我国不同地区阿片类镇痛药物在癌痛治疗中的使用情况及个人经济负担
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摘要
目的:了解我国不同地区阿片类镇痛药的使用情况与趋势,评估癌痛治疗吗啡临床需要量及满足临床需要的程度,评价个人药费可负担性,为我国合理使用阿片类镇痛药,提高癌痛控制水平和患者生活质量提出政策建议。方法:采用回顾性分析方法,分析2006～2016年我国7个片区的阿片类镇痛药使用强度(MUD)及其各阶段年复合增长率(CAGR)。基于我国7个片区肿瘤登记数据和国际疼痛标准治疗指南,测算2015年不同地区的吗啡需要量。将药品价格以DDD值标化为限定日费用(DDC),采用改进后的WHO/HAI标准调查法评价阿片类镇痛药用于癌痛治疗的个人药费可负担性。结果:全国MUD从2006年的1.45DDD/10万人天增长至2016年的6.93DDD/10万人天,整体增长率呈现为前高后低。不同地区间MUD差异较大,且MUD极差有逐年加大趋势。2016年MUD最大地区为华南(9.67DDD/10万人天),最小为西北(3.28DDD/10万人天)。2015年,全国吗啡等效当量实际使用量仅占癌痛治疗吗啡需要量的21.5%,华东(26%)和华南(36%)等地区高于西南(11%)和西北(12%)。各类阿片类镇痛药的DDC范围为10.80～848.88元,除吗啡注射剂外,其余药品的疗程自付费用均大于1 d的日均可支配收入。结论:我国阿片类镇痛药用于癌痛治疗整体使用不足,且不同经济水平的地区使用差异较大,癌痛患者长期使用镇痛药物治疗的个人药费负担较重。应全面加快推行癌痛规范化治疗示范病房和疼痛门诊,完善相应保障体系,合理引导广大城乡居民可负担的癌痛治疗药品价格,降低个人费用负担,提高癌症患者生存质量,使更多癌痛患者得到经济有效的治疗。
Objective: This study aims to learn the level and trend of opioid analgesics use in different regions of China, as well as the utilization and patient affordability of opioid analgesics for cancer pain treatment. Methods: The study used a retrospective method to analyze the utilization of opioid analgesics in Morphine Use Density(MUD, daily defined doses of morphine used per 100 000 population) and its growth rate from 2006 to 2016 in China and in its 7 regions. Regional needs of opioid analgesics(in morphine equivalents) for cancer pain treatment were measured based on regional cancer registration data and standard treatment course as defined by the international treatment guidelines for cancer pain. The study adopts WHO/HAI method to evaluate the patient affordability of opioid analgesics for cancer pain treatment with the standardized prices(DDC, cost of daily defined doses). Results: The national MUD increased from 1.45 DDDs/100 000/day in 2006 to 6.93 DDD/100 000/day in 2016, with a higher growth rate in early years and lower growth rate in the last 6 years. Southern China had the largest MUD in 2016(9.67 DDD/100 000/day), Northwest China had the lowest MUD(3.28 DDD/100 000/day). The actual use of morphine equivalents accounted for only 21.5% of the needs of morphine for cancer pain treatment, which was 26% in the Eastern China, 36% in the Southern China, 11% in the Southwest and 12% in the Northwest. The DDC of all studied opioid analgesics ranged from CNY 10.80 to 848.88. Except morphine injection, the out-of-pocket payments for the standard treatment course of all other opioid analgesics were more than one daily disposable income of all regions of China. Conclusion:The opioid analgesics use for the treatment of cancer pain were insufficient in China, which varies largely in different regions with different economic development. Long-term use may lead heavy economic burden to the cancer patients. All these findings call for actions to strengthen the cancer pain treatment and care, and to relief the patient affordability.
Objective: This study aims to learn the level and trend of opioid analgesics use in different regions of China, as well as the utilization and patient affordability of opioid analgesics for cancer pain treatment. Methods: The study used a retrospective method to analyze the utilization of opioid analgesics in Morphine Use Density(MUD, daily defined doses of morphine used per 100 000 population) and its growth rate from 2006 to 2016 in China and in its 7 regions. Regional needs of opioid analgesics(in morphine equivalents) for cancer pain treatment were measured based on regional cancer registration data and standard treatment course as defined by the international treatment guidelines for cancer pain. The study adopts WHO/HAI method to evaluate the patient affordability of opioid analgesics for cancer pain treatment with the standardized prices(DDC, cost of daily defined doses). Results: The national MUD increased from 1.45 DDDs/100 000/day in 2006 to 6.93 DDD/100 000/day in 2016, with a higher growth rate in early years and lower growth rate in the last 6 years. Southern China had the largest MUD in 2016(9.67 DDD/100 000/day), Northwest China had the lowest MUD(3.28 DDD/100 000/day). The actual use of morphine equivalents accounted for only 21.5% of the needs of morphine for cancer pain treatment, which was 26% in the Eastern China, 36% in the Southern China, 11% in the Southwest and 12% in the Northwest. The DDC of all studied opioid analgesics ranged from CNY 10.80 to 848.88. Except morphine injection, the out-of-pocket payments for the standard treatment course of all other opioid analgesics were more than one daily disposable income of all regions of China. Conclusion:The opioid analgesics use for the treatment of cancer pain were insufficient in China, which varies largely in different regions with different economic development. Long-term use may lead heavy economic burden to the cancer patients. All these findings call for actions to strengthen the cancer pain treatment and care, and to relief the patient affordability.
引文
1 Chen W,Zheng R,Baade PD.Cancer statistics in China 2015[J].Ca Cancer J Clin,2016,66(2):115-132
2 国家卫健委.癌症疼痛诊疗规范(2018年版)[J].临床肿瘤学杂志,2018,23(10):937-944
3 Mh BVE,Hochstenbach LM,Joosten BE.Update on Prevalence of Pain in Patients with Cancer:Systematic Review and Meta-Analysis[J].Journal of Pain & Symptom Management,2016,51(6):1070-1090
4 Zaza C,Baine N.Cancer pain and psychosocial factors:a critical review of the literature[J].Journal of Pain & Symptom Management,2002,24(5):526-542
5 Scarborough BM,Smith CB.Optimal pain management for patients with cancer in the modern era[J].Ca A Cancer Journal for Clinicians,2018,68(suppl 2):182-196
6 彭鹏,郑莹,王杰军.癌痛患者的生活质量及其影响因素研究[J].中国肿瘤,2009,9(4):273-277
7 中国抗癌协会癌症康复与姑息治疗专业委员会.全国百家医院癌痛合理用药情况调研[R].2016
8 Nunes BC,Garcia JB,Sakata RK.Morphine as the first drug for the treatment of cancer pain[J].J Palliat Med,2012,15(9):963-964
9 王薇,曹邦伟,宁晓红.北京市癌痛控制20年进步与挑战——北京市多中心癌痛状况调查(FENPAI4090)[J].中国疼痛医学杂志,2014,20(1):5-12
10 王雅杰.癌痛治疗需转变观念[J].药学服务与研究,2009,9(2):81-83
11 国际麻醉品管制局.国际管制药物供应情况:确保医疗和科研所用药物的充分供应不可或缺、充分供应且不受不当限制[R].2015
12 支梦佳,魏兴梅,高翔,等.我国阿片类镇痛药物临床使用现状分析[J].药物流行病学杂志,2018,27(6):400-405
13 程斌,杨国浓,郑小卫.我院癌痛住院患者阿片类镇痛药使用动态分析[J].中国药房,2017,28(11):1462-1466
14 孙焱林.我国各省区医疗卫生资源配置水平的比较研究[J].中国卫生经济,2013(11):41-43
15 孙静,罗仁.我国医院糖尿病药物治疗及基本药物应用[J].中国药房,2016,27(24):3313-3319
16 国家统计局.中国统计年鉴[M] .北京:中国统计出版社,2017:180-188
17 WHO Collaborating Center for Drug Statistics and Methodology.DDD alterations from 2005-2018.WHOCC - DDD alterations[EB/OL].(2018-01)[2018-12-01] https://www.whocc.no/atc_ddd_index/
18 Zerzan JT,Morden NE,Soumerai S,et al.Trends and geographic variation of opiate medication use in state Medicaid fee-for-service programs,1996 to 2002[J].Medical Care,2006,44(11):1005-1010
19 高江波,黄姣,李双成,等.中国自然地理区划研究的新进展与发展趋势[J].地理科学进展,2010,29(11):1400-1407
20 Jamison DT,Breman JG,MeashamAR.Eds.Disease Control Priorities in Developing Countries[M].2nd ed.New York:Oxford University Press,2006:142-143
21 管晓东,林其敏,信枭雄,等.药品可负担性评价方法研究[J].中国药房,2015,26(28):3892-3895
22 WHO.Medicine prices:a new approach to measurement.Working draft for field-testing and revision[EB/OL].[2010-03-01]http://www.haiweb.org/medicineprices/manual/manuals/MedicinePrices.pdf
23 Duthey B,Scholten W.Adequacy of opioid analgesic consumption at country,global,and regional levels in 2010,its relationship with development level,and changes compared with 2006[J].Journal of Pain & Symptom Management,2014,47(2):283-297
24 王湘,宁晓红.关于改善我国癌痛控制的思考[J].中国新药杂志,2014,23(17):2057-2060
25 Dicheva BM .Cationic thermosensitive liposomes:a novel dual targeted heat-triggered drug delivery approach for endothelial and tumor cells[J].Nano Letters,2013,13(6):2324-2331
26 杨娟.基层医院麻醉药品的管理与使用探讨[J].中医药管理杂志,2017,25(1):89-90
27 Fischer B,Jones W,Jürgen Rehm.Trends and changes in prescription opioid analgesic dispensing in Canada 2005–2012:an update with a focus on recent interventions[J].BMC Health Services Research,2014,14(1):90
28 Deandrea S,Montanari M,Moja L.Prevalence of undertreatment in cancer pain.A review of published literature[J].Ann Oncol,2008,19(12):198519-91
29 Mcdonald DC ,Carlson K ,Izrael D.Geographic Variation in Opioid Prescribing in the U.S.[J].Journal of Pain,2012,13(10):988-996
30 原国家卫生部.卫生部第一批癌痛规范化治疗示范病房名单[EB/OL].(2012-09)[2018-12-01] http://www.nhfpc.gov.cn/mohyzs/s3586/201211/56217.shtml
31 周克明,蒋建军,首峰,等农村癌痛患者临终关怀直接经济负担分析[J].肿瘤预防与治疗,2018,31(1):57-61
32 De Lima L ,Pastrana T ,Radbruch L ,et al.Cross-Sectional Pilot Study to Monitor the Availability,Dispensed Prices,and Affordability of Opioids Around the Globe[J].Journal of Pain and Symptom Management,2014,48(4):649-659
33 曾春生,曾红学,黄作超,等.“癌痛规范化治疗示范病房”创建前后癌痛药使用分析[J].中国疼痛医学杂志,2015,21(4):312-314
34 陈健苗,魏妙华,张利平,等.临床药师参与癌痛规范化治疗的典型病例分析[J].中国临床药学杂志,2015,24(5):320-323
35 曹舫,王琳,田云,等.2012～2013年我院癌痛治疗药品用药分析[J].西北药学杂志,2015,30(1):82-84
2 国家卫健委.癌症疼痛诊疗规范(2018年版)[J].临床肿瘤学杂志,2018,23(10):937-944
3 Mh BVE,Hochstenbach LM,Joosten BE.Update on Prevalence of Pain in Patients with Cancer:Systematic Review and Meta-Analysis[J].Journal of Pain & Symptom Management,2016,51(6):1070-1090
4 Zaza C,Baine N.Cancer pain and psychosocial factors:a critical review of the literature[J].Journal of Pain & Symptom Management,2002,24(5):526-542
5 Scarborough BM,Smith CB.Optimal pain management for patients with cancer in the modern era[J].Ca A Cancer Journal for Clinicians,2018,68(suppl 2):182-196
6 彭鹏,郑莹,王杰军.癌痛患者的生活质量及其影响因素研究[J].中国肿瘤,2009,9(4):273-277
7 中国抗癌协会癌症康复与姑息治疗专业委员会.全国百家医院癌痛合理用药情况调研[R].2016
8 Nunes BC,Garcia JB,Sakata RK.Morphine as the first drug for the treatment of cancer pain[J].J Palliat Med,2012,15(9):963-964
9 王薇,曹邦伟,宁晓红.北京市癌痛控制20年进步与挑战——北京市多中心癌痛状况调查(FENPAI4090)[J].中国疼痛医学杂志,2014,20(1):5-12
10 王雅杰.癌痛治疗需转变观念[J].药学服务与研究,2009,9(2):81-83
11 国际麻醉品管制局.国际管制药物供应情况:确保医疗和科研所用药物的充分供应不可或缺、充分供应且不受不当限制[R].2015
12 支梦佳,魏兴梅,高翔,等.我国阿片类镇痛药物临床使用现状分析[J].药物流行病学杂志,2018,27(6):400-405
13 程斌,杨国浓,郑小卫.我院癌痛住院患者阿片类镇痛药使用动态分析[J].中国药房,2017,28(11):1462-1466
14 孙焱林.我国各省区医疗卫生资源配置水平的比较研究[J].中国卫生经济,2013(11):41-43
15 孙静,罗仁.我国医院糖尿病药物治疗及基本药物应用[J].中国药房,2016,27(24):3313-3319
16 国家统计局.中国统计年鉴[M] .北京:中国统计出版社,2017:180-188
17 WHO Collaborating Center for Drug Statistics and Methodology.DDD alterations from 2005-2018.WHOCC - DDD alterations[EB/OL].(2018-01)[2018-12-01] https://www.whocc.no/atc_ddd_index/
18 Zerzan JT,Morden NE,Soumerai S,et al.Trends and geographic variation of opiate medication use in state Medicaid fee-for-service programs,1996 to 2002[J].Medical Care,2006,44(11):1005-1010
19 高江波,黄姣,李双成,等.中国自然地理区划研究的新进展与发展趋势[J].地理科学进展,2010,29(11):1400-1407
20 Jamison DT,Breman JG,MeashamAR.Eds.Disease Control Priorities in Developing Countries[M].2nd ed.New York:Oxford University Press,2006:142-143
21 管晓东,林其敏,信枭雄,等.药品可负担性评价方法研究[J].中国药房,2015,26(28):3892-3895
22 WHO.Medicine prices:a new approach to measurement.Working draft for field-testing and revision[EB/OL].[2010-03-01]http://www.haiweb.org/medicineprices/manual/manuals/MedicinePrices.pdf
23 Duthey B,Scholten W.Adequacy of opioid analgesic consumption at country,global,and regional levels in 2010,its relationship with development level,and changes compared with 2006[J].Journal of Pain & Symptom Management,2014,47(2):283-297
24 王湘,宁晓红.关于改善我国癌痛控制的思考[J].中国新药杂志,2014,23(17):2057-2060
25 Dicheva BM .Cationic thermosensitive liposomes:a novel dual targeted heat-triggered drug delivery approach for endothelial and tumor cells[J].Nano Letters,2013,13(6):2324-2331
26 杨娟.基层医院麻醉药品的管理与使用探讨[J].中医药管理杂志,2017,25(1):89-90
27 Fischer B,Jones W,Jürgen Rehm.Trends and changes in prescription opioid analgesic dispensing in Canada 2005–2012:an update with a focus on recent interventions[J].BMC Health Services Research,2014,14(1):90
28 Deandrea S,Montanari M,Moja L.Prevalence of undertreatment in cancer pain.A review of published literature[J].Ann Oncol,2008,19(12):198519-91
29 Mcdonald DC ,Carlson K ,Izrael D.Geographic Variation in Opioid Prescribing in the U.S.[J].Journal of Pain,2012,13(10):988-996
30 原国家卫生部.卫生部第一批癌痛规范化治疗示范病房名单[EB/OL].(2012-09)[2018-12-01] http://www.nhfpc.gov.cn/mohyzs/s3586/201211/56217.shtml
31 周克明,蒋建军,首峰,等农村癌痛患者临终关怀直接经济负担分析[J].肿瘤预防与治疗,2018,31(1):57-61
32 De Lima L ,Pastrana T ,Radbruch L ,et al.Cross-Sectional Pilot Study to Monitor the Availability,Dispensed Prices,and Affordability of Opioids Around the Globe[J].Journal of Pain and Symptom Management,2014,48(4):649-659
33 曾春生,曾红学,黄作超,等.“癌痛规范化治疗示范病房”创建前后癌痛药使用分析[J].中国疼痛医学杂志,2015,21(4):312-314
34 陈健苗,魏妙华,张利平,等.临床药师参与癌痛规范化治疗的典型病例分析[J].中国临床药学杂志,2015,24(5):320-323
35 曹舫,王琳,田云,等.2012～2013年我院癌痛治疗药品用药分析[J].西北药学杂志,2015,30(1):82-84