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系統識別號 U0007-1408201118502600
論文名稱(中文) 東部某區域教學醫院---藥事服務對使用鴉片類止痛劑門診病人之疼痛改善評估
論文名稱(英文) The Study of a Pharmacist Intervention for Pain Management and Care of Ambulatory Cancer Patients Using Opioid Analgesics A Prospective Pilot Study in a Teaching Hospital of Eastern Taiwan
校院名稱 臺北醫學大學
系所名稱(中) 藥學研究所
系所名稱(英) Graduate Institute of Pharmacy
學年度 99
學期 2
出版年 100
研究生(中文) 鄭庭棻
研究生(英文) Ting-Fen Cheng
學號 M301098027
學位類別 碩士
語文別 中文
口試日期 2011-06-24
論文頁數 94頁
口試委員 指導教授-許秀蘊
共同指導教授-陳盛煊
委員-闕壯卿
委員-吳姿樺
委員-陳香吟
中文關鍵字 癌症疼痛  服藥遵從性  鴉片類止痛劑  藥師  藥事照護 
英文關鍵字 cancer pain  medication adherence  opioid analgesics  pharmacist  pharmacy care 
學科別分類
中文摘要 背景及目的:
疼痛獲得緩解是每一個病人的權利。ㄧ般而言使用鴉片類止痛劑之癌症病人缺乏止痛療效和經歷嚴重疼痛的原因,可能是缺乏服藥遵從性與害怕鴉片類藥品成癮的副作用。本篇計畫主要探討於東部某區域教學醫院門診進行藥師介入藥事服務於使用鴉片類止痛劑之癌症病人前後,評估病人遵從行為的改變及療效評估。
方法:
本試驗為ㄧ前瞻性在門診癌症病人進行同一病人藥師介入前及介入後,使用台灣版服藥遵從性敘述量表 (Taiwanese Version of Self-reporting Measure of Medication Adherence) 及詢問病人平時止痛藥怎麼吃,來評估癌症病人服用鴉片類止痛藥的服藥遵從性,並佐以疼痛評估工具評估病人止痛藥之療效,以研究藥師介入可能對門診癌症疼痛病人服藥遵從性、止痛療效之改善成效。
結果:
本研究以18個完成受訪者的資料進行分析經由第一次接受問卷的遵從性分數總分為16分與最後一次遵從性問卷比較,對比結果顯示經由藥師的說明用藥指導後,有意義地增加病人服用止痛藥的服藥遵從性由10.39±4.53分增加為15.33±1.94分 (n = 18, p <0.05) ;藉由面對面實地詢問病人止痛藥的服法與醫師止痛藥處方用法之比對,由前測7個人增加至後測14個人之處方遵循。疼痛分數為次要結果指標,病人最疼痛分數由4.44±2.33分降為2.78±1.96分 (n = 18, p <0.05) 。
討論與結論:
藥師藉由台灣版服藥遵從性敘述量表介入藥事服務,了解病人止痛藥的用藥觀念再加上詢問病人如何服用藥品的實際行為,透過詢問病人疼痛發作的時間與服藥後疼痛指數,說明為何需要服用止痛藥之用意,因而增加病人的服藥遵從性,減低病人的疼痛指數。藥師主動提供癌症病人疼痛用藥處理與照護的模式應列在專業藥師日常工作職責之中。在未來,藥師應走出調劑台與癌症病人和其他醫療人員互動,提供以病人為中心的最佳疼痛處理和藥事照護。
英文摘要 Background and Research Aims:
Pain relief is every patient’s right. Generally speaking cancer patients on opioid analgesics may lack of analgesic effect and suffer from severe pain due to problems in (i) medication adherence (ii) fear of addictive side effects of opioid analgesics. Pharmacist intervention for cancer patients may reduce pain scores after taking the analgesics through the rational use of pain medication to achieve optimal pain control, reduce side effects and thus improve patient quality of life.
Method:
The present study was designed as a prospective pilot study. The pharmacist intervention involved (i) the proper use of opioid analgesics for cancer patients (ii) the evaluation of patient adherence and efficacy of pain control before and after pharmacist intervention. (iii) Patient face to face interview and the Taiwan version of medication adherence scale (Taiwanese Version of Self-reporting Measure of Medication Adherence) were used to assess the medication adherence and (iv) the faces scale of pain assessment tool was used to assess/ask each patient about the efficacy of painkillers.
Results:
(i) Four items 16 points medication adherence score before pharmacist intervention was 10.39±4.53 (n = 18) which increased significantly to 15.33±1.94 (p <0.05).
(ii) Face to face medication consultation provide by a pharmacist increased full adherence patient’s number from 7 to 14.
(iii) The pain score before pharmacist intervention was 4.44±2.33 (n = 18) which decreased significantly to 2.78±1.96 (p <0.05).
Discussion and Conclusion:
The present results indicate that the pharmacist intervention can significantly increase patient’s adherence to the proper use of opioid analgesics in outpatient department of radiation oncology clinic. The outcome of pharmacy care can significantly decrease patient’s pain score. This kind of pharmacist-provide pain management and care to cancer patients should be implemented daily as one of responsibilities of a professional pharmacist. In the future, pharmacist should walk out dispensing table and start to interact with cancer patients and other healthcare professional staffs to provide the best patient-centered pain management and pharmaceutical care.
論文目次 致謝
中文摘要 I
Abstract III
目錄 V
表目錄 IX
圖目錄 X
縮寫簡表 XI
第一章 緒論 1
第二章 文獻查證 3
2.1疼痛簡介 3
2.1.1疼痛的定義 3
2.1.2癌症疼痛的種類與原因 3
2.1.3癌症疼痛的盛行率 7
2.2疼痛評估與工具 8
2.2.1疼痛評估 8
2.2.2疼痛評估工具 9
2.3疼痛的藥物治療 13
2.3.1控制性藥物 14
2.3.2 緩解性藥物 18
2.3.3 成癮性 19
2.3.4 疼痛的階梯式治療原則 19
2.4 服藥順從性 22
2.5藥師介入門診癌症病人疼痛之研究 29
第三章 研究目的 31
第四章 研究方法 32
4.1研究設計 32
4.2研究場所及對象 33
4.2.1研究場所 33
4.2.2納入對象 33
4.2.3排除對象 33
4.3研究工具 35
4.3.1病人的服藥遵從性 35
4.3.2病人的疼痛強度評估工具 36
4.4研究假說 36
4.4.1服藥順從性部分 36
4.4.2病人的疼痛指數部分 36
4.4.3需要時止痛藥服藥頻率的部分 37
4.4.4止痛劑種類的部分 37
4.4.5支持性用藥 (Supportive medication) 的部分 37
4.4.6就診記錄與類別 38
4.4.7醫師處方依循WHO止痛藥使用around-the-clock原則 38
4.4.8藥師衛教病人之問題類型 38
4.5研究資料收集 39
4.5.1研究期間 39
4.5.2研究材料 39
4.5.3分析項目 40
4.5.4病人個案追蹤 40
4.6研究分析方法 41
4.6.1描述性統計 41
4.6.2魏克遜符號等級檢定Wilcoxon Signed Ranks Test 41
第五章 研究結果 42
5.1 病人特性分析 42
5.1.1 病人基本資料特性 42
5.1.2 疾病特性 43
5.2 臨床結果 47
5.2.1 服藥遵從性的改變 47
5.2.2 疼痛分數的改變 55
5.2.3需要時止痛藥服藥頻率的改變 55
5.2.4止痛劑種類的改變 59
5.2.5支持性用藥 (Supportive medication) 的改變 61
5.2.6就診次數與類別的改變 62
5.2.7醫師處方依循WHO止痛藥使用around-the-clock原則 62
5.2.8 藥師衛教病人之問題類型 63
5.2.9病人個案報告 65
第六章 討論 74
6.1研究對象與工具 74
6.2服藥遵從性與疼痛控制之相關性 75
6.3 疼痛控制與鴉片類止痛劑之相關討論 76
6.3.1 鴉片類止痛劑之療效相關性討論 76
6.3.2 鴉片類止痛劑做為需要時緩解性用藥相關性討論 78
6.3.3鴉片類止痛劑與副作用之支持性用藥相關性討論 79
6.3.4常規領藥次數與就診次數的改變 80
6.3.5藥師在癌症疼痛處理的部分 80
6.3.6衛教方式 81
6.4研究限制 82
第七章 結論與未來展望 83
參考文獻 85
附錄一 衛教單張 91
附錄二 病人基本資料 93
附錄三 台灣版服藥遵從性敘述量表、疼痛指數與衛教項目 94
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