain (疼痛概论）,*Michael Rigas, Economic Considerations in the Pharmacologic Management of Pain. P&Ts 1997:454,2019/1/21,Classification of Pain (疼痛的分类)
6、Temporal Classification(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,部位和性质经常是含糊的) There may be indications of sleep disturbances, loss of appetite,decreased libido,weight loss and depress
7、ion. (经常伴有睡眠干扰,食欲不振,性欲下降, 体重降低及抑郁) Physiologic Classification(生理学分类) Somatic, Visceral, Neuropathic(躯体,内脏,神经性),General Introduction of Pain (疼痛概论）,2019/1/21,Pain Management Principles(疼痛控制原则)* Acute Pain patient education on postoperative pain the need for regularly scheduled analgesics as opposed t
8、o 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 preemptive analgesic strategies for surgical patients the sp
9、ecific analgesic strategies offered to patients,General Introduction of Pain (疼痛概论）,* guidelines and quality assurance standards from the Agency for Health Care Policy and Research (AHCPR),2019/1/21,Chronic Pain WHO analgesic ladder (WHO阶梯疗法) NonopioidAdjuvant Weak opioid Nonopioid Adjuvant Strong o
10、pioid NonopioidAdjuvant can provide satisfactory pain relief to 70-90% of this patient population* (可使70-90%的中到重度癌痛患者得到满意地缓解) 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径),General Introduction of Pain (疼痛概论）,*WHO cited in Portenoy R. Issues in the economic
11、analysis of therapies for cancer pain. Oncology. 1995;9(11):S71,2019/1/21,Pharmacologic Therapies of Pain (疼痛的药物治疗),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 relie
12、f 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, 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,*Inturrisi C. Management of cancer pain:pharmacology and principles of management. Cancer, 1989;63:2308,2019/1/21,Nonnarcotic Analgesics(非麻醉性镇痛药) Aspirin, Acetaminophen and NSAIDs (阿斯匹林,对乙酰氨
13、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) ceiling effect (天花板效应) an increase in the dosage beyond the recommended maximum dose not result in an increase in analgesia, and potentially increases side effects not suitable use for chronic,evolving pain* (不适合用于
14、慢性,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 advanced cancer. Preliminary report. Pain. 1992;(51):153,2019/1/21,Narcotic Analgesics (麻醉性镇痛药) Narcotic medication should be administered on a regular basis so as to main
15、tain 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 exacerbate the pain.* (麻醉性镇痛药物的使用应按时给
16、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 Therapies of Pain (疼痛的药物治疗),*Ralphs J et al. Opiate reduction in chronic pain patients: Pain. 1994;56:279,2019/1/21,Agonist commonly 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,如癌痛) Agonist-antagon
17、ist often used in acute postoperative pain management, but are of limited use in chronic pain (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),Pharmacologic Therapies of Pain (疼痛的药物治疗),2019/1/21,Adverse effects of narcotics Despite the proven efficacy of narcotics in the management of pain, the development of ad
18、verse effects is also typical with these agents (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) 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 admini
19、stration* (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),Pharmacologic Therapies of Pain (疼痛的药物治疗),*Inturrisi C. Management of cancer pain:pharmacology and principles of management. Cancer, 1989;63:2308,2019/1/21,Common adverse effects sedation, nausea, vomiting, constipation, respiratory depress
20、ion and tolerance (镇静;恶心;呕吐;便秘;呼吸抑制及耐药性) 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),2019/1/21,Adjunctive Therapies(辅助性治疗) anticonvulsants, antidepressant, stimulants, an
21、tihistamine, 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) most of these agents are very inexpensive and they can be very cost-effective when appropriately co-prescribed to help control pain.(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),Pharmacologic Therapies of
22、 Pain (疼痛的药物治疗),2019/1/21,Various Routes of Administration- Advantages and Disadvantages,不 同 给 药 途 径 的 优 缺 点 比较,2019/1/21,Proprietary Drugs Versus Generics (专利药物与仿制药物),The objective of making formularies is to maximize cost-effectiveness by excluding or limiting expensive medications as long as the
23、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),*Johnson J, et al. Pharmacoeconomic analysis in formulary decisions:an international perspective. Am J Hosp Pharm. 1994;51:2593,2019/1/21,Nonpharmacologic Approaches to Pain Management (非药物治疗方法),Factors to b
24、e considered are whether the intervention effectively mobilizes a patient, reduces 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) Physical Interventions(物理疗法) Behavioral Intervention
25、s(行为疗法),*Portenoy R. et al. Issues in the economic analysis of therapies for cancer pain. Oncology. 1995;9(11):S71,2019/1/21,Economic 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 pa
26、in on mood and immobility can result in numerous 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
27、治疗以及为此耽误工作的代价都是非常高的),2019/1/21,Primary Issues(主要因素) the cost of pharmacotherapy -the most important analgesic approach for cancer pain (药物治疗费用-对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 co
28、st-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) 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),Economic Issues in the Management of Pain (疼痛控制中的经济因素),2019/1/21,Other Issues(其它因素) the differences in treatment settings (治疗
29、方案的差异) the need to justify services (服务需求的调整) reimbursement biases (报销目录的倾斜) the potential for conflict of interest (潜在的公私利益冲突),Economic Issues in the Management of Pain (疼痛控制中的经济因素),2019/1/21,Pharmacoeconomics-Methods and Guidelines (药物经济学的方法及指导原则),Methods Cost-minimization Analysis Outcomes are co
30、nsidered to be equal and compare only the imputes or costs of each alternative when efficacy and side effects are similar Cost-benefit Analysis 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(bene
31、fit minus cost) Cost-effectiveness Analysis measures 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),2019/1/21,Pharmacoeconomics-Methods and Guidelines (药物经济学的方法及指导原则),Cos
32、t-utility Analysis Outcomes expressed in nonmonetary units are adjusted for health-related quality of life. Cost-of-illness Analysis attempts to identify all direct and indirect costs of treating a certain disease or illness,2019/1/21,Basic Principles to Guide the Pharmaco-economic Process(指导原则) Def
33、ine the problem Determine the studys perspective Determine the alternatives and outcomes Select the appropriate pharmacoeconomic method Place monetary values on the outcomes Identify study resources Establish the probabilities of the outcomes Apply decision analysis Perform a sensitivity or incremen
34、tal cost analysis Present the results,Pharmacoeconomics-Methods and Guidelines (药物经济学的方法及指导原则),2019/1/21,Implications for Pharmacy and Therapeutics Committees(P&T) Several implications for P&T committees that should be considered Consider the larger picture Determine if the agents compared with the
35、new drug are relevant to their institution Consider that the cost-effectiveness of drugs varies among patient groups and indications Caution against potential bias in industry-sponsored economic research,Pharmacoeconomics-Methods and Guidelines (药物经济学的方法及指导原则),2019/1/21,The Role of Pharmacist in Pharmacoeconomic,Pharmcists 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巩固他们的中心作用),*Michael Rigas, Economic Considerations in the Pharmacologic Management of Pain. P&Ts 1997:454,