Dificuldades sociais, legais e burocráticas para prescrição de opioides
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Data
2020-02-28
Autores
Calônego, Marco Antônio Marchetti
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Universidade Estadual Paulista (Unesp)
Resumo
Introdução: A dor é uma experiência pessoal, subjetiva, que envolve aspectos sensitivos e culturais que podem ser alterados pelas variáveis socioculturais e psíquicas do indivíduo, do meio e, apesar de classificações diversas, geralmente relacionada ao sofrimento. No Brasil estudos indicam que, embora cerca de 50% dos pacientes portadores de dor estejam medicados, a maior parte deles está descontente com os resultados do tratamento. Em situação de dor aguda traumática, apenas 7% dos pacientes tem suas dores totalmente aliviadas e, em pacientes em vigência de dor de intensidade moderada a grande, somente 25% receberam opioides como parte de seu tratamento, apesar de recomendação da OMS de uso destes analgésicos, como descrito na escada analgésica. Objetivo: Compreender as razões da baixa prescrição dos opioides no tratamento da dor no Brasil, com ênfase aos entraves sociais, legais e burocráticos existentes. Métodos: Trata-se de um estudo epidemiológico, prospectivo, analítico observacional e transversal, aprovado pela Comissão de Ética em Pesquisa, e realizado a partir de questionário investigativo disponibilizado em plataforma online, com perguntas fechadas e abordagem quantitativa. Foram convidados a participarem do estudo, por meio de mensagens eletrônicas a médicos atuantes em território Nacional. Aqueles que concordaram em participar assinaram, eletronicamente, o Termo de Consentimento Livre e Esclarecido (TCLE) online. Para análise estatística foram realizados os testes de qui-quadrado seguidos por testes Z e testes t de Student. Resultados: Participaram da pesquisa 389 médicos, a maioria possui algum tipo de pós-graduação (82,78%), porém, mais da metade nunca teve qualquer contato com matéria de dor e cuidados paliativos (58,61%). Os principais motivos apontados em nossa pesquisa para a não prescrição com mais frequência de opioides potentes/fortes, são o receio de se induzir ao vício (52,19%), as dificuldades na obtenção do receituário “tipo A” (50,13%), o receio de induzir à dependência (49,36%) e a falta de conhecimento farmacológico (42,67%). Entretanto, em 42,16% dos casos, é relatado pelos médicos a existência de recusa, por parte dos pacientes, do emprego de opioides por motivo de medo exagerado do vício, da dependência física e da tolerância (86,59%) ou por motivos sociais e culturais (40,85%). A recusa dos pacientes foi superada durante a prática médica com a explicação da importância e segurança do medicamento (96,50%). Em nossa pesquisa 41,65% informam não conhecerem a legislação atual que rege a prescrição de opioides. Por fim, foram considerados pelos profissionais como principais fatores que podem facilitar a prescrição de opioides, o conhecimento da farmacologia destes analgésicos (73,01%), o melhor conhecimento das normas que regem a sua prescrição (67,10%) e a diminuição na burocracia envolvida na prescrição (51,16%). Conclusão: Concluiu-se que a baixa prescrição de opioides no Brasil é fato incontroverso e possui inúmeras justificativas de ordem social, legal e burocrática. Verificamos a existência de opiofobia, relatadas pelos pacientes e entre os médicos entrevistados. Legalmente, restrições exacerbadas são impostas à prescrição desses fármacos, burocratizando e inviabilizando a sua utilização. Necessário reconstruir o conhecimento leigo e profissional que, aliados à realização de estudos populacionais e reconstrução da legislação vigente, tornará viável a proposição de novas formas de prescrição desses medicamentos.
Introduction: Pain is a personal, subjective experience, involving sensitive and cultural aspects that can be altered by the socio-cultural and psychological variables of the individual, the environment and, despite different classifications, it is frequently related to suffering. In Brazil studies indicate that, although about 50% of pain patients are medicated, most of them are unhappy with the treatment outcomes. In situations of acute traumatic pain, only 7% of patients have their pain totally relieved and, in patients with moderate to severe pain, only 25% received opioids as part of their treatment, despite of the WHO recommendation to use these analgesics, as described on the analgesic ladder. Objective: To understand the reasons for the low prescription of opioids in the treatment of pain in Brazil, with emphasis on the existing social, legal and bureaucratic barriers. Method: This is a prospective, observational and cross-sectional epidemiological study, approved by the Research Ethics Committee, and carried out using an investigative questionnaire available on an online platform, with closed questions and a quantitative approach. Participants were invited to participate in the study, through electronic messages to medical doctors working in the national territory. Those who agreed to participate signed, electronically, the Free and Informed Consent Term (ICF) online. For statistical analysis, chi-square tests were performed followed by Z tests and Student's t tests. Results: The total of 389 medical doctors participated in the research, most of whom have some type of postgraduate degree (82.78%), however, more than half have never had any contact with pain and palliative care subjects (58.61%). The main reasons pointed out in our research for not prescribing more frequently potent / strong opioids are the fear of inducing addiction (52.19%), difficulties in obtaining the “type A” prescription form (50.13% ), the fear of inducing dependence (49.36%), and the lack of pharmacological knowledge (42.67%). However, in 42.16% of cases, doctors report the refusal of patients to use opioids due to exaggerated fear of addiction, physical dependence and tolerance (86.59%) or because of some social and cultural reasons (40.85%). The patients' refusal was overcome during medical practice with the explanation of the importance and safety profile of the medication (96.50%). In our survey, 41.65% reported not knowing the current legislation governing the prescription of opioids. Finally, the professionals considered the main factors that can facilitate the prescription of opioids, the knowledge of the pharmacology of these analgesics (73.01%), the better knowledge of the rules governing their prescription (67.10%), and the decrease in the bureaucracy involved in their prescription (51,16%). Conclusion: It was concluded that the low prescription of opioids in Brazil is an uncontroversial fact and has numerous justifications of social, legal and bureaucratic nature. We verified the existence of opiophobia, reported by the patients and doctors interviewed. Legally, exacerbated restrictions are imposed on the prescription of these drugs, bureaucratizing and preventing their use. It is necessary to reconstruct lay and professional knowledge which, together with population studies and the reconstruction of current legislation, will make it feasible to propose new ways of prescribing these drugs.
Introduction: Pain is a personal, subjective experience, involving sensitive and cultural aspects that can be altered by the socio-cultural and psychological variables of the individual, the environment and, despite different classifications, it is frequently related to suffering. In Brazil studies indicate that, although about 50% of pain patients are medicated, most of them are unhappy with the treatment outcomes. In situations of acute traumatic pain, only 7% of patients have their pain totally relieved and, in patients with moderate to severe pain, only 25% received opioids as part of their treatment, despite of the WHO recommendation to use these analgesics, as described on the analgesic ladder. Objective: To understand the reasons for the low prescription of opioids in the treatment of pain in Brazil, with emphasis on the existing social, legal and bureaucratic barriers. Method: This is a prospective, observational and cross-sectional epidemiological study, approved by the Research Ethics Committee, and carried out using an investigative questionnaire available on an online platform, with closed questions and a quantitative approach. Participants were invited to participate in the study, through electronic messages to medical doctors working in the national territory. Those who agreed to participate signed, electronically, the Free and Informed Consent Term (ICF) online. For statistical analysis, chi-square tests were performed followed by Z tests and Student's t tests. Results: The total of 389 medical doctors participated in the research, most of whom have some type of postgraduate degree (82.78%), however, more than half have never had any contact with pain and palliative care subjects (58.61%). The main reasons pointed out in our research for not prescribing more frequently potent / strong opioids are the fear of inducing addiction (52.19%), difficulties in obtaining the “type A” prescription form (50.13% ), the fear of inducing dependence (49.36%), and the lack of pharmacological knowledge (42.67%). However, in 42.16% of cases, doctors report the refusal of patients to use opioids due to exaggerated fear of addiction, physical dependence and tolerance (86.59%) or because of some social and cultural reasons (40.85%). The patients' refusal was overcome during medical practice with the explanation of the importance and safety profile of the medication (96.50%). In our survey, 41.65% reported not knowing the current legislation governing the prescription of opioids. Finally, the professionals considered the main factors that can facilitate the prescription of opioids, the knowledge of the pharmacology of these analgesics (73.01%), the better knowledge of the rules governing their prescription (67.10%), and the decrease in the bureaucracy involved in their prescription (51,16%). Conclusion: It was concluded that the low prescription of opioids in Brazil is an uncontroversial fact and has numerous justifications of social, legal and bureaucratic nature. We verified the existence of opiophobia, reported by the patients and doctors interviewed. Legally, exacerbated restrictions are imposed on the prescription of these drugs, bureaucratizing and preventing their use. It is necessary to reconstruct lay and professional knowledge which, together with population studies and the reconstruction of current legislation, will make it feasible to propose new ways of prescribing these drugs.
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Palavras-chave
Analgésicos opioides, Legislação, Prescrição, Opioid analgesics, Legislation, Prescription