• Pain Management
• Affordability of Care

Adequate relief of the pain associated with cancer is now recognized as a patient right, and opioid analgesics are essential for effective relief of this pain [Cherny NI et al. Ann Oncol 2010]. However, an opioid regulatory paradox exists with 2 conflicting needs: these drugs should be available to the patients who need them, but they should be prevented from becoming a source of abuse. Restrictions on the availability and accessibility of opioids in Africa, Asia, Latin America and the Caribbean, and the Middle East pose a major public health problem. Nathan I. Cherny, MD, European Society of Medical Oncology (ESMO) Palliative Care Working Group and Shaare Zedek Medical Center, Jerusalem, Israel, reported new data on the state of management of cancer pain in these countries.

The International Collaborative Project to Evaluate the Availability and Accessibility of Opioids for the Management of Cancer Pain in Africa, Asia, Latin America, and the Middle East assessed the formulary availability and cost to the consumer of the range of opioid drugs used in the management of cancer, along with the barriers to the accessibility of opioid drugs for patients with cancer pain in each participating country. Several coordinating partner organizations worked together to complete this study initiated by ESMO, including the European Association for Palliative Care, the Pain and Policy Studies Group at the University of Wisconsin Carbone Cancer Center, the Union for International Cancer Control, and the World Health Organization (WHO).

Out of the 161 countries and Indian states that received surveys, 93 reported data, which represents a population of ∼4.8 billion. The survey evaluated the formulary availability and cost of 7 essential opioids: codeine, and morphine (oral immediate release, oral controlled release, and injectable formulations), oral immediate release oxycodone, oral methadone, and the fentanyl transdermal patch. Over half of the countries studied had a limited or very limited formulary with respect to opioids. On the other hand, all the Indian states had immediate release morphine on formulary, but most required the patient to cover the full cost of any opioid.

In addition to formulary availability and cost, the International Collaborative Project reported on 8 other barriers to obtaining opioids: actual availability of the opioids, patient eligibility restrictions such as requiring permits, restrictions on which physicians can prescribe opioids, restrictions on the number of days the prescription can be written for, increased bureaucratic burden with opioid prescriptions, restrictions on pharmacists, restrictions on where patients are allowed to fill prescriptions, and negative laws regarding medical use of opioids. Of the 93 countries reporting data, 84% had 4 or more of these barriers, and 39% had 6 or more barriers.

Prof. Cherny concluded that “in many places across Africa, Asia, the Middle East, and Latin America and the Caribbean, governments are failing cancer patients in delivery of adequate pain relief.” He outlined actions for reducing the barriers to obtaining opioids in order of priority, as follows: 1) formulary review, 2) improving affordability, 3) improving availability of opioids on formulary by better distribution and dispensing, 4) examination of drug control policies, and 5) repeal of excessive restrictions.

In the same session, Kathleen M. Foley, MD, Memorial Sloan-Kettering Cancer Center, New York, New York, USA, discussed “a global policy approach to freedom from cancer pain.” Dr. Foley explained the WHO Public Health Model for pain management, which involves drug availability, education and implementation under the overarching umbrella of policy.

To help implement WHO policies in individual countries, a “palliative care roadmap” is used by the Open Society Foundation's International Palliative Care Initiative. This roadmap outlines the process of identifying national champions for palliative care, completing a country needs assessment, holding a national stakeholders meeting, creating various government task forces, and developing a palliative care concept for the individual country.

The Global Access to Pain Relief Initiative has made progress in a few exemplary countries. For instance, in Uganda, opioid access has been expanded and morphine is now free for all patients. Dr. Foley concluded that countries such as Uganda show that it is possible to improve accessibility to essential pain medicines, and now steps need to be taken to do this globally.

• © 2012 MD Conference Express®