The major barriers to implementing adequate pain control for cancer patients on a global scale are restrictive government regulations and lack of access to supplies of morphine. Individual countries may lack morphine suppliers, and regulations in countries where morphine is available may prevent doctors from prescribing doses strong enough to alleviate pain and suffering.
Although a number of international organizations have made strong statements hoping to address the problem of inadequate pain control in cancer patients, this has not led to widespread reform in allowing access to standard care, said Kathleen Foley, MD, Memorial Sloan-Kettering Cancer Center in New York City, at the ESMO 2012 Congress.6 These organizations include the Council of Europe, International Narcotics Control Board, United Nations, World Health Organization, Commission on Narcotic Drugs, and Human Rights Watch, among others.
Foley believes that the problems are solvable, but mainly on a country-by-country basis. She reported success stories for programs funded by the International Palliative Care Initiative. The model for these programs is to 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, this has been done in 20 countries.
“We use international documents with symbolic language to guide this policy at a country level. These passionate champions are driving this movement within each country,” she told listeners.
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.
In Romania, 35-year-old restrictive policies were changed. Now there are no limits on daily morphine dose or patient diagnosis. “Past policies were burdensome for patients, and physicians, and these are new beginnings,” Foley said.
In Colombia, a new palliative care law was passed in 2009, and as a result of that law, each district of the country has 1 pharmacy that can provide opioids 24 hours a day.
In Guatemala, efforts are ongoing to bring a morphine supply from Guatemala City to rural areas and to provide further education to legislators, physicians, and patients.
“It’s hard to believe, but in 2012, the first injectable morphine prescription was written in Guatemala, at a hospital where bone marrow transplant is available,” she said.
In Nigeria, the government is now supportive of getting cancer patients access to pain control. In Serbia, a pain policy fellow is working with the government, which has adopted a pain policy stating that opioids are essential for pain relief. In Armenia, a policy is in place, but a supplier still needs to be found.
“Uganda is a great success story,” she continued. The initiative created a strategic health plan, added liquid morphine to the essential list, adopted new guidelines, and authorized prescription by nurses. Seventy-nine providers have been trained.
“We argue that no country should be allowed to enter the EU [European Union] unless they have opioids and a pain policy for cancer care. The solution is to identify champions at a country level and work with them. We can do this,” Foley said.
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