The frequency of narcotic drug use in China is less than 0.4% of that in the United States, and 60% of patients' pain is not controlled?

On September 4, 2019, Beijing Municipal Bureau of market supervision and administration strengthened the management of paracetamol oxycodone tablets, aiming at domestic paracetamol oxycodone tablet packaging manufacturers and agents The operating enterprises have made a series of regulations to strictly control the problem of drug overflow, but considering the current use of clinical narcotic drugs in China, on the one hand, they may vigorously strengthen national supervision, on the other hand, they emphasize "reasonable" drug use, so as to minimize the suffering of the patients In a real sense, the realization of "control, use" is the urgent need of the current society Each year, more than 3.8 million new cancer patients and 2.4 million new cancer pain patients are found in China According to the survey of cancer pain in 1997 by the Ministry of health, the incidence of cancer pain was 61.6% But 60% of pain patients have not received effective analgesic treatment, only 16% of patients who need palliative / analgesic treatment use morphine for treatment, so it is urgent to pay attention to cancer pain treatment! 1、 Pain is an unpleasant subjective feeling and emotional experience related to tissue injury or potential injury It is the fifth vital sign after heart rate, respiration, blood pressure and body temperature There is now a consensus around the world that chronic pain is a disease and that pain relief / elimination is a fundamental human right In all pain, cancer pain is the most prominent pain Once cancer pain occurs, it often accompanies patients to the end of life 2 The current situation of cancer pain at home and abroad in the world, many cancer patients are suffering from pain Compared with the developed countries, the current situation of cancer treatment and cancer pain treatment in China is facing great challenges According to the statistics of who, there are more than 18 million new cancer patients in the world every year, more than 9 million people suffer from cancer pain, and the incidence of cancer pain is about 60% According to the epic survey, 31% of patients go to hospital for treatment because of pain, 73% of cancer patients have pain symptoms, 94% of them have moderate or severe pain More than 50% of patients are in pain, ≥ once a day In January 2019, China National Cancer Center released the latest National Cancer statistical data The report mainly found that in 2015, the number of new cancer cases in China was about 3.929 million, and the number of cancer deaths in China was about 2.338 million On average, 7.5 people were diagnosed as cancer every minute Among these cancer patients, the incidence of pain in patients with primary cancer is about 25%, and that in patients with advanced cancer is 60% - 80% One third of them are severe pain 3 The importance of cancer pain treatment in cancer treatment, analgesia and anti-cancer equally important Pain is one of the most common and intolerable symptoms of cancer patients, which causes great harm to the body and spirit of patients, and even makes patients lose the will to survive At present, at least 60% of cancer pain patients in China have not received effective analgesic treatment, and their quality of life is poor Cancer pain treatment is the basis of palliative treatment and the primary task of palliative treatment There are many cancers that can't be cured at present Analgesia is sometimes the only treatment for end-stage patients Analgesia should be carried out to the last moment of patients' lives! 4 The current situation of opioids use in China the commonly used drugs for cancer pain relief include non steroidal anti-inflammatory drugs, opioids and adjuvant analgesics, among which the most commonly used drugs for advanced cancer pain are opioids According to the lancet, among the 298.5 tons of morphine equivalent opioids used in the world every year, less than 4% of the world's allocable morphine is used in low and middle-income countries Picture source: berterame s, erthal J, Thomas J, et al Use of and barriers to access to opioid analysis: a worldwide, regional, and national study [J] The lancet, 2016: s010673616001616 According to the global morphine equivalent distribution map, only 16% of the patients who need palliative / analgesic treatment in China use morphine China, which accounts for one fifth of the world's population, consumes only 2% of the world's morphine, and its per capita morphine consumption is less than one in 100 in the UK Photo source: http:// 2016 INCB data shows that China's s s-ddd (average daily consumption per million people) ranks 89th in the world and 22nd in Asia In 2018, China ranked the second largest economy in the world with us $13.6 trillion However, the frequency of narcotic drug use in China is relatively low among the top ten countries of GDP The lack of palliative care and pain control is one of the most serious health inequities in the world Note: * the limited daily dose for statistical purposes; the top 10 sources of GDP are from left to right: International aeronautics control board (INCB) aeronautic drugs 2011 report, average consumption in s-ddd per million pollutants per day, 2008-2010 from p275 International Monetary Fund (IMF) selected countries and subjects GDP, 2011 report 5 Causes of insufficient use of opioid analgesics in China 5.1 the core task of domestic supervision and supply in China is to prevent the occurrence of abuse under the premise of reasonable use of narcotic drugs Therefore, a series of strict control measures have been formulated to control the whole process from production to use with emphasis on "manageable" In the United States, it emphasizes individual rights, from the perspective of convenient use of patients, and according to the level of clinical application and medical value, it implements hierarchical management of controlled goods, emphasizing "availability" In October 2017, President trump of the United States signed a new administrative memorandum to declare a national public health emergency due to the opiate drug crisis Opioid abuse has become one of the most serious and developing drug problems in the United States in recent years However, China's "manageable" mode has led to the insufficient use of narcotic drugs Although China's opioid drug control has made great improvement compared with the previous one, due to the relatively cumbersome process, the implementation is affected by many factors, such as one product dual regulation, planned procurement, doctors' prescription right of narcotic drugs, outpatient prescription hospital, etc., which greatly limits the use of patients 5.2 doctors and patients have insufficient knowledge of opioids, patients and their families have insufficient knowledge of pain treatment: patients are unwilling to report pain, patients will not report pain, patients mistakenly think that pain is a normal process of disease, patients fear the addiction and adverse reactions of analgesic drugs, patients and their families lack education on pain assessment Lack of knowledge and skills about pain treatment among medical staff: lack of knowledge and skills related to pain evaluation among medical staff; lack of guidance for patients and their families, so that patients can not report pain accurately and timely; neglect the existence of patients' pain, and do not evaluate the effect of pain treatment in time; lack of pain management for patients, unable to dynamically observe the changes of patients' pain, and pain causing factors and treatment The treatment evaluation is insufficient 5.3 the lack of training of medical personnel and the lack of awareness of health professionals are also the main obstacles to the use of opioid analgesics in China 5.4 single opiate preparation in China At present, the main forms of opioids in China are oral formulations and transdermal patches, while the new preparations abroad include long-acting injections of acetic acid, naltrexone, long-acting injections, morphine sulfate long-acting injections, and the development and application of new injections based on nanoparticles, microemulsions, liposomes, in situ gels and microspheres, in order to improve drug stability and achieve high levels of drugs Effective, quick and long-term provide a reliable guarantee Based on the restriction of domestic supervision and the level of preparation, China lags far behind the developed countries in the formulation of opioids 2、 Five basic principles of cancer pain drug therapy 1 1 according to the ladder drug: according to the level of pain to choose the appropriate drugs the first ladder drug: light to moderate cancer pain patients, can choose non steroidal anti-inflammatory drugs The second step: for patients with moderate cancer pain, weak opioids or low-dose strong opioids are selected When the analgesic effect is not satisfactory, non steroidal anti-inflammatory drugs and some auxiliary drugs (sedatives, anticonvulsants and antidepressants) can be combined The third step: for patients with severe cancer pain, strong opioids were used 1.2 oral administration is convenient, simple, economic and easy to accept, with stable blood concentration, as effective as intravenous injection, convenient dose adjustment, more autonomy, less addiction and drug resistance It is the most commonly used route of administration Other routes of administration, including intravenous, subcutaneous, rectal and percutaneous administration, can also be selected according to the specific conditions of patients 1.3 medication on time refers to the regular administration of painkillers according to the specified time interval 1.4 individualized administration refers to the formulation of individualized medication plan according to the patient's condition and the dose of cancer pain relief drugs 1.5 pay attention to specific details 3 Current situation of research and development of analgesic drugs 1 Classification of commonly used analgesic drugs for cancer pain relief in China include non steroidal anti-inflammatory drugs, opioids and some auxiliary analgesic drugs, see the table below for details 2 At present, the commonly used drugs for severe pain are morphine hydrochloride sustained-release tablets, oxycodone sustained-release tablets and fentanyl patch These three drugs have advantages and disadvantages in the treatment of cancer pain The details are as follows Morphine is the representative of opioid analgesics WHD takes the consumption of medical morphine as the scale of cancer pain treatment, and its consumption is an important index to evaluate the improvement of cancer pain in a country Morphine is generally recognized as the gold standard for the treatment of moderate and severe cancer pain, because it has definite curative effect, good effect and low price, the cost-effectiveness ratio of pharmacoeconomics is 13.40, the side effects are fully studied, the side effects are equivalent to the same kind of drugs, the dosage can be adjusted in time according to the degree of cancer pain, and there is no ceiling effect Oxycodone is one of the first choice drugs for cancer pain treatment recommended by NCCN adult cancer pain guidelines Its equivalent analgesic effect intensity is 1.5 times of that of morphine At present, the clinical application of oxycodone is slow and controlled-release preparation The preparation adopts acrocontin controlled-release technology The drug shows a biphasic absorption peak in vivo 38% immediate release part can take effect quickly within 1h, 62% sustained-release part can maintain the patient's blood drug concentration, and analgesia lasts for 12 hours 。 The cost-effectiveness ratio of oxycodone sustained-release tablets is 16.12, and the price is higher than that of morphine Fentanyl has a selective high affinity for μ receptor, and its equivalent analgesic effect is 75-100 times that of morphine Fentanyl transdermal delivery route is non-invasive skin adhesive The drug is slowly released into the blood through the skin, avoiding the first pass effect of the liver, not affected by gastrointestinal factors, and reducing the individual differences in medication The analgesic effect of fentanyl transdermal patch can last for 72 hours, which reduces the times of administration and is convenient to use It is especially suitable for cancer pain patients with eating difficulties, severe vomiting or constipation However, fentanyl transdermal patch is not suitable for patients with intolerant opioids Even if the minimum dose of fentanyl transdermal patch is used in the early stage of treatment, there is still a risk of serious or life-threatening pulmonary insufficiency Moreover, the dosage of fentanyl should be determined according to the individual condition of patients, and the dosage should be evaluated regularly after administration In addition, the pharmacoeconomic cost-effectiveness ratio of fentanyl patch is 21.62, and the cost of treatment is more expensive In conclusion, morphine is the first choice for the treatment of moderate and severe cancer pain Robert twycross, the founder of palliative medicine in the world, recommends the use of morphine preparation 4、 Summary of morphine in opioid analgesics in China