Take off the colored glasses to let cancer patients get better treatment

On April 8, the "Opioid Drug Management and Use" seminar sponsored by "Physician Daily" was held in Beijing.
More than twenty experts and scholars from the four major domestic anesthesia-related professional fields, representatives of member units of the Anesthetic Association and Xinhua News Agency, Media representatives from China Daily and China Net discussed the standardized management, correct use of opioids, and the satisfaction of patients' needs for pain relief.

On April 15, the "Physician Daily" published a report under the title of "Balancing Patient Needs for Pain Relief and Compliance Management", pointing out the lack of clinical use of opioids in my country and the unreasonable attitudes towards opioids from all walks of life.
Platform to spread.

Xinhua News Agency published a report titled "Don't bear the pain, say "no" to cancer pain", and commented: "Physician Daily" held a seminar on the management and use of opioids for the third time, meeting the needs of patients for pain relief.
The useful discussion was conducted on the use of legal norms, which was enthusiastic and not irrational.

In addition, the reporter of "Physician Daily" also combined expert opinions, once again consulted a number of medical and legal experts on the two cases displayed in the seminar, distinguished right from wrong from a clinical perspective, commented on the case from the legal level, and discussed the standardized management of opioids.
And use.

"Doctors who don't prescribe narcotic drugs are still doctors.

But cancer patients who can't get narcotic drugs can only endure pain.

" said Nie Xue, a lawyer at Beijing Huawei Law Firm, who used narcotic drugs to relieve pain.
The act of confuse with the crimes of smuggling, trafficking, transportation, and manufacturing of drugs will damage the right of many cancer patients to receive appropriate analgesia.

"Combined with legal provisions, academic views and the current situation of the two cases, there are still missing elements for the identification of Dr.
Lin suspected of drug trafficking and Dr.
Huang suspected of drug crimes.

" Lawyer Liu from a law firm said, according to criminal proceedings, "excluded.
" As the standard of proof for all reasonable doubts, it is recommended that the judicial organs uphold the principle of modest restraint in the criminal law for a comprehensive investigation and prudent handling. "Physician Daily" will continue to pay attention to the two cases.

★Discussion guest★Special guest: Liu Duanqi, former deputy secretary-general of the Chinese Anti-Cancer Association, Wu Xiaoming, Chief Physician, Department of Oncology, Army General Hospital, Liu Bo, Chief Physician, General Department, Cancer Hospital, Chinese Academy of Medical Sciences, Chen Fan, Director, Department of Oncology, Shandong Cancer Hospital, Peking University Cancer Hospital, Chinese and Western Medicine Department of Integrative Medicine and Geriatric Oncology Deputy Chief Physician Song Ruliang Director of the Guangdong Research Center for the Rule of Law Xu Zhihui Xu Zhihui, Deputy Chairman of the Medical Law Professional Committee of Wuxi Medical Association, Nie Xue, Beijing Huawei Law Firm Lawyers Liu Law Firm Host: Zhang Yanping "Physician News" The executive vice president and executive editor-in-chief of the agency Case 1 Drug traffickers were sentenced to 7 years in the first trial for arranging anesthetic drug tube beds.
According to the Beijing News, in April 2018, Yang Mou, a postoperative patient with advanced esophageal cancer manipulated by drug traffickers Qing went to the General Surgery Department of a hospital in Changzhou for treatment.

After admission, Yang Mouqing kept crying out of pain in the ward, and Wang Mou, the director of the department at the time, prescribed dihydroetorphine hydrochloride sublingual tablets for analgesic treatment.
The resident Lin Mouqing tube bed.

In September of the same year, Liu Mouju, a patient manipulated by drug traffickers, came to the hospital and asked the doctor to prescribe dihydroetorphine hydrochloride sublingual tablets for analgesia in the same way.

However, Yang Mouqing and Liu Mouju’s actual hospital stay was very short.
During their absence from the hospital, the drugs were taken on behalf of Wei Mouqing, who pretended to be Yang Mouqing’s “little daughter”, for most of the time.

Dihydroetorphine hydrochloride sublingual tablets, which were originally only used in the hospital, were continuously prescribed.

During the "hospitalization" of the two, Lin prescribed more than 4,000 dihydroetorphine hydrochloride sublingual tablets, of which only 8 were taken by Yang.

11 months later, on March 3, 2019, Dr.
Lin was arrested by Changzhou police on suspicion of drug trafficking.

Approved by the People’s Procuratorate of Taiqian County, Henan Province, he was arrested by the Public Security Bureau of Taiqian County on April 4.

On August 19, 2020, the drug trafficking case of Lin, Yang, Liu, and Wei opened at the Taiqian County People’s Court.
On September 23, the court made a criminal ruling (2019) Yu 0927 Xing Chu No.
273 In the first instance, Lin, Yang, Liu and Wei were found guilty of drug trafficking, and Lin was sentenced to 7 years in prison. Lin said that he did not know that Yang Mouqing, Liu Mouju and others were drug traffickers, and did not obtain any financial benefits in the whole process, and he did not have the right to prescribe dihydroetorphine hydrochloride sublingual tablets.
Prescriptions must be signed by a higher-level doctor before taking the medicine, and Yang Mouqing and Liu Mouju’s treatment plans were not developed and implemented by themselves.

I just did what I should do as a doctor, and I was innocent.

After the incident, Section Director Wang was also suspended.

On December 1, 2020, the Intermediate People's Court of Puyang City, Henan Province opened a court session to hear the case.
After the trial, the court found that some of the facts found in the original trial were unclear and the evidence was insufficient.

In accordance with the provisions of Article 236, Paragraph 1, Item (3) of the Criminal Procedure Law of the People’s Republic of China, the ruling is as follows: 1.
The People’s Court of Taiqian County, Henan Province (2019) Yu 0927 Xing Chu No.
273 criminal Judgment; 2.
Send it back to the People’s Court of Taiqian County, Henan Province for a new trial.

Case 2 Spot check found that the prescription of anesthetic drugs was large.
2 doctors and 10 patients’ family members were investigated.
During 2004-2005, a pain doctor Huang in a hospital brought subcutaneous analgesic pump analgesia technology back to the local area during the period of training to solve the late stage.
Home pain relief for cancer patients.

He believes that subcutaneous analgesic pump analgesia is very suitable for local customs and habits, and it solves the problem that patients cannot effectively relieve pain at home before they die.

Dr.
Huang said that due to the problem of opioid tolerance for cancer pain relief, patients with advanced cancer pain use a large amount of anesthetics.

According to the WHO's "three-step analgesic principle", according to the patient's condition, I will provide sufficient anesthetics as needed to relieve the pain symptoms of advanced cancer patients and improve their quality of life.

At the same time, he also said that the morphine injection needed for analgesia was sucked on the spot with an analgesic pump.
Oral analgesics also had a batch number.
In the past ten years, there has not been a drug loss incident in the department.

On February 4, 2021, the local police found during a random inspection of "precursor chemical companies" that the prescription of anesthetic drugs in Dr.
Huang's department was too large, and the case was filed for investigation.
Two doctors and ten patients in the pain department The family members took them to the Public Security Bureau for questioning. According to the medical records and prescription notes provided by Dr.
Huang, Xiao Moumou, a patient with bone metastases from advanced lung cancer (stage IV), has been using oxycodone hydrochloride sustained-release tablets to control cancer pain.

From January 18th to February 3rd, 2017, oxycodone hydrochloride sustained-release tablets 320 mg daily, the pain could not be relieved, the NRS score was 8-9, which increased by 50%, and the dose was increased to 480 mg.
The pain was still not controlled.
Well, the NRS score still reaches 7-8 points, with explosive pain 4 to 5 times a day.

Taking into account the poor analgesic effect, Dr.
Huang administered morphine subcutaneous analgesic pump analgesia on February 10.
According to the equivalent conversion of the drug, oral oxycodone hydrochloride relief tablets were converted into morphine hydrochloride injections and re-titrated.

On the same day, 320 mg of morphine hydrochloride injection was used, and the patient's pain was completely relieved.
The NRS score was 1 point and no explosive pain occurred.
Subcutaneous morphine analgesic pump was continued to be administered to the patient for analgesia, and the dose was reduced to 220 mg daily.

After days of investigation, the police found no loss of anesthetic drugs.

But as of press date, the police are still investigating the hospital and copying a large number of prescriptions for narcotic drugs.

Dr.
Huang said that he has helped many patients with cancer pain treatment for more than ten years, but this encounter also left him with a lot of "shadow" in his heart.

He said that it's okay for me to feel wronged personally, just as I make a little contribution to the industry.

I hope this matter can be handled properly, so as to prevent the professionals from encountering the same difficulties and suffering the same injuries in subsequent work.

Discuss that drug traffickers arbitrarily purchase narcotic drugs.
The "pot" cannot be left to the doctor Zhang Yanping: How do you view the attitudes of the public security and judicial authorities on narcotic drugs? In case 1, is Dr.
Lin guilty of drug trafficking? Chen Fan: As a clinician, I feel sad to see these two cases.

Affected by the special historical background of the two Opium Wars, all walks of life in our society did have some misunderstandings about the use and management of narcotic drugs—some functional departments’ misunderstandings about narcotic drug management led to the State Council’s decision in 1987.
The "Administrative Measures for Narcotic Drugs" promulgated and implemented on November 28 have yet to benefit all patients. These two cases also show that we are accustomed to "excessive control" of opioids, and even confuse the professional behavior of doctors with the crime of "drug trafficking", which is not conducive to social stability and development.

In case 1, the director of the department considered the intercostal neuralgia and cancer pain in patients after esophageal cancer surgery, and performed analgesia, which was reasonable and reasonable.

Although from a professional point of view, the department director’s treatment plan is flawed; although from the perspective of hospital management, the hospital does not implement the inpatient management system and process, but Dr.
Lin is neither the creator of the treatment plan nor does it have dihydroetol hydrochloride.
The prescription right of brown sublingual tablets does not obtain economic benefits from it, and its behavior does not constitute a crime.

In the use of narcotic drugs, doctors need to be trained, standardized, and improved.

However, the case of drug traffickers using real patients to purchase narcotic drugs can be described as unpredictable, and the responsibility cannot be placed on doctors blindly.

Lawyer Liu: In terms of subjective constitutional elements, the crimes stipulated in the "Criminal Law of the People's Republic of China" include intentional crimes and negligent crimes.

Therefore, the criminal law community generally believes that if there are only objective violations of the law, it is not enough to be regarded as a crime.

Specifically, the crime of drug trafficking refers to the behavior of illegally selling drugs that requires the perpetrator to know that it is drugs and for the purpose of trafficking.

It can be seen that the subjective conviction element is that the perpetrator is knowingly and deliberately about his criminal behavior.

Nie Xue: Article 347 of the "Criminal Law of the People's Republic of China" stipulates that: regardless of the number of smuggling, trafficking, transportation, or manufacturing of drugs, criminal responsibility should be investigated and criminal penalties should be imposed.

However, Dr.
Lin did not have the subjective intention and behavior of smuggling, trafficking, transporting, or manufacturing drugs, only the subjective intention and behavior of prescribing painkillers for terminal cancer patients.

If Dr.
Lin doesn't know that the drug dealer is a drug dealer, and if the medicine is in the hands of the drug dealer, it cannot constitute the crime of smuggling, trafficking, transporting, or manufacturing drugs.

In this case, Dr.
Lin was convicted and sentenced in the first instance and sent back for retrial in the second instance.
We have reason to expect that the retrial will make a different verdict. Hainan Cancer Hospital has carried out self-control analgesia technology for cancer pain patients to improve vigilance and strict management to prevent narcotic drugs from falling into the hands of drug traffickers.
Zhang Yanping: Are there any shortages in Dr.
Lin's clinical medication? What enlightenment does this case bring to the majority of doctors? Liu Duanqi: Many doctors in my country pay insufficient attention to cancer pain management.
Some doctors do not use pain assessment scales in clinical practice, and evaluate patients based on experience or personal feelings.
There is also a phenomenon of disbelief or over-belief in the main complaint of patients.
There are also misunderstandings in the choice of pain medications.

Liu Bo: From the perspective of clinical medication, the doctor's treatment plan in case one is flawed: the patient Yang Mouqing had neuralgia and cancer pain after esophageal cancer surgery.

According to the "Cancer Pain Diagnosis and Treatment Standards (2018 Edition)", commonly used analgesics that can be used include morphine, oxycodone, hydromorphone and other drugs, and dihydroetorphine hydrochloride is not recommended.

At the same time, according to current guidelines and literature reports, the drug is rarely used for cancer pain treatment-while the drug has a strong analgesic effect, it also has great toxic side effects and is not suitable for cancer pain treatment.

In addition, this patient has neuropathic pain, which can be combined with gabapentin or pregabalin during medication.

It can be seen that there are irregularities in the assessment and treatment of cancer pain in the surgery of the hospital, and it is necessary to strengthen the study of standardized treatment of cancer pain.

From a legal point of view, according to the "Regulations on the Administration of Narcotic Drugs and Psychotropic Drugs Prescriptions", the prescription of dihydroetorphine hydrochloride is a one-time commonly used amount and is limited to use in hospitals above the second level.

The hospital's continuous prescription of dihydroetorphine hydrochloride sublingual tablets for Yang Mouqing shows that the hospital's management of the drug is seriously inadequate.

Xu Zhihui: Dr.
Lin does violate the rules, but it belongs to the civil category.

The "Regulations on the Administration of Narcotic Drugs and Psychotropic Drugs Prescriptions" clearly states that patients have the right to entrust relatives or guardians to receive anesthetic drugs on their behalf, but the actual user must be checked, and the agent's name, gender, age, ID number, department, and issuance must be checked Date, etc.
; according to the "Guiding Principles for the Clinical Application of Narcotic Drugs", after doctors start opioid treatment, patients should see a doctor at least once a week in order to adjust prescriptions. However, Dr.
Lin neither seriously checked the identity of the representative; nor did he follow the rule of "patients see a doctor at least once a week", which made Wei succeed in pretending to receive the drug and was at fault.

Nie Xue: This case reminds medical staff that all-pervasive drug traffickers may use terminal cancer patients to obtain narcotic drugs, thereby achieving the purpose of drug production and trafficking.

An anesthesia prescription must be prescribed in strict accordance with laws, regulations, and normative guidelines, and the patient must actually consume it.

Let the light of rule of law and reason illuminate the way forward for narcotic drugs Zhang Yanping: How to evaluate the treatment plan of Dr.
Huang in Case 2? What enlightenment does his experience bring to clinicians? How to make cancer pain patients no longer bear the pain? Wu Xiaoming: In the second case, Dr.
Huang's treatment plan is not problematic.

First of all, whether it is the National Comprehensive Cancer Network (NCCN) guidelines or the consensus of experts on refractory cancer pain in my country, they all advocate the use of PCA analgesic pumps when patients with advanced and severe cancer pain cannot control their pain by oral high-dose opioids.

In clinical work, we will encounter some patients with advanced cancer pain.
Due to the progress of the disease and the problem of opioid tolerance, even if the oral administration of opioids is increased, the pain cannot be completely relieved, but the PCA analgesic pump can effectively achieve pain relief.
Purpose, to relieve the pain of "life is better than death" for patients.

Secondly, Dr.
Huang did not use drugs beyond the instructions.
The "Usage and Dosage" in the drug instructions of morphine hydrochloride injection stipulates: the usual amount for subcutaneous injection for adults: 5-15mg once, 15-40mg per day; maximum amount: 20mg once, 60mg per day.

However, the instructions also indicate in the "drug overdose": For patients with severe cancer pain, the use of morphine can exceed the above-mentioned dose (that is, it is not subject to the limit of the maximum amount of morphine in the Pharmacopoeia).

At the same time, the pharmacological profile "typical starting dose" following the "WHO Guidelines for the Management of Adults and Adolescent Cancer Pain and Radiation Therapy" shows that the typical starting dose of morphine for the treatment of chronic cancer pain in adults without liver and kidney disease is 2mg/ 4h subcutaneously or intravenously, but there is no maximum dose.

Although the amount of anesthetic drugs prescribed by Dr.
Huang was too large, it complied with the instructions.

Moreover, the police did not find any loss of narcotic drugs during the investigation.

In this case, it is worth noting that if supplementary analgesics are added based on the nature of the pain, it may be possible to reduce the amount of opioids.

Liu Bo: Narcotic drugs have obvious duality: on the one hand, they have a strong analgesic effect and are medically indispensable drugs, but at the same time, they are prone to dependence if they are used continuously and irregularly.
If they flow into illegal channels, Be reduced to drugs, causing serious social harm.

Therefore, in clinical work, doctors must standardize management to solve the pain problem for patients while preventing abuse.

When prescribing opioids for patients, doctors should first conduct a comprehensive and standardized assessment of the patient’s pain and prescribe an appropriate dose for the patient.

After the prescription effect is stable, a reasonable follow-up period will be established to dynamically monitor and evaluate the degree of pain relief and drug side effects.

At the same time, the supervision of these drugs must also be in place, standardized and systematic management, special prescriptions are required to prescribe anesthesia and psychotropic drugs, and the drug dispensing room needs to register anesthesia and psychotropic drug prescriptions, and each ward and operation After the injection is used, the laboratory should collect the empty ampoules, check the batch number and quantity, and make a record.

The remaining liquid should be destroyed under the supervision of two persons, and the whole drug should be returned to the warehouse.

The comprehensive implementation and implementation of various laws and regulations is also an important means to protect patients' medication use and reduce drug loss and abuse.

Nie Xue: If you wear "tinted glasses" for the use of narcotic drugs, and confuse the doctor's use of narcotic drugs for pain relief with the crimes of smuggling, trafficking, transportation, and drug manufacturing, it may endanger my country’s inadequate cancer pain treatment.
It may harm many cancer patients and cause mental harm to patients, family members and even doctors, and even leave a psychological shadow.

Cancer pain patients no longer bear the pain and need the support of the whole society.

It is necessary to remind the majority of medical staff that, in accordance with Article 355 of the Criminal Law of the People’s Republic of China, "Illegal Provision of Narcotic Drugs and Psychotropic Drugs", medical staff provide narcotics and psychoactive drugs to people who take or inject drugs in violation of regulations.
Drugs constitute the crime of illegally providing narcotic drugs and psychotropic drugs; those who provide narcotic drugs or psychoactive drugs to criminals who smuggle or sell drugs or for profit-making purposes to people who inject or inject drugs constitute smuggling, trafficking, transportation, or manufacturing.
Drug crime.

It can be seen that the legitimate use of narcotic drugs and psychotropic drugs should and can be protected by law; the illegal use of narcotic drugs and psychoactive drugs must bear corresponding legal responsibilities.

Extending the thinking and methods of the rule of law to resolve the legal problems of off-label use ▲ Song Ruliang, director of the Guangdong Research Center for the Rule of Law, although the two cases do not involve the issue of off-label use of drugs, clinically, the phenomenon of off-label use of drugs is not uncommon, and it is caused by off-label use of drugs.
The legal issues of the doctors have always been a hanging sword.

The legal risk caused by the drug insert is a major event that deserves close attention.

The drug instructions are not only the basis for doctors to prescribe drugs, patients' medications, pharmacists' prescriptions and prescriptions, and drug evaluation by all parties, but also the statutory basis for the government to use and evaluate drugs.
However, the phenomenon of delayed drug instructions is very common.

The modification and improvement of the drug insert sheet is related to both the doctor and the patient.
Therefore, it is necessary to emphasize the rule of law thinking and method to resolve the problem of the drug insert sheet.

From a legal perspective, whoever approves is responsible.
This means that the drug regulatory department has the responsibility and obligation to make the drug inserts dynamic, up-to-date, and reliable.
Therefore, it should take the initiative to discover problems through daily supervision and supervise them as soon as possible.
Improve the drug instructions.

Secondly, at the level of industry, associations, hospitals, and doctors, the problem of lagging drug inserts should be formally reported to the regulatory authorities.
The deputies of the people’s congresses and CPPCC members of the doctors should also actively speak out to condense everyone’s awareness and will on compliance with drugs.
The safety basis of the manual comes up.

But at present, there are few acts of urging relevant departments or companies to revise the manuals in the name of schools, associations and hospitals.
More often, they are "fearing to offend others" by "developing new ways", that is, through the formation of industry consensus, hospital regulations, and even Transfer risks through consultation with patients. Finally, drug manufacturers have the responsibility to ensure that the indications of the drug inserts are timely and comprehensive.

In fact, many drugs have the problem of lagging drug instructions, but most of the pharmaceutical companies do not want to be "the early bird".
Whether the drug insert sheet is timely, objective and comprehensive is one of the criteria for judging whether a pharmaceutical company performs its social responsibility well.

Improving the drug inserts and contributing the wisdom and strength of the enterprise is not the money, but the sense of responsibility.

When it comes to narcotic drugs, the legal risks caused by the drug instructions are more prominent.

When a person is dying, instead of focusing on the risk of drug addiction, doctors should relieve the patient's pain as much as possible and allow him to pass away peacefully, painlessly, and with dignity.

This is not only the last comfort to a person, but also a manifestation of the benevolence of the doctor.

To this end, an environment and atmosphere for understanding doctors should be created in the system, mechanism, and legal system.

On April 8th, at the "Opioid Drug Management and Use" seminar hosted by the "Physician Daily", more than 20 experts and scholars from the four major domestic anesthesia-related professional fields, representatives of member units of the Anesthetic Association and Xinhua News Agency, Media representatives from China Daily and China.
com gathered together to create an upsurge of discussion about the management and use of opioids.

"Physician Daily" April 22, 2021 A2-A3 Typesetting: Li Hui Editor: Xin Ya Review: Xu Fengyan For more content, please click: Waiting for you! The third "Young and Middle-aged Cardiovascular Elites" event kicked off unexpectedly｜Shanghai doctor Yang Jianmin rescued people from high altitude: the biggest test is that the medicines for emergency facilities are very limited.
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