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Menahem S, Freud T, Batat E, Shvartzman P. Opioid consumption by cancer patients in an Israeli Health Maintenance Organization from 2007-2018. Support Care Cancer 2023; 31:560. [PMID: 37668801 DOI: 10.1007/s00520-023-08027-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 08/28/2023] [Indexed: 09/06/2023]
Abstract
PURPOSE Opioids are the cornerstone of therapy for cancer patients with moderate to severe pain. The objective was to characterize opioid purchases by cancer patients in Clalit Health Services (CHS), the largest Health Maintenance Organization in Israel, over the years 2007-2018. METHODS Data for all CHS cancer patients aged 18 years old and above who purchased an opioid at least once during the 12-year study period were obtained from computerized databases. The amount of opioids was converted into oral morphine equivalents (OME). RESULTS 108,543 cancer patients who purchased opioids at least once were enrolled. They comprised 30.5% of the CHS purchasers of opioids in the study period. The total number of cancer patients who purchased an opioid at least once increased gradually from 13,057 in 2007 to 20,675 (58% increase) in 2018, while the annual number of CHS cancer patients increased by only 39%. The annual OME per capita increased from 753 mg in 2007 to 1,432 mg in 2018 (91% increase). In 2007 8.1% of the cancer patients purchased opioids and 9.2% in 2018. Two thirds of all cancer patients purchased opioids for three months or less, 11.9% continued for more than one year, and 5.8% for more than two years. CONCLUSIONS There is a clinically non-significant increase in the rate of cancer patients purchasing opioids. About two thirds of the cancer patients purchased opioids for only three months, and 94% for up to two years. Under-treatment of cancer pain should still be of concern. While patients are prescribed higher doses, under-prescription may still be a problem..
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Affiliation(s)
- Sasson Menahem
- Pain and Palliative Care Unit, Kappy and Eric Flanders National Palliative Care Resource Center, The Haim Doron Division of Community Health,Faculty of Health Sciences, Ben-Gurion University of the Negev, PO BOX 653, Beer-Sheva, Israel
- Siaal Research Center for Family Medicine and Primary Care, Department of Family Medicine, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Community Division, Clalit Health Services, Southern District, Beer-Sheva, Israel
| | - Tamar Freud
- Siaal Research Center for Family Medicine and Primary Care, Department of Family Medicine, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Erez Batat
- Health Planning and Policy Wing, Clalit Health Services, Community Division, Tel-Aviv, Israel
| | - Pesach Shvartzman
- Pain and Palliative Care Unit, Kappy and Eric Flanders National Palliative Care Resource Center, The Haim Doron Division of Community Health,Faculty of Health Sciences, Ben-Gurion University of the Negev, PO BOX 653, Beer-Sheva, Israel.
- Siaal Research Center for Family Medicine and Primary Care, Department of Family Medicine, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
- Community Division, Clalit Health Services, Southern District, Beer-Sheva, Israel.
- Pain and Palliative Care Unit, Soroka University Medical Center, Beer-Sheva, Israel.
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Wang JJ, Chu YR, Teng SF, Chu CC, Ho CH, Chu LL. Prevalence of opioid prescriptions in Taiwan (2008-2018). J Chin Med Assoc 2022; 85:603-609. [PMID: 35353736 DOI: 10.1097/jcma.0000000000000720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Opioids are effective for severe pain; however, the safety issue is also a primary concern. To better understand the opioid use in Taiwan, we conducted this study. METHODS Data on patients with opioid prescriptions, including morphine, fentanyl, pethidine, codeine, oxycodone, hydromorphone, and buprenorphine were collected using the Taiwan National Health Insurance Database (NHID). RESULTS Our analysis of opioid prescriptions from 2008 to 2018 in Taiwan indicated that (1) A slow increase in prevalence of opioid prescription was found during the study period. Among the drugs studied, morphine accounted for the majority of the prescriptions written, with a gradual increase annually. Pethidine prescriptions showed a significant and rapid decline over the years; (2) medical centers prescribed the largest number of opioids, followed by regional hospitals, local hospitals, and clinics; (3) the number of prescriptions per year per capita in cancer group was much higher than that in noncancer group. In noncancer group, most of the prescriptions were used in acute pain service (98.7%); and (4) use of opioids increased with age in both cancer and noncancer patients. CONCLUSION The total number of opioid prescriptions in Taiwan gradually increased annually, among which morphine was the most commonly used opioid. Cancer patients consumed more opioid prescriptions than noncancer patients and most of the prescriptions in noncancer patients were used in acute pain service. The number of prescriptions increased with the age of the patients in both cancer and noncancer patients. The low prescription rate of opioids in chronic pain in Taiwan is not similar as those in high opioid-consuming countries, such as United States.
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Affiliation(s)
- Jhi-Joung Wang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan, ROC
- Department of Anesthesiology, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Yu-Roo Chu
- Division of Controlled Drugs, Food and Drug Administration, Ministry of Health and Welfare, Taipei, Taiwan, ROC
| | - Shu-Fang Teng
- Division of Controlled Drugs, Food and Drug Administration, Ministry of Health and Welfare, Taipei, Taiwan, ROC
| | - Chin-Chen Chu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan, ROC
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan, ROC
| | - Li-Ling Chu
- Department of Pharmacy, Chi Mei Medical Center, Tainan, Taiwan, ROC
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Wu TC, Hsu CH, Sun WZ, Chen HM, Lin CP, Shao YY. Impact of expanded strong opioid availability on opioid prescription patterns in patients with cancer: A population-wide cohort study in Taiwan. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2021; 16:100255. [PMID: 34590061 PMCID: PMC8406032 DOI: 10.1016/j.lanwpc.2021.100255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/07/2021] [Accepted: 08/03/2021] [Indexed: 01/03/2023]
Abstract
Background One of the major barriers to adequate cancer pain management in Taiwan is the limited prescription options regarding strong opioids. Internationally recommended strong opioids, including oxycodone and hydromorphone, were not introduced in Taiwan until late 2014. We analysed the patterns in opioid prescription for cancer pain management, after the introduction of new opioid options. Methods All inpatient and outpatient clinical visits from January 1, 2012, to December 31, 2017, with the diagnosis of cancer and the analgesic prescriptions were collected from the database of National Health Insurance, Taiwan, and analysed. Opioids were grouped into strong opioids, weak opioids, and guideline non-recommended opioids. Findings A total of 1, 292, 905 patients with cancers were included. Approximately 50% of patients used analgesics, 50% of which were opioids; the proportions were stable during the study period. The annual cumulative opioid use per patient (defined daily dose, DDD) significantly decreased from 36•41±102•59 (Mean±SD) in 2012 to 32•42±100•99 in 2017 (p < •001). The annual cumulative strong opioid use per patient increased significantly from 17•54±89•23 in 2012 to 19•28±94•97 in 2017 (+9•90%, p < •001). In parallel, the annual cumulative weak opioids use per patient decreased from 18•64±40•81 in 2012 to 13•04±26•79 in 2017 (-30•04%, p < •001). Among extended-release strong opioids, the use of transdermal fentanyl significantly decreased after oxycodone and hydromorphone were introduced (p < •001). Interpretation Increased therapeutic options in strong opioid prescriptions led opioid prescription patterns to evolve towards international cancer pain management guidelines. In addition, increased accessibility to a wider range of different strong opioids may facilitate more efficient opioid titration and rotation - and thus decrease, not increase, the opioid usage. Funding This study was supported by Ministry of Science and Technology, Taiwan (MOST-106-2314-B-002-213 and MOST-108-2314-B-002-072-MY3), Ministry of Health and Welfare, Taiwan (MOHW109-TDU-B-211-114002), National Taiwan University Hospital, Taipei, Taiwan (NTUH-103-002314 and NTUH. 105-S2954), and National Center of Excellence for Clinical Trial & Research, National Taiwan University Hospital, Taipei, Taiwan (NCTRC201208 and NCTRC201603).
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Affiliation(s)
- Tsung-Che Wu
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Oncology, National Taiwan University Biomedical Park Hospital, Hsinchu, Taiwan
| | - Chih-Hung Hsu
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Medical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Wei-Zen Sun
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Anesthesiology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ho-Min Chen
- Health Data Research Center, National Taiwan University, Taipei, Taiwan
| | - Chih-Peng Lin
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Anesthesiology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Yun Shao
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Medical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
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Chen TC, Wang TC, Lin CP, Bonar K, Ashcroft DM, Chan KA, Chen LC. Increasing tramadol utilisation under strict regulatory control of opioid prescribing - A cross-sectional study in Taiwan from 2002 through 2016. J Formos Med Assoc 2020; 120:810-818. [PMID: 33011035 DOI: 10.1016/j.jfma.2020.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/27/2020] [Accepted: 09/15/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND/PURPOSE Prescribing of opioids to patients with non-cancer pain is strictly regulated in Taiwan, but tramadol is not included in the regulation on chronic opioid prescribing. This study aims to identify the utilization trend of prescribing tramadol and other opioid analgesics and investigate the influence of government regulation on opioid prescribing in Taiwan. METHODS This cross-sectional study used the Taiwan National Health Insurance claims database and the cancer registry from 2001 through 2016. The annual number of adult opioid users, opioid utilization (Defined Daily Doses [DDDs]/1000 registrants) and the number of supply days were enumerated for each calendar year and stratified by cancer or non-cancer patients. Descriptive statistics were used to report the trends in utilization for each calendar year. RESULTS The regulation strictly limited persistent use of opioids for patients with non-cancer pain, of which only a small proportion of fentanyl (20%) and morphine (<2%) users were prescribed with an annual number of supply days greater than 28 days. The annual utilization of morphine (6.4-53.5 vs. 1.1 to 9.6 DDD/1000 registrants) and fentanyl (8.3-37.0 vs. 0.16 to 1.8 DDD/1000 registrants) to patients with cancer was consistently higher than patients without cancer. In contrast to morphine and fentanyl, the utilization of tramadol prescribed to patients without cancer increased 92.2-fold (3.7-341.2 DDD/1000 registrants) from 2002 to 2016. CONCLUSION The regulation in Taiwan limited the prescribing of selective opioids for patients with non-cancer pain and the substitution of tramadol for other opioids may have safety implications.
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Affiliation(s)
- Teng-Chou Chen
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester, M13 9PT, United Kingdom.
| | - Ting-Chun Wang
- Health Data Research Center, National Taiwan University, Taipei, Taiwan
| | - Chih-Peng Lin
- Department of Anesthesiology, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kerina Bonar
- Mundipharma Research Limited, Cambridge Science Park, Milton Road, Cambridge, CB4 0AB, United Kingdom
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester, M13 9PT, United Kingdom; NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - K Arnold Chan
- Health Data Research Center, National Taiwan University, Taipei, Taiwan
| | - Li-Chia Chen
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester, M13 9PT, United Kingdom
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Solving the deficit of cancer pain management skills by education programs. Support Care Cancer 2020; 29:1843-1848. [PMID: 32779009 DOI: 10.1007/s00520-020-05651-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Suboptimal cancer pain management is a worldwide problem. We examined whether an educational program on cancer pain management implemented during training could benefit primary care physicians. METHODS We enrolled all the primary care physicians who visited the oncology ward at a medical center for the first time. Educational classes on cancer pain management were conducted. The participants' abilities in cancer pain management were measured in a pretest before the classes and approximately 2 weeks later in the first posttest. The second posttest was conducted on participants who visited the oncology ward again. All 3 tests had the same set of questions and were scored on a scale of 0 to 100. RESULTS In total, 247 participants were enrolled. Less than 10% of them considered their previous education on cancer pain management adequate. The test scores increased significantly from the pretest to the first posttest (mean 65.6 vs. 89.7, p < 0.001). The participants' self-reported cancer pain management abilities, on a scale of 0 to 100, also improved significantly (mean 57.8 vs. 75.5, p < 0.001). The pretest scores were not associated with the participants' self-reported abilities or their perceptions about the adequacy of previous training on cancer pain management. The mean score on the second posttest, conducted 234.5 days after the program, on an average, remained similar to that of the first posttest (p = 0.254). CONCLUSION A specific educational program on cancer pain management provided to primary care physicians improved their pain management skills substantially, with persistent effects.
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Cancer pain management needs and perspectives of patients from Chinese backgrounds: a systematic review of the Chinese and English literature. Palliat Support Care 2018; 16:785-799. [DOI: 10.1017/s1478951517001171] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AbstractObjectiveMore than half of all cancer patients experience unrelieved pain. Culture can significantly affect patients’ cancer pain-related beliefs and behaviors. Little is known about cultural impact on Chinese cancer patients’ pain management. The objective of this review was to describe pain management experiences of cancer patients from Chinese backgrounds and to identify barriers affecting their pain management.MethodA systematic review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they reported pain management experiences of adult cancer patients from Chinese backgrounds. Five databases were searched for peer-reviewed articles published in English or Chinese journals between1990 and 2015. The quality of included studies was assessed using Joanna Briggs Institution's appraisal tools.ResultsOf 3,904 identified records, 23 articles met criteria and provided primary data from 6,110 patients. Suboptimal analgesic use, delays in receiving treatment, reluctance to report pain, and/or poor adherence to prescribed analgesics contributed to the patients’ inadequate pain control. Patient-related barriers included fatalism, desire to be good, low pain control belief, pain endurance beliefs, and negative effect beliefs. Patients and family shared barriers about fear of addiction and concerns on analgesic side effects and disease progression. Health professional–related barriers were poor communication, ineffective management of pain, and analgesic side effects. Healthcare system–related barriers included limited access to analgesics and/or after hour pain services and lack of health insurance.Significance of resultsChinese cancer patients’ misconceptions regarding pain and analgesics may present as the main barriers to optimal pain relief. Findings of this review may inform health interventions to improve cancer pain management outcomes for patients from Chinese backgrounds. Future studies on patients’ nonpharmacology intervention-related experiences are required to inform multidisciplinary and biopsychosocial approaches for culturally appropriate pain management.
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Shao YY, Hsiue EHC, Hsu CH, Yao CA, Chen HM, Lai MS, Cheng AL. National Policies Fostering Hospice Care Increased Hospice Utilization and Reduced the Invasiveness of End-of-Life Care for Cancer Patients. Oncologist 2017; 22:843-849. [PMID: 28408618 DOI: 10.1634/theoncologist.2016-0367] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 12/19/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND In 2011, two national policies aiming to foster hospice services for terminal cancer patients took effect in Taiwan. The single-payer National Health Insurance of Taiwan started to reimburse full hospice services. The national hospital accreditation program, which graded all hospitals, incorporated hospice utilization in its evaluation. We assessed the impact of these national policies. METHODS A cohort of 249,394 patients aged ≥18 years who died of cancer between 2008 and 2013 were identified from the National Death Registry. We retrieved utilization data of medical services and compared the health care utilization in the final month of life before and after the implementation of the new policies. RESULTS After the policy changes, hospice utilization increased from 20.8% to 36.2%. In a multivariate analysis adjusting for patient demographics, cancer features, and hospital characteristics, hospice utilization significantly increased after 2011 (adjusted odds ratio [AOR] 2.35, p < .001), accompanied by a decrease in intensive care unit (ICU) admissions, invasive mechanical ventilation (IMV), and cardiopulmonary resuscitation (CPR; AORs 0.87, 0.75, and 0.80, respectively; all p < .001). The patients who received hospice services were significantly less likely to receive ICU admissions, IMV, and CPR (AORs 0.20, 0.12, and 0.10, respectively; all p < .001). Hospice utilization was associated with an adjusted net savings of U.S. $696.90 (25.2%, p < .001) per patient in the final month of life. CONCLUSION The national policy changes fostering hospice care significantly increased hospice utilization, decreased invasive end-of-life care, and reduced the medical costs of terminal cancer patients. IMPLICATIONS FOR PRACTICE National policies fostering hospice care significantly increased hospice utilization, decreased invasive end-of-life care, and reduced the medical costs of terminal cancer patients.
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Affiliation(s)
- Yu-Yun Shao
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan
- National Taiwan University Cancer Center, Taipei, Taiwan
| | | | - Chih-Hung Hsu
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-An Yao
- Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ho-Min Chen
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Shu Lai
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Taiwan Cancer Registry, Taipei, Taiwan
| | - Ann-Lii Cheng
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- National Taiwan University Cancer Center, Taipei, Taiwan
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Long-term use of opioids in 210 officially registered patients with chronic noncancer pain in Taiwan: A cross-sectional study. J Formos Med Assoc 2017; 116:257-265. [DOI: 10.1016/j.jfma.2016.10.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 10/30/2016] [Accepted: 10/31/2016] [Indexed: 01/20/2023] Open
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Kang KH, Kuo LF, Cheng IC, Chang CS, Tsay WI. Trends in major opioid analgesic consumption in Taiwan, 2002-2014. J Formos Med Assoc 2016; 116:529-535. [PMID: 27717535 DOI: 10.1016/j.jfma.2016.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 09/08/2016] [Accepted: 09/08/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND/PURPOSE According to WHO guideline, the consumption of opioids is an important sign of national progress in cancer pain relief. However, precise data on the consumption of opioid analgesics consumption in Taiwan has not been published. We investigate opioid analgesic consumption in Taiwan between 2002 and 2014 compare the results with those in other countries to see what we could learn about other methods of pain management. To find out the different patterns between Taiwan and other country, improves the quality of pain management. METHODS We extracted from the Controlled Drugs Management Information System (CDMIS) database, the consumption data of morphine, fentanyl, and pethidine, three strong opioids, and of codeine and buprenorphine, two weak ones. Data were presented as defined daily doses for statistical purposes per million inhabitants per day (S-DDD/m/d). The number of inhabitants was extracted from the Taiwan Ministry of Interior Statistics population database. RESULTS During the thirteen studied years, the total consumption of opioids markedly increased in Taiwan. By category, the consumption of morphine, fentanyl and buprenorphine increased, but the use of pethidine and codeine decreased. Compared with the selected regions and countries, the use of opioid in Taiwan progressed in Asia, but it was still lower than in Western countries. CONCLUSION Opioid analgesics are probable addictive; however, they can improve a patients' quality of life if properly used. The Taiwan FDA continuously introduces new opioid analgesics and educates physicians on how to use them correctly. These measures will improve the quality of pain management in Taiwan.
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Affiliation(s)
- Kai-Hsiang Kang
- Division of Controlled Drugs, Food and Drug Administration, Ministry of Health and Welfare, Taipei, Taiwan; Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli County, Taiwan
| | - Li-Fen Kuo
- Division of Controlled Drugs, Food and Drug Administration, Ministry of Health and Welfare, Taipei, Taiwan
| | - I-Chen Cheng
- Division of Controlled Drugs, Food and Drug Administration, Ministry of Health and Welfare, Taipei, Taiwan
| | - Chih-Shiuh Chang
- Division of Controlled Drugs, Food and Drug Administration, Ministry of Health and Welfare, Taipei, Taiwan
| | - Wen-Ing Tsay
- Division of Controlled Drugs, Food and Drug Administration, Ministry of Health and Welfare, Taipei, Taiwan.
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