Pain Management and Health Insurance Coverage Issues in Taiwan

Pain management and health insurance reimbursement issues?

Hello, pharmacist: I am a patient with bone metastasis from breast cancer, currently only receiving pain management.
I previously consulted a physician online for treatment recommendations, and the physician suggested the following: for cancer treatment, I could take oral targeted therapy and receive ZOMETA injections monthly.
For pain management, it was recommended to use APO + VOLTAREN SR 75MG/TAB, a non-steroidal anti-inflammatory drug (NSAID).
If the dosage is heavy, I could switch to VOLTAREN SR 75MG/TAB combined with a pain reliever containing acetaminophen.
It was also advised to take a proton pump inhibitor like Pantoloc or takepron alongside these medications.
However, after discussing with my attending physician at the hospital, he replied that oral targeted therapy requires prior approval and, given my condition, it is too late for that.
Regarding pain medications, the health insurance regulations only allow the prescription of one type of pain reliever, so he could only prescribe VOLTAREN SR 75MG/TAB, one tablet in the morning and one in the evening.
For the proton pump inhibitor, he asked me to purchase it out of pocket (but taking that medication did not alleviate my abdominal and gastric bloating and burning sensation, so during my follow-up in mid-May, I told him that I no longer needed the out-of-pocket medication).
Currently, the abdominal and gastric bloating and burning sensation persist, and he indicated that it might be due to cancer cells spreading to the abdomen (but he did not order any related tests).
During this period, a morphine patch was prescribed, but after four hours of application, I started feeling dizzy and continued to vomit.
After vomiting until the next day when I saw the physician, he said it was due to my constitution and advised me to remove it, so he continued to prescribe VOLTAREN SR 75MG/TAB, one tablet in the morning and one in the evening, without adding any other medications.
However, the pain relief is inadequate, and I still experience pain at a level of 5 or 6 out of 10 after taking it.
May I ask if the health insurance covers the medications suggested by the online consulting physician for pain management, or as stated by the hospital physician, am I only allowed to have one type of pain reliever prescribed? Thank you!

kim, 40~49 year old female. Ask Date: 2014/06/03

Dr. Liao Huiling reply Pharmacology

Hello! Regarding the regulations on the use of medications covered by the National Health Insurance, I recommend that you contact the National Health Insurance Administration directly to clarify your many questions.

Reply Date: 2014/06/03

More Info

In Taiwan, pain management for cancer patients, particularly those with metastatic conditions, can be quite complex due to health insurance regulations and the limitations imposed on medication prescriptions. Your situation highlights several critical issues regarding pain management, medication options, and the bureaucratic hurdles that can arise in the healthcare system.

Firstly, it is essential to understand that the National Health Insurance (NHI) in Taiwan has specific guidelines regarding the prescription of pain medications, especially for chronic conditions like cancer. Generally, physicians are encouraged to prescribe medications that are deemed essential for managing a patient's condition, but they must also adhere to the NHI's regulations, which can sometimes limit the number of medications prescribed simultaneously. This is likely why your physician mentioned that only one type of analgesic could be prescribed at a time.

In your case, the recommendation to use a combination of Voltaren (a non-steroidal anti-inflammatory drug, or NSAID) and other pain relief medications, such as those containing acetaminophen, is a common practice in pain management. However, the NHI's restrictions may prevent your doctor from prescribing multiple pain medications concurrently, even if they are clinically justified. This can lead to inadequate pain control, as you have experienced, where the prescribed medication does not sufficiently alleviate your discomfort.

Regarding the use of Zometa (zoledronic acid), which is often prescribed for patients with bone metastases to help manage pain and prevent skeletal-related events, it is unfortunate that you were informed that it was too late for this treatment. Zometa is typically administered to patients with bone metastases to help strengthen bones and reduce pain, and it should ideally be part of a comprehensive treatment plan. If you feel that this option was not adequately explored, it may be worth seeking a second opinion from another oncologist or a pain management specialist who can evaluate your situation more thoroughly.

The gastrointestinal symptoms you are experiencing, such as abdominal pain and discomfort, are concerning, especially in the context of metastatic cancer. While your physician suggested that these symptoms might be due to cancer spreading to the abdomen, it is crucial to have appropriate imaging studies or evaluations to confirm this diagnosis. If you are experiencing significant gastrointestinal distress, it is essential to communicate this clearly to your healthcare provider and advocate for further investigation, such as imaging or endoscopy, to rule out other potential causes.

In terms of managing your pain effectively, you might consider discussing alternative pain management strategies with your healthcare provider. This could include exploring other classes of medications, such as opioids (if appropriate), adjuvant therapies like antidepressants or anticonvulsants that can help with neuropathic pain, or even non-pharmacological approaches such as physical therapy, acupuncture, or palliative care consultations.

Lastly, if you feel that your current treatment plan is not adequately addressing your pain or other symptoms, it is essential to advocate for yourself. You have the right to seek a second opinion or request a referral to a pain management specialist who can provide a more tailored approach to your care. Additionally, consider discussing the possibility of a palliative care consultation, which focuses on improving the quality of life for patients with serious illnesses and can provide comprehensive support for managing pain and other distressing symptoms.

In summary, navigating pain management within the constraints of Taiwan's health insurance system can be challenging, especially for cancer patients. It is crucial to maintain open communication with your healthcare providers, advocate for your needs, and explore all available options to ensure that your pain is managed effectively.

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