Access to pain relief - World Hospice and Palliative Care Day

ContentsKeyForeword1. Introduction1.1 Pain incidence1.2 Opioid analgesics1.3 The importance of being able to accesspalliative care, morphine and other analgesics1.4 Unavailability of opioids2. Help the Hospices’ survey on access toanalgesics2.1 Survey results: access to analgesics3. Why are opioids not accessible topalliative care patients?3.1 National laws3.2 Fear of addiction, tolerance and side effects 3.3 Poorly developed healthcare systems and supply3.4 Expense3.5 Lack of knowledge – healthcare workers, publicand policy makers4. Essential elements required to increaseavailability4.1 Education4.2 Addressing the fears4.3 Accountability4.4 Reviewing laws and policies4.5 Strengthening health facilities5. Recent advances in increasing accessto analgesics5.1 Individuals5.2 WHO and INCB 5.3 Resolutions advocating for an increase inaccessibility to opioid analgesics5.4 Changes in national laws5.5 Some regional initiatives5.6 Some country initiatives5.7 Proposed projects6. Educational opportunities7. What you can do7.1 Advocacy7.2 Education 7.3 Support for hospices through internationalorganisations and directly7.4 Research8. References9. Further resourcesii

WORLD DAY REPORTWith this publication Help the Hospices gives an overviewof the widespread lack of access to analgesia. If we donot work together to change this, many of us will discover,sooner or later, what it means to need good analgesia; ifwe personally do not encounter this lack of access, wewill watch a relative or a friend that does.In this publication you will find the results of a survey heldamong palliative care workers. The results picture aserious situation. It is noted that the survey population willgive a positive bias of the situation, as palliative careworkers are likely to have relatively good access toopioids and other analgesics compared to an averagedoctor.My impression, mainly derived from the per capitastatistics of opioid consumption, is that the situation iseven worse than that found by the survey. The differencesbetween the countries with the highest consumption andthe remainder of the countries – the large majority – arevery wide. These statistics show that only 10 to 15countries have a reasonable per capita consumption, andeven in these countries underuse for medical reasons areoccasionally reported.For many people, pain is part of their daily life. Everyminute they are reminded of it; there is no means ofescape. We can wonder why so many people do not haveaccess to analgesia and have to suffer so much pain,when there is an excess of opioids in the world. Onereason is the longstanding fear of drug dependence anddrug abuse. This fear is, in my view, unfounded. In fact,the relation between drug abuse/drug dependence andlicit medical use of controlled medicines is weak.More importantly, our countermeasures against thediversion of drugs required for medical use are out ofbalance. Globally, several hundreds of millions of peoplewill require analgesia at least once in their lifetime, whilstonly a small fraction of this number misuses opioids.There are restrictions on the handling of opioids for licitmedical use which aim to prevent any possibility ofabuse. However, many countries impose stricterregulations than required by the drug conventions to givegood accountability. Yet we know that the source of themajority of opioids used in abuse is from illicit cultivationand not from the medical circuit. Furthermore, we knowthat it is quite rare for licit opioid medicines to be divertedfor abuse. Although it is important to remain on one'sguard, we should not exaggerate but pay attention to theside of the balance where the feather is, and not to theside where the lead weight is already.Fortunately, the international community agrees that weneed change. Both the UN's Economic and SocialCouncil and the World Health Assembly recently acceptedresolutions that have provided the basis for further actionby the World Health Organization. I have pleasure to workon this, and to experience strong support from manyindividuals, governments and also NGOs such as Helpthe Hospices. They are in support of improving cancercare, HIV care and palliative care for all.Together we have a strong case, and together we will beable to make the change.Dr Willem ScholtenTechnical OfficerDepartment of Medicines Policy and StandardsWorld Health Organizationv

Oral morphine and oral methadone:are ‘strong’ opioid analgesics (pain relieving drugs);have been proven to be very effective analgesics,wholly or partly relieving most types of pain;are cheap;are both established medicines with known,predictable and preventable side effect profiles;have a wide therapeutic index – the range of dosesover which they can be effective without being toxicis exceptionally large; therefore doses can beindividualised easily;are easy to administer;are easy to adjust (doses) for each individual and ifanalgesic requirements change.Oral morphine has been included on the WHO EMLsince 1985. (11)Essential medicines are intended to be available:at all times in adequate amountsin the appropriate dosage formswith assured qualityat a price the individual and communitycan afford. (12)The WHO EML guides countries as to the drugs toinclude in their own essential medicines list, takingaccount of disease prevalence. (13)Essential medicines are those that satisfy the priorityhealthcare needs of the population. (12)Many patients are unable to access morphine,methadone or an equivalent opioid.Based on INCB reports, the WHO estimated in2006 (14) :80% of cancer patients have no access tothe pain relieving drugs required~7% of all people in the world will sufferfrom cancer pain that can be treated, but willnot be treated.** Based on 80% of world population having no access toanalgesia, 12% of all death causes being from cancer and70% of cancer patients suffering pain – (0.8 x 0.12 x 0.7) x100 = ~ 7%.4

WORLD DAY REPORT1.3 The importance of being ableto access palliative care,morphine and other analgesicsAt the age of 21, Mr AB was diagnosed with a giant celltumour and underwent a midtarsal amputation in 1979.When it recurred, in 1985, he went through an abovekneeamputation. He was able to have a reasonablequality of life with an artificial limb until 1992 when thedisease recurred. He was in pain; radiotherapy helpedonly briefly.His severe pain meant he lost his means of livelihoodand life became a huge burden. He had to send threeof his four children to an orphanage.He was one of the first patients in the Pain andPalliative Care Clinic (PPCS) when it opened in 1994 inCalicut Medical College. By then Mr AB had been inpain for about two years. In the PPCS he was startedon oral morphine and other medication. His pain wassoon relieved. PPCS found him a livelihood by installinga coffee-vending machine in the hospital. It brought themeans not only to get his children back from theorphanage but also to allow them all to be educated.His disease is slowly progressive. His morphinerequirement slowly went up to finally reach 1,000mg aday, and at that time a pathological fracture in his femurwas found. Excision of the fractured bone broughtdown the pain and since 1999 (ie for the last sevenyears), his pain has been well controlled on a steadydose of 600mg of morphine a day.He is 48 now. Recently he had a single fraction ofpalliative irradiation to the stump which has ulcerated.He is pain free on morphine and is able to work frommorning to evening. His eldest son has a job and theother children are continuing their education.Case study provided by Prof M. R. Rajagopal,Chairman, Pallium, India5

JM is 33 year old male with Kaposi’s Sarcoma, acancer occurring more frequently in HIV patients. Hehas a huge woody oedematous left leg. JM was one ofthe first cancer and HIV/AIDS patients to join the NdiMoyo Palliative Care programme, Malawi, in August2006.However, he enrolled with me as a patient long beforethe Centre opened. JM lives with his wife and their fourchildren. They are very poor and at first JM was living indenial of his condition.JM noticed the swelling of his left leg in 1999 and wentto traditional healers. His leg got worse. In 2000 hevisited Salima District Hospital where Kaposis Sarcomawas diagnosed. As he did not get relief from hissymptoms, he alternated between the hospital andtraditional healers until October 2002, when a friendreferred him to me for pain relief at the Salima Parishhome based care clinic where I was working as avolunteer nurse.He presented with moderate burning pains, bone painand extensive fungal infections. These were managedwith amitriptyline 12.5mg bd, ibuprofen 400mg tds andantifungals with good effect. At this time he was testedHIV positive. We controlled his pain well and treatedopportunistic infections until February 2004, when hedeveloped severe pain and blisters all over his left leg.As a result he became one of the very first patients inSalima to be given morphine, which he was only able toaccess from ‘Lighthouse’ in Lilongwe (over 100km fromhis home).He started on 5mg of oral morphine every four hourswith 10mg at night. He responded well and is atpresent pain free on oral morphine (7.5mg four hourlywith 15mg at night). For a couple of months the doseneeded to be increased to 10mg four-hourly and 20mgat night. Throughout he has continued to haveibuprofen, and since July 2004 has had free ART.Access to analgesia and palliative care has reallybenefited JM; he is one of very many in Malawi whowould benefit if they were able to access it. Besidesmedical treatment, we have provided him and his familywith emotional support and used a comfort fund toassist them with transport and food at times of need. Inaddition, after a long advocacy fight by us, he and hisfamily now benefit regularly from food aid distributed bythe World Food Programme. He is now happy, able towalk, cycle, able to take care of his family, and wecontinue to travel with them on his journey.Case study provided by Lucy Finch, Nurse andFounder of Ndi Moyo Palliative Care Centre, Malawi.6

WORLD DAY REPORT10090807060Graph 3: Access to ‘weak opioids’always availablealways availableThe availability of ‘weak opioids’ was markedlydecreased in Africa compared to Asia and LatinAmerica.Note: In some places ‘weak opioids’ are expensive andhence the step of using a weak opioid is substitutedwith a smaller dose of a strong opioid. This isacceptable practice.% 50403020always availablenever available10 never availablenever available0Africa Asia Latin AmericaTwenty-five per cent of African Palliative CareServices never have a weak opioid available.Between 25 – 35% in Latin America and Asia donot ‘always’ have a weak opioid available.always availableavailable most of the timeavailable half of the timeoccasionally availablenever available11

%100%90%80%70%60%50%40%30%20%always availableGraph 6: Access to one or more ‘strong opioids’never availablealways availablealways availablenever available10% never available‘Oral or patch strong opioids’ included tablets,solution, normal and slow release preparations of:oral morphineoral methadoneoxycodonehydromorphonefentanyl patchesand an option for ‘other’.Pethidine was excluded from the analysis as it isnot recommended in chronic pain relief owing totoxicity following accumulation.Over 20% of palliative care providers in Africacan never access a ‘strong opioid’.0Africa Asia Latin Americaalways availableavailable most of the timeavailable half of the timeoccasionally availablenever availableThirty-five per cent of palliative care providers inLatin America and 25% in Asia cannot alwaysaccess any ‘strong opioids’.14

WORLD DAY REPORT%Graph 7: Access to NSAIDs100 always available always available90always availablealways available8070always available605040always availableGraphs 7, 8, 9 and 10 illustrate the overall results forthe availability of some of the other recommendedanalgesics. The variation in access to different drugssuggests multiple reasons for lack of access.The current WHO EML (13) includes one NSAID,ibuprofen.The ‘expert committee’ has recommended to theWHO that the next revision of the EML shouldinclude two NSAIDs. (16)NSAIDs do differ in properties, effectiveness andside effects. It is not known how to predict whichNSAID a pain will be relieved by.302010never availablenever availableNeveravailable0Availability of Availability of an Availability of Availability of Availability of Availability of anOne NSAID alternative NSAID One NSAID alternative NSAID One NSAID alternative NSAIDAfrica Africa Asia Asia Latin America Latin Americaalways availableavailable most of the timeavailable half of the timeoccasionally availablenever available15

16100%90%80%70%60%%50%40%alwaysavailableGraph 8: Access to neuropathic analgesicsalways availablealwaysavailablealwaysavailableavailable mostof the timeavailable halfof the timeoccasionallyavailable30% neveravailable20%10%0%neveravailablenever availablenever availableTricyclic Antidepressant Carbamazepine, Phenytoin or Sodium Dexamethasone tabs or injValproate‘Neuropathic pains’ covers a wide spectrum: someTherespond better to tricyclics whilst others respond betterto anticonvulsants. No significant difference has beenshown between different tricyclic antidepressants anddifferent anticonvulsants in the control of neuropathicpain (with the exception of increased effectiveness ofgabapentin compared to tricyclics in post herpetic(18, 19)neuralgia).tricyclic amitriptylline and the anticonvulsantscarbamazepine, phenytoin and sodium valproate areon the current WHO EML; all have different significantside effect profiles and drug interactions. Note: opioidscan also be very effective in relieving some neuropathicpains. Opioids can be used in conjunction withtricyclics, anticonvulsants and dexamethasone.Thirty-seven per cent of palliative care units donot have a constant supply of any drug from the‘anti-convulsant class’.Nearly 30% do not have a constant supply of oneof the tricyclics.Twenty five per cent do not have a constantsupply of dexamethasone.Twelve per cent never have access to ananticonvulsant.Dexamethasone is useful for relieving a numberof symptoms common in palliative patientsincluding:pain – especially nerve compression painand liver capsular painaphthous ulcersraised intracranial pressurespinal cord compressionintestinal obstructionureteric obstructionlarge airway obstructionsuperior vena cava obstructioncerebral tumourshypercalcaemia in lymphomasweating and hot flushes.It can also act as an:antiemeticappetite stimulant.The current WHO EML (13) recommends only theinjectable form of dexamethasone; the ‘expertgroup’ advised the addition of the tablets. (16)

WORLD DAY REPORT100%90%80%70%Graph 9: Access to gabapentinneveravailablealways availableGabapentin was included in the recommended list ofpalliative care drugs to be added to the WHO EML. (16)It has not been proved to be more effective than otheranticonvulsants for neuropathic pain (except postherpetic neuralgia) but is usually better tolerated, withfewer side effects and drug interactions. Its cost is likelyto be a factor decreasing access.60%% 50%40%always available30%20%neveravailablenever available10% alwaysavailable0%Africa Asia Latin Americaalways availableavailable most of the timeavailable half of the timeoccasionally availablenever available17

100%90%80%70%alwaysavailableGraph 10: Access to other analgesicsalwaysavailablealways availableGraph 10 illustrates the availability of some of the otheranalgesics currently on (diazepam and paracetamol),or recommended to be on (hyoscine), the WHOEML. (13, 16) Baclofen is included as it is effective formuscle spasm in a similar way to diazepam but hasfewer side effects.60%Seven per cent of palliative care units never haveaccess to paracetamol (acetaminophen).%50%40%30%20%10%never availableNeveravailableneveravailable0Hyoscine tabs or inj Oral Diazepam or Baclofen Paracetamol/ Acetaminophenalways availableavailable most of the timeavailable half of the timeoccasionally availablenever available18

WORLD DAY REPORT3. Why are opioids notaccessible to palliativecare patients?Help the Hospices surveyed palliative care providers toask why they felt oral morphine* was not accessible totheir patients (responses from 69 HCWs all in differentorganisations): 24 in Asia; 28 in Africa; and 17 in LatinAmerica).Reasons for the lack of availability could becategorised as:1. Excessively strict national laws and regulations.2. Fear of addiction, tolerance and side effects.3. Poorly developed healthcare systems and supply.4. Lack of knowledge – HCWs, public and policymakers.* Oral morphine was used in the questions on reasons for lack ofaccess, but it is assumed that many of the reasons are equallyapplicable to oral methadone and other ‘strong/step 3’ opioids.19

3.1 National laws100%90%80%70%60%%50%Graph 11: Factors decreasing access: laws and regulatory barriersIn some countries laws governing the handling ofmorphine and other controlled drugs are impractical orso stringent that they prevent HCWs using morphinewhen they feel it appropriate. These laws were aimedat preventing misuse; they were adopted prior toadvances in knowledge about pain and opioids, andwere not intended to block pain relief. Other surveyshave also highlighted this. (20)40%30%20%10%0%Africa Asia Latin AmericaStrict laws and/or complex Strict laws and/or complex Lack of HCWs ableprocedures required to procedures required for to prescribeimport, manufacture, prescribing/dispensing oral and/or dispensedistribute or store oralmorphinemorphine20

WORLD DAY REPORT1. Process requires several forms, speciallicenses and/or authorisation stamps whichare time consuming and/or difficult toacquire and thus deter HCWs fromprescribing opioids.“Palliative care doctors have a right to prescribemorphine but cannot obtain it if they work in ahospice which is not registered in the MoH as amedical organisation.”“Drug companies are not willing to import oralmorphine solution as they will not make enoughprofit due to spending months on legal papers.”“I waited nearly one and a half years to get myfirst licence to prescribe oral morphine.”“Licences are hard to obtain. This is to ensurethat only genuine companies are allowed toimport morphine as a way of ensuring that thereis no misuse, and to ensure that the accountingbodies to INCB are not so many from onecountry.”“Licences are hard to obtain. You need to writean exam then apply for a licence.”“Bureaucracy for collecting morphine delayswork in the hospitals and centres.”“A supply of opioids is now available in thecentral medical stores but many practitioners areunaware, and even some of those who have theinformation have not accessed it as they areunwilling to follow the due process, which theyregard as tedious.”21

2. Length of supply allowed is short requiringrepeated journeys – which are potentiallyexpensive, a long way and difficult when ill– and repeated consultations with alreadybusy doctors.a. In Honduras only a three day supply of oralmorphine is dispensed.b. In Malawi only three days supply of analgesics aredispensed.c. Until the recent review of Romanian law, doctorscould only prescribe three days supply of morphine(for a small number of specified diseases specialauthorisation from a government consultant could beobtained for ‘long term prescribing’ allowing 10 – 15days supply on a repeated basis for threemonths). (20)d. In Israel, unless the doctor confirms that the patientlives far from a pharmacy, supply can only be givenfor 10 days at a time. Opioids are only available frompharmacies with Health Sick Insurance. In someareas there are few or no pharmacies with HealthSick Insurance, meaning patients have to travel along way for a few days supply. In addition, if any ofthe details required are omitted by mistake, thepharmacist will send the patient back to the doctor,which, when distances are far and patients’ are ill,can deter patients from obtaining their drugs.3. A maximum dose is stipulated. This doesnot account for patient variability and thefact that there is no maximum dose ofmorphine.a. Until reviewed recently, the Romania pharmacopeiastipulated that no more than 60mg per day should(20, 21)be prescribedb. Drug laws in Israel state that no more than 60mg perday can be prescribed for non-cancer patients(confirmation that patient has cancer needs to be onprescription).4. Lack of HCWs qualified to prescribecontrolled drugs.a. In Honduras, Tamil Nadu, Mongolia, Peru andKyrgyzstan only specialist palliative care and/oroncology doctors are allowed to prescribe morphine.b. In the Philippines only doctors with two speciallicences are able to prescribe morphine.c. Seventeen per cent of countries/regions werereported to require specific licences which were hardto obtain before being allowed to prescribemorphine.d. In Malawi (where clinical officers and doctors canprescribe opioids) there is only one doctor for every100,000 people. (22) Prior to a recent amendment,Ugandan laws allowed only doctors to prescribeopioids; in rural communities there is only onedoctor for 50,000 people. Therefore, most peopleare unable to access a doctor. These figurescompared to 164 doctors per 100,000 in the UK,where since May 2006 specialist nurses canprescribe opioids in addition to doctors.5. Lack of HCWs able to dispensecontrolled drugs.a. Ugandan law allows only pharmacists to dispenseoral morphine. In 2000 there were only 19pharmacists outside the capital (ie 19 pharmacists tocover a population of just over 21million). (23)b. In the Philippines only pharmacists with S3 licensesare allowed to dispense oral morphine.22

WORLD DAY REPORT3.2 Fear of addiction, toleranceand side effects100%90%80%70%% HCWs60%felt r eason 50%for40%decr esed30%access20%10%0%Graph 12: Factors decreasing access: fears of addiction, tolerance or side effectsAfrica Asia Latin AmericaThe main reasons HCWs felt that oral morphine is notavailable are owing to fears of addiction, toleranceand/or other side effects. In Africa over 50% felt thatother HCWs fear their patients will become addicted ifgiven oral morphine. A high percentage also felt thatHCWs fear accusation of misusing morphine if theyprescribe/dispense it. The reasons why these shouldnot be feared are addressed on pages 30 – 33.Patients fear addiction HCWs fear diversion to HCWs fear accusation ofnon-medical use by ‘public’misuse/harmful use if foundhandling morphineRelatives/carers fear addiction Policy makers fear diversion Fear of tolerancetreatmentsto non-medical use by HCWsHCWs fear addiction by patient Policy makers fear they will end Fear of side effectsup with wrong person and/or(excluding addiction andmisuse/harmful use by ‘public’ tolerance)“Pharmaceuticals do not want to produce theirown morphine due to myths and ignorance.”“Patients fear its (morphine) use, because itsuse is related with close end stage of life.”“Patients and relatives fear use of morphinethinking death is near.”23

3.3 Poorly developed healthcaresystems and supply% HCWs100%90%80%70%60%50%Graph 13: Factors decreasing access:poor access to healthcarePoor access to health centres/doctorsowing to distancePoor access to health centres/doctorsowing to expensePoor access to health centres/owing topreference for traditional/local medicines, treatmentsIn some areas, lack of access to morphine simplyreflects the difficulty for numerous people to accesshealth facilities. The lack of HCWs able to prescribe anddispense opioids is discussed under ‘national laws’(pages 20 – 22) This was felt to be more of a problemin Africa and Latin America than Asia – which is alsoreflected in the availability of some of the non-opioiddrugs, eg NSAIDs. Comparing the availability ofNSAIDs with the strong opioids indicates that this isnot the only factor, as access to NSAIDs is stillmarkedly higher.40%30%20%10%0%Africa Asia Latin America“We are very aware that we do not provideadequate pain relief for our patients. We get ourdrugs from the local hospital and they only allowus basic pain analgesics. The hospital is notgood on drug procurement, and there are oftenshortages so they don’t give us what we order.”24

WORLD DAY REPORTGraph 14: Factors decreasing access: supply and expense100%“Only small quantity used in a year comparedto the fees required for importation.”% HCWs90%80%70%60%50%“Morphine is not available continuously. Smallamount imported and next order placed afterfinishing and reporting previous supply. Drugimporter does not inform the health centresabout the arrival of the next supply. Thus thereis a long period of drug absence becausewaiting for importing and informing.”40%30%20%10%0%Africa Asia Latin AmericaNot available from drug suppliers Unable to manufacture Too expensive“Nobody prepares morphine in the city. It isprepared 600km away and delivery takes twodays. Pharmaceuticals don’t want to producetheir own morphine… The lab preparationcosts US$80 per litre. I have spoken topharmaceuticals and in three years I have hadno success.”“Small budget for health centres does not allowmorphine to be ordered in an adequatequantity. Thus only small quantities are orderedand imported.”25

3.4 ExpenseOral morphine is an inexpensive drug. Slow releasepreparations can be more expensive due to patents butare not required to provide good pain relief. Normalrelease preparations should be inexpensive to make;oral solution can often be made locally very cheaply.However, over one billion people live on less than $1 aday. (24) Palliative patients often lose their ability to earnor grow food so that even inexpensive drugs becomeimpossible to obtain. (25)Twenty-six per cent felt oral morphine was tooexpensive.Examples include:a. One main hospice in Zimbabwe can only accessnormal release oral morphine for half of the patientswho require it, as it is so expensive.b. In Honduras morphine (and all the other opioidanalgesics, eg oxycodone, hydromorphine, fentanyl)is available readily to private patients but, owing toexpense, only rarely available to non-private patients.PromotionIn 2004, a survey found that the relative cost ofanalgesics in developing countries was significantlyhigher than in developed countries. Another paperreported how the high costs of opioids in Argentina(26, 27, 28)restricted their availability.of non-generic forms (ie patented versions ofthe drug) has caused morphine to be unaffordable insome areas. When expensive formulations of opioidsappear on the market, inexpensive immediate releasemorphine often becomes unavailable. Opioids are stillpoorly understood and underutilised in manydeveloping countries. Promotion of expensiveformulations disrupts the balance in their favour, asthere is seldom any promotion or education on thecheaper formulations. For example, in India even at themoment there are institutions which have onlysustained release morphine. There are others whichhave no morphine at all but have transdermal fentanyl,though the regulatory barriers are the same for both. (29)26

WORLD DAY REPORT3.5 Lack of knowledge – HCWs,public and policy makers100%Graph 15: Factors decreasing access: lack of knowledge90% Lack of knowledge on painassessment, how to control80% pain and/or use andtitration of oral morphine70%60%% HCWs50%Not on your country’s EssentialMedicines ListPoor access to health centresdue to preference fortraditional/local medicines or40% treatments“One of the main reasons in my state is thepaucity of doctors prescribing morphinebecause of the lack of training/interest inpalliative care.”“It is simply irrational that oral morphine is notavailable in the country whereas expensivefentanyl patches can be made available for therich patients. Lack of doctors training,awareness and cure orientated approach of thesociety as well as of the medical communitymakes palliative medicine an unknown field.”30%20%10%0%Africa Asia Latin America27

100%90%80%Graph 16: Factors decreasing access: training70%Undergraduate trainingincluded treatment of pain &60%% HCWs use of opioids50%Undertaken/ing postgraduate course on treatment40% of pain & use of opioidsExclusion from a country’s essential drug list implieslack of understanding of the value of oral morphine inpain relief and possibly misunderstanding of fears bypolicy makers.In Latin America and Asia less than 30% of the HCWssurveyed had pain management included in theirprofessional training. However, the majority, more than70%, of respondents had gone on to achieve furthertraining for themselves.As an undergraduate: 82% of HCWs in LatinAmerica and 71% of HCWs in Asia had notraining on pain or opioids.30%20%10%0%Africa Asia Latin America“There seems to be poor knowledge of palliativecare prescribing and fear at all levels of usingopioids even when they are available, includingamongst specialist doctors. For example, in my10 years experience… when we have suggestedusing, or asked about knowledge of using,combinations of, for example, haloperidol/hyoscine combos with or without opioids forterminal patients, it is negatively received.”28

WORLD DAY REPORT4. Essential elementsrequired to increaseavailabilitySimply providing a supply of any drug will not increaseaccess; a number of interlinked factors need to beaddressed.4.1 EducationEducation is fundamental, ensuring that HCWsare aware of:how to diagnose pain and other symptoms;which analgesics to use when, in what dose, howmany times a day, and for how long beforereassessment;how to prevent and minimise side effects;how to access advice and share knowledge;how to access local palliative care facilities;legal requirements and what, if any, records arenecessary;where necessary drugs can be sourced;dispelling ‘morphine myths’.It also empowers patients, carers, volunteers and eachcommunity through knowledge:that pain and other symptoms can be relieved;of how to access palliative care facilities;of how to take drugs, minimise side effects, what todo if side effects occur (compliance is significantlyhigher when patients understand reasons for theirmedicines, and knowledge of potential side effectsincreases trust).A survey in Uganda illustrated how educatingcommunities can increase access and allayfears regarding morphine. (30)Finally, education is the key to ensuring that palliativecare is supported and legislation is not restrictive byeducating policy makers on:what palliative care is;the support INCB and international treaties give toensuring opioids are available for medical purposes;how to account for movement of opioids andrecords required;the importance of integrating palliative care intocancer and AIDS policies;how current laws can be improved to allow accesswhilst preventing diversion.Training is also vital for drug regulatory personnel andpolice, to ensure knowledge of who can possess andhandle controlled drugs, and the records required.It is important also to ensure donors and NGOs areaware of a country’s priorities and requirements.29

4.2. Addressing the fearsA number of HCWs, government officials and patientsfear that having morphine available to relieve pain willlead to drug addiction (by HCWs, patients or throughdiversion to the general public).Dependence on a drug can be divided into:Therapeutic dependence – analgesics do notremove the cause of the pain, therefore as long asthe pain remains (eg the tumour is still pressing on anerve) the patient will require the analgesic to remainpain free. Thus, patients may require morphine forthe rest of their life in order to remain pain free.Pharmacological dependence – the body producesits own pain relieving substances, endorphins, acertain level of which are circulating around the bodynormally. These are chemically similar to opioids.When a patient is given morphine regularly theirbody ‘senses’ an increase in ‘pain relieving’substances and responds by producing fewernatural endorphins. Consequently, if a patientsuddenly stops taking morphine, they will have alower level of endorphins than they had before theystarted taking morphine. This produces withdrawalsymptoms. A similar reaction occurs with steroids.This can be simply avoided by slowly reducing thedose in patients that have been on morphine for afew weeks if the cause of the pain has resolved.Addiction (sometimes referred to as psychologicaldependence) – this is what is feared: abnormal,compulsive behaviour, including a desperation toobtain the drug in order to experience its psychiceffects, characteristically having continued usedespite harm.Studies show addiction or psychologicaldependence is extremely rare when opioids are(31, 32, 33)used for pain.Availability for medical use does not go hand-inhandwith diversion for illegal purpose. (34)Twenty-one per cent of respondents felt that theircolleagues fear that patients will become tolerant tomorphine, resulting in the need for higher and higherdoses to relieve their pain so that perhaps when painbecomes very severe morphine would no longer beeffective. This can cause HCWs to delay startingmorphine and other opioids, reserving them for‘exceptionally severe pain’.Once a patient is on the correct dose of opioid torelieve a pain, the dose will not need to be increased,unless the illness progresses, causing further pain, orthere is another source of pain or other factors increasethe pain (social, spiritual, psychological). Then, whenthis pain is controlled, the dose will be kept stableagain. It is also important to explain to patients andrelatives that:the pain may not become worse;not all pains are 100% responsive to morphine, butthere are other types of analgesics which can betried.“Morphine should not be withheld until the painbecomes unbearable.”Note: a patient’s pain requirement may increase evenwhen there is no sign of disease progression.Pain is not only physical; psychological, spiritual andsocial factors impact on pain intensity.Pain may not be solely due to the ‘main disease’.Disease progression may not be easy to detect.In addition, remember:There is also no maximum dose of morphine. Thedose should be increased to that required to relievepain.Different pains respond to different analgesics.Some pains are only ‘partly’ responsive to opioids.Different opioids have different binding efficacies todifferent receptors, and therefore different analgesicproperties and side effects.Everybody has different pain thresholds, andexpress and cope with pain in different ways.“Only the patient knows how intense and frequenta pain is – a pain is what the patient says it is.”30

WORLD DAY REPORTDispelling the fear of tolerance:Ms CD, a 54 year old Argentinean nun, has had alocally advanced phaeochromocytoma with lungmetastases since 1997. In November 1997 she wasreferred to the palliative care team and started with30mg a day of immediate release morphine. In August1998 the morphine was changed to 15mg a day ofmethadone. Until August 2006 her disease has beenstable, and her pain well controlled. She now receives10 mg a day of methadone.During eight years on methadone she has had a veryactive life in her religious community; she is able totravel and performs several daily activities.Case study provided by Dr Mariela Bertolino, DrRoberto Wenk and Dr Guillermo Mammana, from thePalliative Care Unit , Tornu Hospital-FEMEBAFoundation.31

Thirty-eight per cent of respondents felt that fearside effects limited the use of oral morphine.All drugs have side effects. The side effects of morphineand other opioids are known and can be easilyminimised.Not all patients will experience side effectsThe following case study illustrates clearly how opioids donot render patients permanently drowsy, nor impaircognitive skills, nor are only used near the end of life –but how they can greatly enhance the life of the patientand their family.Ms EF had advanced nasopharyneal cancer. Shereceived oncology treatment and was referred to thepalliative care services in March 2003 with severe pain.The palliative care team started her on 12mg a day ofmethadone plus adjuvant analgesics. Her pain was wellcontrolled, allowing her to enjoy two more years ofactive life. Here she is pictured with her husband,members of the palliative care team and two tangodancing teachers. She died at home in May 2005. Atthis time she was on 3mg of oral oxycodone PRN,(usually taken twice a day) plus adjuvants.One side effect which many fear is respiratorydepression – tolerance occurs to respiratory depressionso that when the dose of morphine is increasedgradually, respiratory depression does not occur. It is forthis reason that patients are started on smaller doses ofmorphine which are titrated up until the pain is relieved(not because the patient has become tolerant to thepain relieving properties). In addition, pain is arespiratory stimulus, so the respiratory depressive effectis ‘cancelled out’ when morphine is used to relieve pain.Other side effects such as sickness and drowsiness canalso be minimised by increasing the dose slowly.Tolerance to the constipating effect of morphine doesnot occur but can be anticipated and prevented usinglaxatives.Mr JK was a surgeon from Eastern Europediagnosed with disseminated cancer of theoesophagus. On diagnosis he was given somepalliative chemotherapy. Initially he experiencedsevere pain which limited him in his activities.Following referral to the palliative care team forpain control, his pain was controlled verysatisfactorily with a 50 microgramme fentanylpatch and occasional immediate releasemorphine for breakthrough pain. Control of hispain allowed him to return to work, where hewas able to perform operations. Sadly hepassed away at the end of 2006, but until thenhe was very busy attending meetingsthroughout the country, giving short lectures aswell as enjoying weekends away with his family.Case study provided by Roberto Wenk, MD, MarielaBertolino, MD, and María Minatel, MD.Programa Argentino de Medicina Paliativa-FundaciónFEMEBA, Buenos Aires, Argentina32

WORLD DAY REPORTHow side effects can be managed:Ms HI was a patient with ovarian carcinoma who wastreated for four years by the palliative care team, afterdiscontinuing chemotherapy. She had threeenterocutanea fistulas during these years and severeabdominal pain related with the progression of thedisease.Her pain was soon controlled with opioids.Unfortunately, she initially experienced someneurotoxicity, but the palliative care team managed thissuccessfully by rotation of class and doses of differentopioids (morphine, oxycodone and methadone).Successful control of her pain and the side effectsmeant she was able to greatly enjoy many parts of thenext four years. She had an active life, she developedwork projects and most importantly was able to takecare of her two daughters. She was also able toundertake long-distance trips for some months to Spainto see one of her sisters. Ms HI died in the palliative care unit in 2005, havingdeveloped brain metastases.Case study provided by Dr Mariela Bertolino, Dr Roberto Wenk and Dr Guillermo Mammana, from the Palliative Care Unit , Tornu Hopital-FEMEBAFoundation.33

4.3. AccountabilityOpioids are regulated under the 1961 UN Singleconvention on Narcotic Drugs (amended by the 1972and 1988 protocols). The purpose of the regulation is toguarantee their availability for medical purposes, whilstpreventing abuse. The INCB monitor implementation ofthe conventions. The INCB requires each country tosubmit:an estimate of the quantity of each specified drug(including opioids) it will require for medical use –the amount imported or produced by a countryshould not exceed its agreed annual estimate;quarterly forms detailing the medical use of thespecified drugs (including opioids) within thecountry.Time, resources and definition of responsibilities needsto be made within the drug regulatory authority forthese activities, and to ensure accountability throughoutthe handling of these drugs.Factors limiting access to opioids include:fear by government officials and/or HCWs thatopioid abuse will occur;fear by HCWs that they will be accused of abusingopioids if they handle them.By keeping accurate records of the movement ofopioids and other restricted drugs, these worries canbe dispelled and the INCB requirements fulfilled. It isrecommended that records:are easy to complete;are kept throughout the whole supply chain(importation to patient supply or destruction orreturned);include details of:quantities acquired (imported/fromwholesaler/main hospital)supplier (eg wholesaler/doctor)amount dispensed or suppliedwhom it was dispensed/supplied toseparate running balance of the amount instock for each form and strength kept (thisshould be verified with a regular physicalcount of the stock).Seventy-five per cent of HCWs responded that theykept some form of record of handling morphine in theirpractice. Standardisation and provision of record booksfrom a central government level, the INCB or the WHOwould simplify this process.HCWs should advise drug authorities how significantchanges in palliative care services might alter thenational requirements for morphine and other stipulateddrugs. When estimating increases consider:the number of new patients likely to access theservice(s);the percentage of these likely to require morphine(or other drugs);the average dose of morphine any patient requiringmorphine is likely to require.34

WORLD DAY REPORT4.4.Reviewing laws and policiesPolicy change will only occur if governmentsunderstand the importance of palliative care and theneed to increase access to drugs for palliative carewithin their country. Thus, before changes to laws andpolicies can be addressed there is a need to:promote the benefit and role of palliative care,highlighting how many patients within the countrycould benefit;ensure all government individuals are aware of theability of inexpensive medicines to relieve pain in themajority of people, including children;document areas where the requirement for palliativecare is not met;develop leadership: workers within palliative carewho are willing to help affect change.National drug laws vary between countries. Drug lawsneed to be relevant and practical to clinical practice.For example, the drug laws were amended in Ugandarecently to allow specialist palliative nurses as well asdoctors to prescribe oral morphine, as the number ofdoctors would not allow access to all patients requiringpain relief.There is a need to ensure palliative care is integratedinto national HIV/AIDS and cancer policies, countries’EMLs and treatment guidelines (and that all theseinclude children).A recent INCB meeting called for relevant countryauthorities to consider and modify any restrictions inplace which are not required by international law andwhich would potentially restrict access for medicalneed. (35)The PPSG has developed methods for evaluatingnational drug policies’ suitability to allow access toopioids for medical purposes whilst maintainingregulation, in cooperation with the WHO, palliative careexperts and government regulators. A tool has beenpublished in conjunction with the WHO (2000) –Achieving balance in national opioids control policy:guidelines for assessment. (36) Details of this and furtherinformation on amending drug laws can be obtainedfrom www.painpolicy.wisc.edu“…consensus among all governments that themedical use of narcotic drugs continues to beindispensable for the relief of pain and sufferingand that adequate provision must be made toensure the availability of narcotic drugs forsuch purposes.” (37) 35

4.5 Strengthening health facilities4.5.1 Human resourcesStrengthening of many countries’ health services isrequired to enable full access to palliative and otherdrugs. It is likely that different structures andapproaches will work better in different countries.It is recommended when establishing or expandingservices to:examine existing services, their effectiveness anddisadvantages;ensure integration with existing models;encourage community participation;ensure cooperation with the private sector;communicate clearly to donors what is required.Lack of trained HCWs contributes to inaccess topalliative drugs in a number of countries. The numberand skill mix of HCWs varies widely between countries.Ways in which to address this problem will also vary,perhaps, for example, utilising and paying laycounsellors, ensuring quality training and support ofvolunteers, and establishing guidelines nurses canfollow, with a referral doctor available.4.5.2 Drug procurementEnsuring a reliable, timely, quality and inexpensive drugsupply is important to ensure patients remain pain freeand prevent withdrawal reactions. Accounting for opioiduse will help estimate quantities required. There are anumber of steps in the drug procurement process:Planning – ensuring sufficient supplies are alwaysavailable but that stock does not expire, ascertainingwhat is the best form to use, finding a reliableimporter or supplier, co-ordination with otherorganisations (it is often more cost effective to havea central source therefore collaboration is important).Importation – sufficient time needs to be given toallow for form filling and potential delays, and goodcommunication between clinicans and procurement‘agents’ is vital.Manufacture – is it cheaper to manufacture locally orin-house; who nearby has the capacity? Is the finalformulation cheaper to import? For small scalemanufacture (production of drugs from raw materialsin your health facility) you will require:reliable source of raw materials;good water supply;accurate weighing scales and measures;funnels, bowls, pestle and mortar;labels;containers for final product;verified formula;trained staff;appropriate storage for raw materials andfinal product;quality control procedures in place.Transportation – who is allowed to collect controlleddrugs from a wholesaler?36

WORLD DAY REPORT4.5.3 Drug costsEstablishing a reliable, quality assured and inexpensivedrug supply and distribution is not always easy.Many pharmaceutical companies are not interested inmanufacturing morphine or in obtaining a licence fortheir formulation in countries where usage is thought tobe low and bureaucracy potentially cumbersome.Perhaps there should be a call to the WHO to establishreliable and inexpensive manufacturing of drugs on theWHO EML?Morphine solution can be made cheaply from thepowdered form. However, many smaller providers lackthe scales, raw materials and qualified staff; only 32%of the respondents worked in units which had facilitiesfor making morphine solution from the powder and thenstoring it in a secure place. Hence, establishing incountrycentral production and adequate distributioncan be a good option. In some places a larger hospitalor NGO organisation has agreed to manufacturemorphine solution as a central supplier.For example:In Uganda in 2000 following advocacy by HospiceUganda, the MoH commissioned a charitableprocurement and manufacturing facility to producemorphine solution which could be distributed tohospitals, health centres and palliative careproviders as requested. Commercial manufacturershad been approached but owing to the lack of profitthey were not interested in manufacturing morphinesolution.In Nigeria supply of morphine through centralimportation had been erratic since 1993. Followingadvocacy by the Society for the Study of Pain andthe Centre for Palliative Care, the University CollegeHospital pharmacy in Ibadan now prepares oralmorphine from the morphine powder (5mg/5ml and50mg/5ml) and supplies patients across the country(with over 130 prescriptions per month beingdispensed for cancer patients from all over thecountry).37

5. Recent advances inincreasing access toanalgesicsOver the last 10 years access to analgesics hasincreased substantially in a number of countries orregions within a country. A few of these are outlinedbelow (this is not a comprehensive list).5.1 IndividualsNumerous individuals have made significant stepsin increasing patient access to analgesics in the last10 years.“I am instructor at the residence of generalmedicine in the hospital where I work, and I trainresidents annually in the formation of generalpalliative care, especially in the treatment of painand opioid use. This has generated somechanges for the better. Furthermore, I produced abasic guide that deals with the process of paintreatment and use of opioids, which is starting tobe used by doctors and nurse interns, andhospital guards. We are currently creating apalliative care team.”5.2 WHO and INCBIn 2005 the World Health Assembly (WHA) andECOSOC adopted resolutions inviting the INCB and theWHO to examine the feasibility of assisting in projectsto increase the availability of opioid analgesics(resolutions ECOSOC 2005/25 and WHA58.22). TheINCB and the WHO agreed that the WHO would act asthe focal point, with the WHO preparing the ‘Access toControlled Medications Programme’. The programme,which will commence in late 2007 or 2008, aims to workwith all involved, including governments and NGOs,addressing the situation in over 150 countries with bador no access.The PPSG has published 22 translations of the WHOpublication Achieving balance (36) which provides aresource for governments and HCWs to evaluate andimprove national laws on preventing access to opioids.www.painpolicy.wisc.edu5.3 Resolutions advocating for anincrease in accessibility to opioidanalgesicsECOSOC 2005/25 – On treatment of pain usingopioid analgesics.WHA 55.22 (25-05-2005) on Cancer prevention andcontrol“...to examine jointly with the International NarcoticsControl Board the feasibility of a possible assistancemechanism that would facilitate the adequatetreatment of pain using opioid analgesics”.38

WORLD DAY REPORT5.4Changes in national laws1. In February 2002 the PPSG, the Eastern Europeanregional office of the WHO and the Open SocietyInstitute (OIS) conducted a workshop on ‘Assuringthe Availability of Opioid Analgesics for Palliative Carewithin Eastern Europe’. From this, Bulgaria, Croatia,Hungary, Lithuania, Poland and Romania completedaction plans to help address regulations whichimpeded access. Romania was chosen as a pilotcountry.2.Hospice Casa Sperantei in Romania wascommissioned by the Romanian MoH to review theiropioid legislation and policy using the WHOguidelines. Recommendations were presented to theMoH in 2003 which would help increase access toopioids for patients, eg increasing the supply ofopioids allowed to be given to patients from threedays to 30 days. The recommendations wereaccepted and the new law, nr 339/Nov 2005, hasbeen in action since July 2006, although it needs tobe printed in the official journal before the regulation(20, 38)can be applied.In Kerala, India, advocacy and amendment of statedrug regulations laws now allows more than 100palliative care units around the state to have accessto oral morphine. An audit demonstrated thatincreased use of oral morphine did not lead todiversion and misuse. (34)3.The Ugandan Government has recently amendeddrug laws to allow clinical officers and nurses whohave completed a specialised course in palliative careto be able to prescribe oral morphine. (39) This followsthe recognition of the shortage of doctors within thecountry. Zimbabwe also allows specifically trainednurses to prescribe oral morphine and theDemocratic Alliance Government in South Africa hasrecently proposed that prescribing by speciallytrained nurses should be allowed in South Africatoo. (17)4.The PPSG has documented recent changes in lawsaimed at improving access to morphine; theseinclude increasing the length of supply which can beprescribed and dispensed:1. France: 1995Seven days increased to 28 days2. Mexico:Five days increased to 30 days3. Italy: 2001Eight days increased to one month;in addition simplified prescription format andallowed two drugs or dosage units on one form4. Germany:One day increased so there is no limit5. Peru:One day increased to 14 days6. India:Five licenses required decreased to two licensesfor morphine9. Romania:Three days supply increased to 30 days supply10. Colombia:10 days increased to 30 days (for strong opioids)39

5.5 Some regional initiatives401. Pallium India (Trust), working with the PPSG and theNational Cancer Institute (USA), has facilitated thecreation of palliative care facilities in three cancercentres in three states, in which effective palliative carefacilities did not previously exist. Working with theAmerican Cancer Society and International Network forCancer Treatment and Research, the trust has alsocatalysed the development of a palliative care trainingcentre in Hyderabad.2. Hospice Africa (Uganda) has been running aprogramme to help train HCWs in other Africancountries and help approach government officials andadvocate the need for palliative care and morphine. Todate, visits/courses for African countries have beenheld in Ethiopia, Tanzania, Malawi, Nigeria, Kenya,Ghana, Zambia, and for South Africa in Kampala andUganda. Funding has come from the RAF (UK) grantand the Diana, Princess of Wales Memorial Fund.3. The African Palliative Care Association (APAC)provides advice on the provision of affordable, culturallyappropriate palliative care throughout Africa. Initial visitsto Sierra Leone (2005) have led to advice to smallinitiatives as well as discussion with Ministry officials asto the importance of palliative care. APCA is currentlyworking in collaboration with the PPSG to help anumber of African countries examine their drug laws, toensure they allow access. In 2006 a workshop wascommissioned to help establish country plans andexamine drug regulations.info@apac.co.ug; www.apac.co.ug4. Help the Hospices runs a Twinning programme forHospices – a two-way sharing of ideas andexperiences. Seewww.hospiceinformation.info/hospicesworldwide/twinning.asp5.6 Some country initiatives1. IndiaIn 2005 the government of India appointed a task forceof experts to assist it in formulating a strategy for thecountry’s National Cancer Control Programme, a fiveyear plan which is due to commence in 2007. The taskforce consisted of separate groups each for anindividual area in cancer control and care. One of thesegroups was on ‘Palliative Care and Rehabilitation’. Thegroup had extensive discussions via email and met acouple of times. Its recommendations, which weresubmitted to the government in May 2006, includedstrategy for:the creation of palliative care facilities, or upgradingthem where they existed, in all of 28 RegionalCancer Centres in the country;the upgrade of five centres to training centres;the creation of 100 other palliative care facilities inother oncology centres so that each state wouldhave at least two palliative care services;the inclusion of palliative care in undergraduatemedical and nursing curriculum, and in thepostgraduate curriculum for oncology trainees;the simplification of narcotic regulations in all states in India (currently 15 of 28 states havecomplicated rules);community participation in palliative care delivery.2. RomaniaHospice Casa Sperantei in Romania:has prepared a training curriculum (20 hours) andhas educated 40 trainers to run a national trainingprogramme in the use and prescribing of opioids.This was funded by Help the Hospices and theOpen Society Institute, New York;under the umbrella of the national postgraduatetraining centre, is running courses for doctors andpharmacists detailing the use and prescribing ofopioid medication in 30 districts of Romania, in orderto facilitate the implementation of the new opioidlegislation. This is funded by the Open SocietyInstitute New York and three drug companies:Janssen, Lannacher and Mundipharma.cshospice@hospice.bv.astral.ro

WORLD DAY REPORT3. NigeriaProfessor Olaitan Soyannwo and four colleagues fromIbadan began advocating for opioid availability in 1996.Their dedication and enthusiasm over the last 10 yearshas led to:the establishment of the Society for the Study ofPain, Nigeria (a chapter of the InternationalAssociation for the Study of Pain);the creation of the Centre for Palliative Care, Nigeria.Their inspiration has led to individual and groupinitiatives including:a home based palliative care service (supported byHospice Africa, UK);training workshops; setting up a pain/palliative care clinic; the development of the National Palliative CareGuidelines adopted in 2006 by the Federal Ministryof Health (including the use of the WHO analgesicladder and opioids for severe pain);the inauguration of a consultative committee forcancer care (including a sub-committee on palliativecare) into the Nigerian MoH in October 2006.Formation of this committee has allowed ProfessorSoyannwo to guide other committee members abouthow their hospitals can access opioids; prior accesswas denied in many hospitals owing to a lack ofknowledge about how to access opioids;symposia for healthcare practitioners;inclusion of palliative care and safe use ofanalgesics in undergraduate and postgraduateteaching, and input into curriculum review;the dissemination of information about opioidaccessibility and safe use through the NigerianSociety of Anaesthetists, the West African college ofSurgeons annual conferences, and in-servicetraining units of hospitals, eg resident doctors,nursing, HIV and cancer centers.4. UgandaDr Anne Merriman and dedicated colleagues set up ahospice in Kampala in 1993 after ensuring thegovernment would allow oral morphine to be used forpain relief. Hospice Uganda has expanded and nowincludes three centres in Uganda, as well as serving asa model Hospice for Africa and aiding other Africancountries in establishing palliative care facilities.Projects and initiatives include:three centres providing home care service forapproximately 900 patients at one time;certified in-country training for healthcareprofessionals in palliative care, currently workingclosely with MoH to ensure training in all districts;providing special training for clinical officers andnurses to lead palliative care units in their hospitalsor teams. These nurses and clinical officers areallowed to prescribe morphine following a recentchange in Ugandan law;certified in-country training for volunteers in palliativecare;training of trainers courses;advocacy leading to:the inclusion of palliative care as an essentialcomponent in the MoH five year strategicplan in 2000 – this in turn led to increasedaccess to oral morphine and amendments toUgandan laws to allow specially trainedclinical officers and nurses to prescribe oralmorphine;the inclusion of palliative care training inprofessional undergraduate courses.41

5.7 Proposed projectsPPSG, a WHO collaborating centre:Internet courses on international pain policy.International Pain Policy Fellowship.New opioid statistics to allow the study ofconsumption (use) for medical purposes andestimated requirement:to aggregate opioids for severe pain intoone number (ie combine figures for use oforal methadone, oral morphine, oraloxycodone etc);to estimate minimum country needs basedon mortality.Guidance as to the essential elements of abalanced national drug law.Opioid availability profile for every country.Provision of support by international experts:speaker supportdatacollaboration.6. Educationalopportunities1. Hospice Uganda – postgraduate multidisciplinarydiploma in palliative care2. Pallium Latinoamerica – distance learning advancedcourse in palliative care (multidisciplinary,postgraduate course in Spanish) www.pallium.org3. Wisconsin fellowship4. Programa Argentino de Medicina Paliativa-FundaciónFEMEBA, Buenos Aires, Argentina – one hundredand sixty hours face to face (70% clinical practice inpalliative care units) postgraduate courses inpalliative care for physicians, nurses andpsychologists. E-courses for physicians andnurses. (40) Both activities are in Spanish(paliativo_femeba@arnet.com.ar)5. The IAHPC website details a number of otherdiplomas and courses in palliative care ­www.hospicecare.com/edu7.What you can do7.1 AdvocacyGovernmentsHCWsPublicCall for provision of reliable and inexpensive sourceof EML drugs7.2 EducationSupport initiatives7.3 Support for hospices throughinternational organisations anddirectlyVolunteeringFinancialCoordination of services7.4ResearchHow to increase access, demonstrating diversion isnot a problem.42

WORLD DAY REPORT8.References1. Lipman A.G. Pain as a human right: The 2004Global Day Against Pain. Journal of Pain andPalliative Care Pharmacotherapy 2005; 19(3):85-100.2. Brennan F. Palliative care as an international humanright. Journal of Pain and Symptom Management2007; 33(5): 494-499.3. Help the Hospices Survey on Access toAnalgesics 20064. Hearn J. and Higginson I.J. Cancer painepidemiology: a systematic review. In Bruera E.D.and Portenoy R.K. editor. Cancer pain, assessmentand management. Cambridge: CambridgeUniversity Press; 2003.5. Norval D.A. Symptoms and sites of painexperienced by AIDS patients. South African MedicalJournal 2004; 94(6): 450-454.6. Merriman A (Personal communication 2006)7. Solano J.P., Gomes B. and Higginson I.J. Acomparison of symptom prevalence in far advancedcancer, AIDS, heart disease, chronic obstructivepulmonary disease and renal disease. Journal ofPain and Symptom Management 2006; 31(1):58-69.8. UNAIDS. Report on global AIDS epidemic. Geneva:UNAIDS; 2006.9. Parkin D.M. et al. Global cancer statistics 2002. CA:A Cancer Journal for Clinicians 2005; 55:74-108.10.Azevedo Sao Leao Ferreira K., Kimura M. andJacobsen Teixeira M. The WHO analgesic ladder forcancer pain control, twenty years of use. How muchpain relief does one get from using it? SupportiveCare in Cancer 2006; 14(11): 1086-1093.11.World Health Organization. Comparative table ofcore medicines on the WHO Essential MedicinesList from 1977-2005 [online]. Available from:http://www.who.int/medicines/publications/essentialmedicines/compar_table_who_edls.xls [Accessed21 August 2007].12.World Health Organization. Essential medicines[online]. Available from:http://www.who.int/topics/essential_medicines[Accessed 21 August 2007].13.World Health Organization. WHO Model List ofEssential Medicines [online]. Available from:http://www.who.int/medicines/publications/essentialmedicines [Accessed 21 August 2007].14.Scholten W (Personal communication 2006)15.De Lima L. The International Association for Hospiceand Palliative Care list of essential medicines forpalliative care. Palliative Medicine 2006; 20(7):647-651.16.De Lima L. Ensuring palliative medicine availability:the development of the IAHPC List of EssentialMedicines for Palliative Care. Journal of Pain andSymptom Management 2007; 33(5): 521-526.17.Relax of morphine regulations. Sunday Times(South Africa) 2006 October 26.18.Sindrup S.H. et al. Efficacy of pharmacologicaltreatments of neuropathic pain: an update andeffect related to mechanism of action. Pain 1999;83(3): 389-400.19.Colins S.L. et al. Antidepressants andanticonvulsants for diabetic neuropathy andpostherpetic neuralgia: a quantitative systematicreview. Journal of Pain and Symptom Management2000; 20(6): 449-458.20.Mosoiu D. et al. Reform of drug control policy forpalliative care in Romania. The Lancet 2006;367(9528): 2110-2117.43

WORLD DAY REPORT9.Further resourcesAchieving balance in national opioids control policy:guidelines for assessmentWorld Health Organization, 2000:www.painpolicy.wisc.edu/publicat/00whoabi/00whoabi.htmCancer Pain ReliefA quarterly WHO newsletter:www.whocancerpain.wisc.eduHelp the Hospices websiteIncludes on-line education material, an internationalsection and information on grants available:www.helpthehospices.org.ukHospice InformationAn international resource on hospice and palliativecare provided by Help the Hospices andSt Christopher’s Hospice offering:Networking at regional, national and internationallevelsAccess to resources and trainingElectronic and print publications including:Worldwide Hospice and Palliative Care Online,Hospice Information Bulletin,International palliative care directories‘Starter packs’ for people who wish to establish aservice or develop links through volunteerplacements or twinning partnershipswww.hospiceinformation.infoInternational Association for Hospice and PalliativeCare websiteContaining:Free monthly newsletterUnder resources (not a comprehensive list):Educational resourcesPain and palliative care assessment andresearch toolsPolicy and advocacy toolsStandards for palliative provisionTreatment guidelinesInformation for patients and relativesAdministrative and programmedevelopment toolswww.hospicecare.com45

International Narcotics Control Board websiteContaining:UN conventions relating to opioidsReports: Technical reports, Treaty Adherence,National EstimatesList of drugs and substances covered by theconventions (‘Yellow List’)Guidelines for National Competent AuthoritiesForms required by INCB regarding opioidsGuidelines for travellersTraining materials:www.incb.orgPart 1 – general informationPart 2 – estimates systemPart 3 – statistical returnsMédecins sans Frontières (MSF)MSF’s is campaigning internationally for greater accessto essential medicines. Website includes pressreleases, reports and publications:www.accessmed-msf.orgPain and Policies Study Group, WisconsinResources on opioid availability, conferencepresentations and monographs:www.painpolicy.wisc.eduPalliative Care MattersIncludes links to International palliative medicinejournals and an electronic version of the PalliativeMedicine Handbook by Ian Back: www.pallcare.infopalliativedrugs.comPromotes and disseminates information about the useof drugs in palliative care: www.palliativedrugs.comWHO Expert Committee on Drug Dependence –Thirty-fourth reportWHO, 2006:www.who.int/medicines/areas/quality_safety/34thecddmeet/en/index.htmlWHO List of Essential MedicinesIncludes concept of essential medicines, currentlist, guidelines and how to submit suggestions forfuture lists:www.who.int/medicines/services/essmedicines_def/en/index.htmlWHO webpage on substances under internationalcontrol, which links to UN conventions relating toopioidswww.who.int/medicines/areas/quality_safety/sub_Int_control/en/index.html46

Access to pain relief – an essential human rightHelp the HospicesHospice House34–44 Britannia StLondon WC1X 9JGTel: 020 7520 8200www.helpthehospices.org.ukRegistered Charity in England and Wales, Help the Hospices No. 1014851Company Limited by Guarantee registered in England No. 2751549. Registered office: Hospice House as above.Printed by Hobbs The Printers, Hampshire.