醫師使用藥物處理癌症疼痛的知識：特別論及模擬病患處方之開立

Physicians' Knowledge about Pharmacological Management of Cancer Pain-- with Special Reference on Their Prescribing Responses to Simulated Patients with Cancer Pain

背景：在臺灣，癌症疼痛的控制情形並不理想，過去的研究顯示醫師的用藥知識不足是影響癌症疼痛控制的重要因素。本研究之目的為探討南臺灣某醫學中心的醫師對於癌症疼痛用藥知識不足的情形，及其對醫師給模擬病人開藥的影響。方法：使用自行設計的癌症疼痛問卷，以無記名方式調查某醫學中心的司照顧癌症病人責任的234名醫師，共完成111名（47.3%）醫師問卷調查。結果：大部分醫師對於癌症疼痛用藥知識（PMCP）有不足的情形（平均分數3.34 ± 0.49，分數全距1～5分）；其中包含癌痛用藥原則（平均分數3.38 ± 0.67）與開藥實務的知識（平均分數3.32 ± 0.46）。嚴重的知識缺失在用藥原則方面為止痛藥途徑與時間的喜好；在開藥實務方面為配西町、吩坦呢貼片，相同止痛藥效力的劑量轉換與不同疼痛種類的止痛用藥。而分析醫師癌症疼痛用藥知識對其模擬開藥的影響，發現醫師給肝癌病人開立正確鴉片類止痛藥的處方與其“開藥實務知識”有關，而與“用藥原則”的知識無關。而醫師癌症疼痛用藥知識之不足與以下臨床背景有關：（1）非疼痛相關之科別，如內科或外科，（2）醫學院畢業未滿五年或超過十年者 ，（3）先前六個月照顧癌症疼痛病人人數較少者，（4）醫師本身曾經有過特別的疼痛經驗。結論：該醫學中心的醫師普遍有癌症疼痛用藥知識不足的情形，而其中開藥實務知識的不足會影響他們給模擬病人開鴉片類的止痛藥。對於癌症疼痛的繼續教育，應包含「癌症疼痛用藥原則」與「開藥實務知識」兩方面，並且需加強上述臨床背景的醫師教育，以改正其錯誤觀念與強化其用藥知識。

Background: Cancer pain control is unsatisfactory in Taiwan. Insufficient knowledge about cancer pain on the part of physicians is an important factor responsible for ineffective cancer pain relief. Therefore, this study was to explore the knowledge deficits of physicians on the specific aspects of pharmacological management of cancer pain (PMCP) and their influences on the prescriptions to simulated patients in a southern medical center in Taiwan. Methods: A set of self-designed questions was delivered to 234 licensed physicians with the responsibility to care for cancer patients and 111 (47.4%) questionnaires were completed and returned anonymously. Results: Most of the physicians showed inadequate knowledge of the pharmacological management of cancer pain (3.34 ± 0.49; range 1~5), which included the principle subscale (3.38 ± 0.67) and the practice subscale (3.32 ± 0.46). Crucial knowledge deficits of principle were identified in the preferential analgesic route and schedule. The severe practice knowledge deficits were on the meperidine, transdermal fentanyl, equianalgesic dose-conversion as well as analgesics for different pain types. Furthermore, physicians' knowledge deficits in the practice subscale, but not the principle subscale, correlated with their correct prescription of opioids to the simulated hepatoma cases. The correlates of physicians' PMCP knowledge deficits were: clinical specialty of medicine or surgery, less than 5 years or more than 10 years from medical school graduation, with limited volume of cancer pain patients being cared, and with personal unusual pain. Conclusions: The PMCP knowledge deficits were prevalent in physicians and thus influenced their prescription of opioids for the simulated cases. An active continuing education program on both the international guidelines and the essential practice skills should be implemented and intensified specifically upon subgroup physicians, to correct their misconceptions and consolidate their PMCP knowledge.