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A Retrospective Analysis of Morphine Consumption for Pain Management at Srinagarind Hospital, Thailand
การวิเคราะห์ปริมาณการใช้ยามอร์ฟีนในการระงับปวดในโรงพยาบาลศรีนครินทร์
Pranee Suecharoen (ปราณี สื่อเจริญ) 1, Somboon Thienthong (สมบูรณ์ เทียนทอง) 2, Suthannee Simajareuk (สุธันนี สิมะจารึก) 3
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หลักการและวัตถุประสงค์: อัตราการใช้ยามอร์ฟีนต่อประชากรเป็นดัชนีชีชี้วัดอย่างหนึ่งในการเทียบเคียงคุณภาพของการดูแลผู้ป่วยที่มีอาการปวดของแต่ละประเทศ แต่ในระดับโรงพยาบาลซึ่งเป็นหน่วยงานย่อย ไม่สามารถใช้ดัชนีชี้วัดต่อประชากรได้ ดัชนีชี้วัดคุณภาพการระงับปวดในระดับโรงพยาบาลนอกจากจะใช้ระดับความปวดของผู้ป่วยแล้ว การใช้ปริมาณมอร์ฟีนต่อปีหรือต่อผู้ป่วยอาจเป็นดัชนีคุณภาพได้เช่นกัน แต่ยังไม่เคยมีรายงานในโรงพยาบาลศรีนครินทร์มาก่อน วัตถุประสงค์ของการศึกษานี้ต้องการทราบปริมาณการใช้มอร์ฟีนต่อปีและต่อผู้ป่วยของโรงพยาบาลศรีนครินทร์
วิธีการศึกษา: เป็นการศึกษาเชิงพรรณนา โดยรวบรวมข้อมูลย้อนหลังในฐานข้อมูลของฝ่ายเภสัชกรรมของโรงพยาบาล และฐานข้อมูลของภาควิชาวิสัญญีวิทยา ระหว่าง พ.ศ. 2549 2556 ข้อมูลสำคัญได้แก่ ยาระงับปวดในกลุ่ม opioids สี่ชนิดคือ morphine, pethidine, fentanyl และ methadone รวมทั้งจำนวนผู้ป่วยต่อปีทั้งผู้ป่วยนอกและผู้ป่วยในที่ได้รับยาดังกล่าว ปริมาณยาที่ได้รับทั้งหมดจะถูกแปลงเป็นมอร์ฟีนโดยเทียบเป็นหน่วยเดียวกันคือ จำนวนกรัมของมอร์ฟีนชนิดรับประทาน
ผลการศึกษา: พบปริมาณการใช้มอร์ฟีนในแต่ละปี เป็นเวลา 8 ปี เท่ากับ14111.17, 7757.51, 8825.78, 13339.33, 11530.29, 14859.96, 11151.08, 16112 กรัม ตามลำดับ จำนวนครั้งที่ผู้ป่วยได้รับยาระงับปวดมอร์ฟีนต่อปี เท่ากับ 628453, 692628, 714763, 743732, 760150, 777507, 823571, 874196 ครั้งต่อปีตามลำดับ โดยสัดส่วนการได้รับมอร์ฟีนของผู้ป่วยต่อครั้งเท่ากับ 0.022, 0.011, 0.012, 0.017, 0.015, 0.019, 0.013, 0.018 กรัม ตามลำดับ
สรุป : ในช่วงแปดปีที่ผ่านมา ปริมาณการใช้มอร์ฟีนต่อปีของโรงพยาบาลและอัตราการได้รับยามอร์ฟีนของผู้ป่วยต่อครั้งไม่มีการเพิ่มขึ้น ดังนั้น การติดตามคุณภาพการดูแลผู้ป่วยที่มีอาการปวดนอกจากจะใช้ระดับความปวดของผู้ป่วยแล้ว ควรใช้อัตราการได้รับยามอร์ฟีนต่อครั้ง และปริมาณการใช้มอร์ฟีนต่อปีของโรงพยาบาล เป็นตัวชี้วัดร่วมด้วย
Background and Objectives: morphine consumption per capita is an indirect indicator commonly used for national evaluation of pain treatment quality. For small scale level like a hospital, direct pain assessment of patient is a practical indicator. However, the amount of yearly morphine used or a trend of morphine consumption per patient or per visit may be useful indicator for monitoring the quality of pain treatment but it is usually neglected. Objective of this study aimed to present the yearly consumption of morphine and morphine consumption per visit at Srinagarind Hospital.
Methods: Interesting data were retrospectively collected from pharmacy unit and department of Anesthesiology, Four types of opioids (morphine, pethidine, fentanyl and methadone) used during the period of 2006-2013 were analyzed and converted to be an oral morphine in gram equivalence. Numbers of patients received opioids per year during the study period were also recorded.
Results: The yearly morphine equivalence consumption during 2006-2013 were 14111.17, 7757.51, 8825.78, 13339.33, 11530.29, 14859.96, 11151.08, 16112 gram, respectively. The total number of patients received opioids were 628453, 692628, 714763, 743732, 760150, 777507, 823571, 874196 visit per year, respectively. The proportions of oral morphine per visit were 0.022, 0.011, 0.012, 0.017, 0.015, 0.019, 0.013, 0.018 gram, respectively.
Conclusion: The yearly morphine supply and the proportion of morphine consumption per visit during 2006-2013 were not increased. Therefore, morphine consumption per year or per visit in combined with pain scores may be useful indicators for monitoring the quality of pain treatment for a hospital level.
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Introduction
Opioids under-used has been concluded as a major cause of inadequate treatment either for acute or cancer pain1,2. In order to improve the quality of pain treatment, both care providers and pain patients expect to have more opioids supplied by the hospital or the government.
The Pain & Policy Studies Group (PPSG) University of Wisconsin-Madison, the research group that interesting in narcotics monitoring, regularly reports opioids consumption among countries includes Thailand3. In the PPSG website, data from Thailand were available from 1980 up to 2012 and only four opioids (morphine, methadone, pethidine and fentanyl) were reported. The report shows that the amounts of morphine and fentanyl consumption are rising whereas methadone and pethidine are decreasing. However, the total morphine equivalence (milligram per capita or per person) of Thailand in the year 2011 was 3.2996. When compares with the well-developed countries such as The United States of America, the morphine equivalence per capita in the same year is approximately 750 mg/capita which is about 250 times more than morphine consumption of Thailand. When compares to ASEAN countries like Viet Nam or Singapore, both countries have approximately two-fold (7.35-7.95 mg / capita) of morphine consumption more than Thailand3. However, morphine consumption in Thailand was almost double increased from 49 kg in 2006 to 80 kg in 2010 as reported by International Narcotic Control Board (INCB)4.
Pain scores of patients are direct indicator for assessment of the quality of pain treatment. Pain scores for adult cancer patients admitted to our hospital, a university hospital, had been surveyed in 20045. The overall prevalence of cancer pain within the first 24 hours of admission was 41.5 percent. In addition, the quality of post-operative pain treatment reported by the acute pain services, department of Anesthesiology in between 2004-2006 found that patients who experienced moderate degree of pain at rest was about 24-28 percent and severe degree of pain was 7-10 percent6. These evidences confirm that either cancer pain patients or post-operative pain patients are remaining under-treated in our setting. However, morphine consumption or availability in our hospital has never been reported. Therefore, the objective of this study aimed to analyze the yearly consumption of morphine and morphine consumption per visit in our hospital.
Materials and Methods
The study was approved by the Ethic Committee of Khon Kaen University [HE 571056]. We retrospectively collected computer based data from department of anesthesiology and pharmacy unit of the hospital during the period of January 2006 to December 2013. Interesting data were number of patients received opioids and total amount of opioids (morphine, methadone, fentanyl and pethidine) used in each year. Four types of opioids were then converted to be the same unit, weight in grams, as oral morphine equivalence7.
Results
The total number of visited-patients received opioids treatment in each year were 628453, 692628, 714763, 743732, 760150, 777507, 823571 and 874196 visits, respectively (Table 1, Fig 1). When divided patients into two groups, cancer group and post-operative group, according to types of the pain treatment (Table 1). Patients in the cancer group were increased from 14,926 in 2006 to 24,099 in 2013. Similarly, the number of post-operative patients in each year also increased, from 12,781 in 2006 to 18,485 in 2013.
The yearly morphine equivalence consumption was 14111.17, 7757.51, 8825.78, 13339.33, 11530.29, 14859.96, 11151.08, and 16112.00 grams, respectively (Fig 2). The proportion of morphine consumption per visit was quit different in each year 22, 11, 12, 17, 15, 19, 13 and 18 mg, respectively (Fig 3). Overall, the average of yearly morphine consumption was 12210.89 grams, and the average proportion of morphine consumption per visit was 15.875 milligrams.
Table 1 Number of patients who visit during 2006-2013
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Year |
Cancer patients |
Post-operative
patients |
Total |
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2006 |
14,926 |
12,781 |
27,707 |
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2007 |
15,921 |
13,872 |
29,793 |
|
2008 |
17,127 |
14,388 |
31,515 |
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2009 |
17,560 |
14,449 |
32,009 |
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2010 |
19,308 |
14,645 |
33,953 |
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2011 |
20,740 |
16,425 |
37,165 |
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2012 |
23,789 |
18,082 |
41,871 |
|
2013 |
24,099 |
18,485 |
42,584 |
Figure 1 The total number of patients received opioids treatment per year.
Figure 2 Four opioids and morphine equivalence consumption (gram) per year
Figure 3 The proportion of oral morphine (gram) per visit
Discussion
This study demonstrated that the numbers of pain patients are increasing whereas morphine supplied is behind their need. The average proportion of morphine consumption per visit in this study was about 15 milligram and the number is not increased during 8 years of the study period. This is correlated well with the report of INCB that only 10% of global opioid was supplied to the developing countries which represent about 80% of the worlds population4. Similar result was reported by PPSG University of Wisconsin-Madison3 in 2011 that the number of morphine consumption per capita of Thailand was about 3.3 mg. It is contrast to the number of visited patients in this study either post-operative patients or cancer patients which is rapidly increased year by year, especially, new cancer cases are expected to reach approximately 125,000 by 2008 compared with 81,000 in 19998. These data makes the authors believe that the quality of pain treatment in our setting either cancer pain or post-operative pain will not better or improve when compare to the previous surveyed at the beginning of this study by Vatanasapt5 and Wongswadiwat6.
In the PPSG report, Thailand has only four types of opioids; morphine, pethidine, fentanyl and methadone but practically clinicians in Thailand as well as clinicians in our hospital also use tramadol and codeine for pain control. If, the authors decided to include tramadol and codeine into this study the amount of morphine equivalent per year will be increased. However, the amount of morphine consumption per year when compared to other countries in ASEAN is still low. Morphine consumption in Viet Nam and Singapore were double that in Thailand as mentioned earlier. In addition, morphine consumption per capita in Malaysia in 2011 was 36.7 mg then rapidly increased to 52.8 mg and 64.4 mg in 2012 and 2013, respectively3.
Limited items of opioids for the treatment of choices in pain patients might be a result in poor quality of pain control in Thailand. In the United State of America and Singapore, the PPSG reports 6 types of opioids used; morphine, pethidine, fentanyl, methadone, oxycodone and hydromophone whereas in Thailand has only 4 items; morphine, pethidine, fentanyl, methadone.
The amount of pethidine and methadone are not increased during this study period. For pethidine, it is correspond with the global consumption of pethidine that declined from 15 tons in 1991 to less than 10 tons in 20104. Pethidine expenditure in Taiwan from 2002 to 2007 was decreased about 30% as well9. A decrease in consumption of pethidine is because of the recommendations by regulatory authorities and health experts who are concerned about its toxicity and potential for abuse. For methadone, the use of methadone in Thailand is strictly reserved for the treatment of opioid addition. In our hospital, a number of opioid addition patients are very small. We sometimes used methadone for treatment of chronic pain patients but it is not a first choice analgesic that makes an overall methadone consumption quit low.
The opioids availability in Thailand is mainly control by the government policies for balancing between medical uses and prevents nonmedical use of such drugs. By increasing types of opioids and amount of each item, these will directly increased morphine consumption per capita. However, to revise or making the policy changes at this level is not easy and even the policies had been changed it does not ensure adequate provision of opioid drugs for medical and scientific purposes10.
The policy of each hospital also affects the opioids availability, mostly depends on their own budget and priority of their problems facing. Since Thailand is a low income country, budget constraint is the most important problem of many hospitals. In this study the authors did not find out reasons that influenced the amount of opioids purchased per year. Shortage of opioids, some time, at the national drug control division (FDA) warehouse also affects the opioids availability of the hospital as well.
There are some limitations of this study, for example, opioids expenditure data that we did not well plan to collect them at the beginning. The amount of each drug reported should have detail of each preparation as well, for example, fentanyl has two types of preparation, transdermal form and injection form. The details of these data are not presented because we aim to look at the trend of overall consumption. Finally, the number of patients in this study is selected only for pain patients not the overall visited patients of the hospital which makes the number of morphine used per visit much more than usual.
Conclusion
The proportion of morphine consumption per visit during 2006-2013 was not increased. Therefore, morphine consumption per visit together with pain scores assessment may be useful indicators for monitoring the quality of pain treatment in a hospital level.
Acknowledgment
The authors would like to thank head department of Anesthesiology and Head of Pharmacy unit, Srinagarind Hospital that allow us using the data based for this report.
References
1. Acute Pain Management Guideline Panel. Acute pain management: operative or medical procedures and trauma. In: Clinical Practice Guideline. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services; AHCPR publication 92-0032, 1992.
2. Management of Cancer Pain Guideline Panel. Management of cancer pain. In: Clinical Practice Guideline. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services; AHCPR publication 94-0529, 1994.
3. Opioids consumption data. The Pain & Policy Studies Group, University of Wisconsin-Madison. Available from http://www.painpolicy.wisc.edu/countryprofiles. [Access on 10/08/2014].
4. Narcotic drugs. International narcotic control board. Available from https://www.incb.org/incb/en/narcoticdrugs/Technical_Reports/2011/narcotic-drugs-technical-report_2011.html. [Access on 12/09/2015].
5. Vatanasapt P, Lertsinudom S, Sookprasert A, Phunmanee A, Pratheepawanit N, Wattanaudomrot S, et al. Prevalence and management of cancer pain in Srinagarind Hospital, Khon Kaen, Thailand. J Med Assoc Thai 2008; 12: 1873-7.
6. Wongswadiwat M, Sriraj W, Yimyaem PR, Simajareuk S, Thienthong S. A benchmark of 3 years experiences in acute pain service at Srinagarind hospital. Acute Pain 2008; 10: 1-8.
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8. Sriplung H, Wiangnon S, Sontipong S, Sumitsawan Y, Martin N. Cancer incidence trends in Thailand, 1989-2000. Asian Pac J Cancer Prev 2006; 7: 239-44.
9. Pan HH, Ho ST, Lu CC, Wang JO, Lin TC, Wang KY. Trends in the consumption of opioid analgesics in Taiwan from 2002 to 2007: a population-based study. J Pain Symptom Manage 2013; 45: 272-8.
10. Husain SA, Brown MS, Maurer MA. Do national drug control laws ensure the availability of opioids for medical and scientific purposes? Bull World Health Organ 2014; 92: 10816.
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