Hundreds of millions of patients with cancer around the world are suffering from unrelieved cancer pain, despite the availability of morphine and other drugs that could alleviate that suffering. The major barriers are twofold: governments failing to ensure an adequate supply of morphine and other opioids, and restrictive policies that limit dosages of morphine and other opioids in countries that have supplies of these drugs on hand.
Scope of the Problem
At the 2012 European Society for Medical Oncology (ESMO) Congress in Vienna, the first presentation of data gathered by the International Collaborative Project to Evaluate the Availability and Accessibility of Opioids for the Management of Cancer Pain revealed more details about the scope of the problem.1 In particular, very few countries in Africa, Asia, the Middle East, Latin and Central America, and the Caribbean had supplies of all seven of the opioid medications deemed essential for control of cancer pain by the International Association for Hospice and Palliative care: These include—but are not limited to—codeine, immediate- and slow-release oral morphine, oral oxycodone, and transdermal fentanyl.
In many countries, fewer than three of the seven essential medications are available. The medications that are available are either unsubsidized or poorly subsidized by the government, and supplies are often inadequate. Moreover, highly restrictive regulations in many countries limit patients’ entitlement to receive prescriptions, limit prescriber privileges, and impose restrictive burdens on duration and amount of medications prescribed. These countries have erected bureaucratic roadblocks in the prescribing and dispensing process.
Wealth of Knowledge
“The study provides an unprecedented wealth of knowledge that will be an essential tool in lobbying governments to reformulate plans for treatment of cancer pain,” stated lead author of the report, Nathan I. Cherny, MD, Shaare Zedek Medical Center Jerusalem, Israel. Dr. Cherny is Chair of the ESMO Palliative Care Working Group. “We now know which countries have suboptimal formulations of medications to relieve pain, how much patients must pay to get the medications, which countries have excessive regulatory barriers that make it impossible for a patient to have access to a prescription or to a nearby pharmacy to have the medication dispensed. The end result is that hundreds of millions of patients with cancer don’t have access to essential pain-relieving medications. This is a shocking picture.”
The study was initiated by ESMO working with more than 20 other organizations, including the Union for International Cancer Control (UICC), World Health Organization (WHO), European Association of Palliative Care (EAPC), and University of Wisconsin Carbone Cancer Center. Data were gathered between December 2010 and July 2012, from 156 reports submitted by experts in 76 countries and 19 states in India. The reports represented 5.7 billion people who live in the countries included in the database.
Dr. Cherny said this report is the first step in a coordinated effort to meet this major global challenge. “We are determined to tackle this problem at every level,” he said.
Country-by-country Solutions
Kathleen M. Foley, MD, Memorial Sloan-Kettering Cancer Center, New York, agreed with Dr. Cherny that the situation regarding lack of pain control for patients with cancer is dire, urgent, and long-standing.2 In fact, all of the major organizations involved in global pain have made public pronouncements and even conducted international campaigns, but little progress has been made on a global level.
Dr. Foley stated that there are solutions to these problems, but they are mainly country-by-country. As Medical Director of the International Palliative Care Initiative, she is involved first-hand in selecting countries to receive grants by the following model: Identify a “national champion” for cancer pain control within a country, perform a needs assessment, hold a stakeholders’ meeting, develop task forces, and then formulate a palliative care concept for that country. So far, grants have been given to 20 countries, Dr. Foley said.
In 2012, the International Palliative Care Initiative funded fellowships in India, Bangladesh, Sri Lanka, Albania, Kyrgyzstan, and Ukraine. Fellows work at the University of Wisconsin in Madison to learn the model described above.
Among its success stories, the Initiative has led to changes in 35-year-old restrictive policies in Romania; new legislation in Colombia guaranteeing at least one pharmacy in each district with access to opioids 24 hours each day; morphine supplies being brought to rural areas in Guatemala, and the education of legislators, physicians, and patients in that country. In addition, Initiative alliances have achieved a buy-in from the government of Nigeria for access to pain control for patients with cancer; worked with the Serbian government to implement a pain policy providing access to essential opioids; and implemented a policy for pain control in Armenia, although access to drug supplies is still a nationwide problem there.
Uganda is one of the best success stories, Dr. Foley told listeners. The Initiative created a strategic health plan, added liquid morphine to the essential list, adopted new guidelines, authorized prescription by nurses, and trained 79 providers. ■
Disclosure: Dr. Foley reported no potential conflicts of interest.
References
1. Cherny NI: The International Collaborative Project to Evaluate the Availability and Accessibility of Opioids for the Management of Cancer Pain: Survey result. 2012 ESMO Congress. Abstract 1707. Presented September 29, 2012.
2. Foley K: A global policy approach to freedom from cancer pain. 2012 ESMO Congress. Presented September 29, 2012.
