Oncology, Pain Relief and Government

The World Health Organization (WHO) says that most pain due to cancer could be relieved using a simple analgesic approach, i.e., oral morphine, and that every national government should institute a cancer pain relief program.⁽¹⁾ The WHO analgesic method has also been endorsed for relief of pain due to HIV/AIDS.⁽²⁾ The method depends on opioid availability and patient access to essential opioid medicines. Recognizing that opioids are controlled strictly as narcotic drugs because of a potential for abuse and drug dependence, WHO recommended that governments (a) evaluate their drug control policies and practices to ensure that patients receive the opioid medications that are necessary for pain relief, and (b) encourage health care workers to report to the appropriate authorities any instance in which oral opioids are not available for cancer patients.

Indeed, the fact that opioids are narcotic drugs regulated by governments is why those interested in pain relief and palliative care for HIV/AIDS and cancer must learn about the drug regulatory system and prepare to work with governments.

The World Health Assembly and the United Nations (UN) Economic and Social Council have become concerned about disparities in availability and patient access to medications such as morphine (Table 1). These UN bodies have adopted resolutions aimed at improving the availability of essential opioid medications for pain relief, especially in low- and middle-income countries.^(3,4) The WHO has also published guidelines for improving the availability of opioid analgesics in the world, entitled “Achieving Balance in National Opioids Control Policy: Guidelines for Assessment.” This document provides 16 guidelines that should be used by governments and health professionals in all countries to assess the national opioids control policies and the administration of such policies in order to determine whether they contain the necessary provisions and procedures and promote the required level of cooperation necessary to ensure the availability of opioid analgesics. The guidelines are based on the international legal and medical principle of balance i.e, that efforts to prevent drug abuse and diversion must not interfere with the adequate availability of opioid analgesics for pain relief.

These Guidelines are available in 22 languages, including Arabic, Bulgarian, Chinese, English, French, German, Hindi, Indonesian, Italian, Lithuanian, Mongolian, Polish, Portuguese, Romanian, Russian, Serbian, Spanish, Swahili, Tagalog, Turkish, Ukrainian and Vietnamese, and can be accessed through the Pain & Policy Studies Group website at http://www.painpolicy.wisc.edu/publicat/00whoabi/00whoabi.htm

As a World Health Organization Collaborating Center, the Pain & Policy Studies Group (PPSG) at the University of Wisconsin has been working in many parts of the world, including India, Italy, Romania and Africa, using the Guidelines to develop effective methods of identifying and overcoming barriers to opioid availability.

India: PPSG assisted palliative care experts and national and state governments to identify regulatory barriers to the availability of opioid analgesics for use in palliative care. National and state policies have begun to change and the long decline in morphine use has been reversed in some areas; there has been little or no morphine abuse or diversion. See published articles: http://www.painpolicy.wisc.edu/publicat/02jpsm3/index.htm;; http://www.painpolicy.wisc.edu/publicat/01lancet/contents.htm;

Italy: PPSG assisted the Ministry of Health to identify barriers to opioid availability, culminating in new legislation and drug registration procedures, new and previously unavailable medications were added to the list of reimbursable drugs and funds were provided for physician education and public awareness about cancer pain management. For further details, see: http://www.painpolicy.wisc.edu/publicat/03ejcc/index.htm

Romania: Collaborative efforts have identified and removed regulatory barriers to the modern medical use of opioid analgesics for cancer and AIDS; the Ministry of Health approved proposed regulations and implemented a new law that was adopted by the Romanian parliament late in 2005. For details, see: www.painpolicy.wisc.edu/publicat/06lancet/index.htm

Africa: PPSG is partnering with the African Palliative Care Association and others to sponsor regional workshops for teams of health professionals and drug regulators from Sub-Saharan African countries; the teams use the WHO Guidelines to develop action plans for improving national policy. See: http://www.apca.co.ug/advocacy/workshop/index.htm

Mind the Gap

Experts in oncology and palliative care are familiar with the gap between what is known about pain relief, and what pain relief is actually offered. Another gap is becoming apparent: the gap between the need to relieve severe pain in millions of patients and the unavailability of opioids to most of the world’s population. This gap is not due to inadequate supply of opioids — the answer is not to calculate how much is needed and then simply provide it to each country. Rather, the unavailability of opioids is due to the inadequate demand for opioids on the part of physicians who fail to prescribe them for their patients’ pain. The reasons behind the weak demand are rooted in factors with which we are all familiar: lack of awareness about pain relief; reluctance to prescribe opioids because pain relief is not a priority, or lack of knowledge about pain and opioids; regulatory restrictions or drug costs that impede availability and patient care, and exaggerated fears of addiction.

PPSG is developing new resources in international pain policy for health care professionals and governments, including an International Pain Policy Fellowship, an internet course and increased technical assistance and collaboration. There is evidence that the barriers can be identified and removed if health professionals work systematically with government. But there is a long way to go.

David Joranson
University of Wisconsin
Wisconsin, USA

References:

(1) World Health Organization. Cancer pain relief. Geneva, Switzerland: World Health Organization; 1986. http://www.who.int/cancer/palliative/

(2) World Health Organization HIV-AIDS. Palliative Care. Geneva, Switzerland: World Health Organization; 2004. http://www.who.int/hiv/topics/palliative/care/en/

(3) World Health Assembly. Cancer Prevention and Control. WHA 58.22 Geneva, Switzerland: World Health Organization; 2005. http://www.who.int/gb/ebwha/pdf_files/WHA58-REC1/english/A58_2005_REC1-en.pdf

(4) United Nations Economic and Social Council. Treatment of pain using opioid analgesics; Resolution 2005-25. Report on the forty-eighth session of the Commission on Narcotic Drugs E/2005/28; 19 March 2004 and 7-11 March 2005; issued 22 July 2005.
http://www.un.org/docs/ecosoc/documents/2005/resolutions/Resolution%202005-25.pdf

1	Austria	115.7151		53	Rep. of Korea	2.0304		105	Mexico	0.1957
2	Canada	64.1751		54	Tunisia	1.9579		106	Azerbaijan	0.1810
3	Denmark	63.0390		55	Ukraine	1.8003		107	Turkey	0.1785
4	Australia	55.9482		56	Latvia	1.7505		108	Dominica	0.1714
5	New Zealand	54.8074		57	Bahamas	1.3943		109	Ecuador	0.1615
6	United States of America	48.8145		58	Jamaica	1.3806		110	Grenada	0.1584
7	Iceland	43.9204		59	Malaysia	1.3013		111	Mauritius	0.1521
8	France	41.8355		60	Macao	1.2809		112	Turkmenistan	0.1443
9	Norway	35.4423		61	Singapore	1.2174		113	Swaziland	0.1437
10	Sweden	28.4913		62	Lebanon	1.1213		114	Kenya	0.1400
11	Switzerland	26.5509		63	Argentina	1.0753		115	Wallis & Futuna Islands	0.1333
12	Falkland Islands	22.6667		64	Republic of Moldova	0.8212		116	Syrian Arab Republic	0.1244
13	United Kingdom	19.1548		65	Bahrain	0.7344		117	Vanuatu	0.1238
14	Netherlands	17.8260		66	Oman	0.7175		118	Chad	0.1197
15	Germany	16.0119		67	United Arab Emirates	0.7053		119	Colombia	0.1176
16	Saint Helena	13.2000		68	Panama	0.6261		120	Morocco	0.1153
17	Ireland	12.8478		69	Greece	0.6068		121	Kyrgyzstan	0.1111
18	Gibraltar	12.2069		70	Zimbabwe	0.5718		122	Viet Nam	0.0993
19	Spain	11.8115		71	Belarus	0.5606		123	Anguilla	0.0833
20	Belgium	10.4698		72	Mongolia	0.5511		124	Nauru	0.0833
21	Portugal	7.9790		73	Thailand	0.5421		125	Uzbekistan	0.0713
22	Poland	6.1887		74	Paraguay	0.5353		126	Zambia	0.0704
23	Czech Republic	5.7657		75	Botswana	0.5200		127	Mali	0.0665
24	New Caledonia	5.6591		76	Brunei Darussalam	0.5200		128	Egypt	0.0588
25	Finland	5.4013		77	Jordan	0.4981		129	Algeria	0.0546
26	Italy	5.3206		78	Dominican republic	0.4752		130	Libyan Arab Jamahiriya	0.0527
27	Israel	5.0158		79	Kazakhstan	0.4727		131	Marshall Islands	0.0526
28	Bulgaria	4.9697		80	Micronesia (Fed. States of)	0.4500		132	Bolivia	0.0524
29	French Polynesia	4.9069		81	Saudi Arabia	0.4463		133	Bhutan	0.0461
30	Japan	4.7174		82	Bosnia & Herzegovina	0.4332		134	Guatemala	0.0333
31	South Africa	4.6682		83	Sri Lanka	0.4248		135	Myanmar	0.0327
32	Estonia	4.5458		84	Peru	0.4163		136	Cape Verde	0.0217
33	Form. Yug. Rep. of Macedonia	4.3582		85	Uganda	0.4001		137	Indonesia	0.0180
34	Slovenia	4.3210		86	Cook Islands	0.3889		138	Senegal	0.0157
35	Slovakia	4.3185		87	Tonga	0.3861		139	Rwanda	0.0136
36	Barbados	3.8044		88	Republic of Palau	0.3500		140	Nepal	0.0126
37	Hong Kong SAR	3.4817		89	Qatar	0.3380		141	Benin	0.0112
38	Uruguay	3.3350		90	Kuwait	0.3376		142	Yemen	0.0100
39	Malta	3.2581		91	Montserrat	0.3333		143	Cambodia	0.0098
40	Costa Rica	3.2375		92	Nicaragua	0.3280		144	Burundi	0.0080
41	Brazil	3.0848		93	Iran (Islamic Republic of)	0.3277		145	Cameroon	0.0076
42	Andorra	3.0000		94	United Republic of Tanzania	0.3250		146	Sao Tome & Principe	0.0065
43	Namibia	2.8653		95	China	0.3221		147	Central African Republic	0.0048
44	Georgia	2.7498		96	British Virgin Islands	0.3182		148	Côte d’Ivoire	0.0032
45	Cyprus	2.7115		97	Saint Vincent & the Grenadines	0.2963		149	Dem. Rep. of the Congo	0.0031
46	Seychelles	2.6627		98	Venezuela	0.2961		150	Sierra Leone	0.0028
47	Hungary	2.5857		99	Russian Federation	0.2807		151	Eritrea	0.0021
48	Lithuania	2.4867		100	Guinea-Bissau	0.2368		152	Burkina Faso	0.0016
49	Chile	2.4758		101	El Salvador	0.2303		153	Pakistan	0.0013
50	Romania	2.4616		102	Turks & Caicos Islands	0.2273		154	Guinea	0.0011
51	Serbia & Montenegro	2.0794		103	Suriname	0.2183		155	Mozambique	0.0006
52	Netherlands Antilles	2.0447		104	Philippines	0.2182
Table 1. Global Morphine Consumption, 2004 (mg/capita). Note: Countries not listed did not report morphine consumption to the International Narcotics Control Board (INCB) for 2004. Source: INCB; United Nations Demographic Yearbook.