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Access to Opioid Analgesics: Essential for Quality Cancer Care

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Cancer Pain

Abstract

Many cancer patients suffer moderate to severe pain, but owing to a focus on the prevention of abuse of and dependence on drugs, medical access to opioid analgesics has been neglected. Today, opioid analgesics are not readily available for medical use in many parts of the world. The World Health Organization (WHO) estimates that 5.5 billion people (83 % of the world’s population) live in countries with low to non-existent access to controlled medicines and have inadequate access to treatment for moderate to severe pain. Although some have been advocating for improved pain management for several decades, only recently has the inadequate access to and availability of opioid analgesics become an internationally recog­nised problem.

Measuring opioid analgesic consumption is possible using data from the International Narcotics Control Board. This requires aggregation of the various opioid analgesics expressed in “mg morphine equivalents”. For determining the level of consumption that will be adequate in a country, its per capita consumption can be compared with the consumption level in most developed countries by calculating the Adequacy of Consumption Measure (ACM). A correction of the need for opioid analgesics depending on the morbidity level in a country is possible by using HIV, cancer, and injuries as a proxy, but this has its limitations owing to the unreliability of health statistics in some countries.

Independent of the method, all methods show that there is a huge disparity between countries: the difference between the countries with the highest and lowest ACM in 2006 was 40,000 folds.

The World Health Organization defined availability, accessibility, and affordability as the key areas of concern around controlled medicines. These three terms relate to the questions: “Is the medicine present in the pharmacy?”, “Is it possible to obtain the medicines from the pharmacy?” and “Has the patient sufficient means to buy it?” If these conditions are not met, the patient’s pain will not be managed. A variety of barriers can be at the root of limited availability, accessibility, and affordability. Four categories of barriers can be distinguished: legislative and policy barriers, knowledge barriers, attitudes barriers, and economic barriers.

The World Health Organization established the Access to Controlled Medicines Programme (ACMP), which developed a number of documents to guide policy makers and health-care professionals to improve access to opioid analgesics and other controlled medicines. The ACMP and a number of NGOs also provide support to countries that want to improve access to controlled medicines e.g. by organising workshops and reviewing (draft) legislation. Moreover, international organisations of health-care professionals also called for adequate access to pain medicines and treatment of pain.

In order to ensure that “effective pain control measures will be available universally to all cancer patients in pain” by 2020, we will need to record our progress toward and analyse the barriers to adequate pain management. Access to opioid analgesics is essential for quality cancer care because by treating the pain, we improve the patient’s quality of life in one important aspect of his or her disease.

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Notes

  1. 1.

    http://www.painpolicy.wisc.edu/

References

  1. Krakauer EL, et al. Opioid inaccessibility and its human consequences: reports from the field. J Pain Palliat Care Pharmacother. 2010;24(3):239–43. Accessible at: http://informahealthcare.com/doi/abs/10.3109/15360288.2010.501852. Accessed 11 Oct 2012.

    Article  PubMed  Google Scholar 

  2. International Narcotics Control Board. Demand for and supply of opiates for medical and scientific needs. In: Report of the International Narcotics Control Board for 1989. New York: United Nations; 1989.

    Google Scholar 

  3. World Health Organization. mhGAP Mental Health Gap Action Programme. Scaling up care for mental, neurological, and substance use disorders. Geneva. 2008. Accessible at: http://whqlibdoc.who.int/publications/2008/9789241596206_eng.pdf. Accessed 12 Oct 2012.

  4. International Narcotics Control Board. Report of the International Narcotics Control Board on the availability of internationally controlled drugs: ensuring adequate access for medical and scientific purposes. New York; 2011, E/INCB/2010/1/Supp.1. ISBN 978-92-1-148260-7. Accessible at: http://www.incb.org/documents/Publications/AnnualReports/AR10_Supp_E.pdf. Accessed 11 Oct 2012.

  5. World Health Organization. Access to Controlled Medications Programme: improving access to medications under international drug conventions: briefing note. Geneva. 2012. Accessible at: http://www.who.int/entity/medicines/areas/quality_safety/ACMP_BrNote_Genrl_EN_Apr2012.pdf. Accessed 8 June 2013.

  6. Single Convention on Narcotic Drugs, 1961, as amended by the Protocol amending the Single Convention on Narcotic Drugs, 1961. In: The International Drug Conventions. United Nations, New York; 2009. ISBN 978 92 1 148248 5. Accessible at: https://www.unodc.org/pdf/convention_1961_en.pdf. Accessed 11 Oct 2012.

  7. International Narcotics Control Board. Narcotic drugs: estimated world requirements for 2012 statistics for 2010. New York: United Nations; 2011. E/INCB/2011/2. ISBN 978-92-1-048149-6. http://www.incb.org/documents/Narcotic-Drugs/Technical-Publications/2011/Narcotic_Drugs_Report_2011.pdf. Accessed on 11 Oct 2012.

  8. ATC Index with DDDs. WHO Collaborating Centre for Drug Statistics and Methodology. Oslo, 2005.

    Google Scholar 

  9. Bekkering GE, et al. Epidemiology of chronic pain and its treatment in the Netherlands. Neth J Med. 2011;69(3):141–52 (Systematic review).

    PubMed  CAS  Google Scholar 

  10. Seya MJ, Gelders SFAM, Achara UA, Milani B, Scholten WK. A first comparison between the consumption of and the need for opioid analgesics at country, regional and global level. J Pain Palliat Care Pharmacother. 2011;25:6–18. Accessible at: http://apps.who.int/medicinedocs/documents/s17976en/s17976en.pdf. Accessed 11 Oct 2012.

    Article  PubMed  Google Scholar 

  11. United Nations Development Programme. Human Development Report 2011, Sustainability and equity: a better future for all. New York: United Nations Development Programme; 2011. ISBN 9780230363311. Accessible at: http://www.undp.org/content/dam/undp/library/corporate/HDR/2011%20Global%20HDR/English/HDR_2011_EN_Complete.pdf. Accessed 11 Oct 2012.

  12. World Health Organization. Ensuring balance in national policies on controlled substances, guidance for availability and accessibility of controlled medicines. Geneva. 2011. ISBN 978 92 4 156417 5. Accessible at: http://whqlibdoc.who.int/publications/2011/9789241564175_eng.pdf. Accessed 1 Oct 2012.

  13. Obrist B, et al. Access to health care in contexts of livelihood insecurity: a framework for analysis and action. PLoS Med. 2007;4(10):e308. doi:10.1371/journal.pmed.0040308. Available at: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0040308. Accessed 14 Oct 2012.

    Article  Google Scholar 

  14. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19(2):127–40. Accessible at: http://www.ncbi.nlm.nih.gov/pubmed/7206846. Accessed 14 Oct 2012.

    Article  PubMed  CAS  Google Scholar 

  15. Wyszewianski L. Access to care: remembering old lessons. Health Serv Res. 2002;37(6):1441–3. doi:10.1111/1475-6773.12171. Accessible at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1464050. Accessed 14 Oct 2012.

    Article  PubMed  Google Scholar 

  16. Cherny NI, et al. Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Europe: a report from the ESMO/EAPC Opioid Policy Initiative. Ann Oncol. 2010;21(3):615–26. Accessible at: http://www.ncbi.nlm.nih.gov/pubmed/20176694. Accessed 14 Oct 2012.

    Article  PubMed  CAS  Google Scholar 

  17. Cameron A, et al. Medicines prices, availability and affordability. In: The World Medicines Situation 2011. Geneva: World Health Organization; 2011. Accessible at: http://apps.who.int/medicinedocs/documents/s18065en/s18065en.pdf. Accessed 14 Oct 2012.

  18. Niëns LM, et al. Quantifying the impoverishing effects of purchasing medicines: a cross-country comparison of the affordability of medicines in the developing world. PLoS Med. 2010;7(8):e1000333. doi:10.1371/journal.pmed.1000333. Accessible at: http://apps.who.int/medicinedocs/documents/s17402e/s17402e.pdf. Accessed 14 Oct 2012.

    Article  PubMed  Google Scholar 

  19. Convention on Psychotropic Substances, 1971. In: The International Drug Conventions. New York: United Nations; 2009. ISBN 978 92 1 148248 5. Accessible at: https://www.unodc.org/pdf/convention_1971_en.pdf. Accessed 14 Oct 2012.

  20. United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, 1988. In: The International Drug Conventions. New York: United Nations; 2009. ISBN 978 92 1 148248 5. Accessible at: https://www.unodc.org/pdf/convention_1988_en.pdf. Accessed 14 Oct 2012.

  21. Guide on estimating requirements for substances under international control, developed by the International Narcotics Control Board and the World Health Organization for use by the Competent National Authorities, International Narcotics Control Board and World Health Organization, Vienna/Geneva. 2012. ISBN 978-92-4-150328-0. Available at: http://whqlibdoc.who.int/publications/2012/9789241503280_eng.pdf. Accessed 14 Oct 2012.

  22. World Health Organization. WHO guidelines on the pharmacological treatment of ­persisting pain in children with medical illnesses. 2012. Available at: http://whqlibdoc.who.int/publications/2012/9789241548120_Guidelines.pdf. Accessed 14 Oct 2012.

  23. Scholten W. Paediatric morphine dosages. WHO Pharmaceuticals Newsletter. 2012;(4):26–28. Accessible at: http://www.who.int/medicines/publications/Newsletter_4_2012.pdf. Accessed 14 Oct 2012.

  24. Minozzi S, et al. Systematic review on dependence following treatment with opioid analgesics for pain relief: a systematic review. Addiction. 2013;108(4):688–98. doi:10.1111/j.1360-0443.2012.04005.x.

    Article  PubMed  Google Scholar 

  25. Gallagher CT. New CD regulations will not obstruct “another Shipman” who intends to kill. Pharm J. 2006;277(7407):13–6.

    Google Scholar 

  26. Inciardi JA, et al. Mechanisms of prescription drug diversion among drug-involved club and street based populations. Pain Med. 2007;8(2):171–83. doi:10.1111/j.1526-4637.2006.00255.x.

    Article  PubMed  Google Scholar 

  27. Inciardi JA, et al. Diversion of prescription drugs by health workers in Cincinnati Ohio. Subst Use Misuse. 2006;41(2):255–64.

    Article  PubMed  Google Scholar 

  28. Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11–4658. Rockville: Substance Abuse and Mental Health Services Administration; 2011. Accessible at: http://oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.pdf. Accessed 15 Oct 2012.

  29. CDC. Vital signs: overdoses of prescription opioid pain relievers – United States, 1999–2008. Morb Mortal Wkly. 2011;60(43):1487–92. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?s_cid=mm6043a4_w. Accessed 2 July 2012.

    Google Scholar 

  30. Hall AJ, Logan JE, Toblin RL, et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA. 2008;300:2613–20.

    Article  PubMed  CAS  Google Scholar 

  31. Dunn KM, et al. Opioid prescriptions for chronic pain and overdose a cohort study. Ann Intern Med. 2010;152:85–92.

    Article  PubMed  Google Scholar 

  32. Milani B, Scholten W. Access to controlled medicines. In: The world medicines situation 2011. 3rd edn. Geneva: World Health Organization; 2011 (Chapter released April 2011). Accessible at: http://www.who.int/entity/medicines/areas/policy/world_medicines_situation/WMS_ch19_wAccess.pdf. Accessed 15 Oct 2012.

  33. International Association for Hospice and Palliative Cate, The Opioid Price Watch Project. Accessible at: http://hospicecare.com/resources/opioid-price-watch/. Accessed 8 June 2013.

  34. Resolution WHA58.22. Cancer prevention and control. In: Fifty-eighth World Health Assembly, Geneva, 25 May 2005. A copy of the resolution can be found in: http://www.who.int/entity/medicines/areas/quality_safety/Framework_ACMP_withcover.pdf. Accessed 15 Oct 2012.

  35. Resolution ECOSOC 2005/25. On treatment of pain using opioid analgesics. New York. 2005. A copy of the resolution can be found in: http://www.who.int/entity/medicines/areas/quality_safety/Framework_ACMP_withcover.pdf. Accessed 15 Oct 2012.

  36. Access to Controlled Medications Programme, Framework. Geneva: World Health Organization; 2007. WHO/PSM/QSM/2007.2. Accessible at: http://www.who.int/entity/medicines/areas/quality_safety/Framework_ACMP_withcover.pdf. Accessed 15 Oct 2012.

  37. Cancer pain relief with a guide to opioid availability. 2nd edn. Geneva: World Health Organization; 1996. ISBN 9789241544825. Accessible at: http://apps.who.int/iris/bitstream/10665/37896/1/9241544821.pdf. Accessed 15 Oct 2012.

  38. Cancer pain relief and palliative care in children. Geneva: World Health Organization; 1998. ISBN 9789241545129. Accessible at: http://apps.who.int/iris/bitstream/10665/42001/1/9241545127.pdf. Accessed 15 Oct 2012.

  39. Scoping document for WHO Guidelines for the pharmacological treatment of persisting pain in adults with medical illnesses. Geneva: World Health Organization, Expert Committee on Drug Dependence, 35th Report. Technical Report Series 973, Geneva 2012. ISBN 978-92-4-120973-1. Accessible at: http://www.who.int/entity/medicines/areas/quality_safety/Final_35th_ECDD.pdf. Accessed 15 Oct 2012.

  40. International Narcotics Control Board. Report of the International Narcotics Control Board for 2007. New York. 2008. E/INCB/2007/1. ISBN 978-92-1-148224-9. Accessible at: http://www.incb.org/documents/Publications/AnnualReports/AR_07_English.pdf. Accessed 16 Oct 2012.

  41. International Narcotics Control Board. Report of the International Narcotics Control Board for 2008. New York. 2009. E/INCB/2008/1. ISBN 978-92-1-148232-4. Accessible at: http://www.incb.org/documents/Publications/AnnualReports/AR_08_English.pdf. Accessed 16 Oct 2012.

  42. WHO Expert Committee on Drug Dependence, Thirty-fifth report. WHO Technical Report Series 973. Geneva: World Health Organization; 2012. ISBN 978 92 4 120973 1, ISSN 0250–8737. Accessible at: http://apps.who.int/iris/bitstream/10665/77747/1/WHO_trs_973_eng.pdf. Accessed 8 June 2013.

  43. Commission on Narcotic Drugs. Resolution 53/4 Promoting adequate availability of internationally controlled licit drugs for medical and scientific purposes while preventing their diversion and abuse. Report on the fifty-third session (2 December 2009 and 8–12 March 2010). Economic and Social Council, Official Records, 2010, Supplement No. 8. E/CN.7/2010/18. Accessible at: https://www.unodc.org/unodc/en/commissions/CND/session/cnd-documents-index.html. Accessed 16 Oct 2012.

  44. Commission on Narcotic Drugs. Resolution 54/6 Promoting adequate availability of internationally controlled narcotic drugs and psychotropic substances for medical and scientific purposes while preventing their diversion and abuse. In: Report on the fifty-fourth session (2 December 2010 and 21–25 March 2011) Economic and Social Council, Official Records, 2011, Supplement No. 8. United Nations, New York, 2011. E/CN.7/2011/15. Accessible at: https://www.unodc.org/unodc/en/commissions/CND/session/cnd-documents-index.html. Accessed 16 Oct 2012.

  45. Declaration of Montréal, declaration that access to pain management is a fundamental human right, Montreal. 2011. Accessible at: http://www.iasp-pain.org/Content/NavigationMenu/Advocacy/DeclarationofMontr233al/default.htm. Accessed 13 Sept 2012.

  46. International Union against Cancer. World Cancer Declaration. Clin J Oncol Nurs. 2006;10(6):721–2. Accessible at: http://www.uicc.org/sites/default/files/private/eWCDEC_2.pdf. Accessed 16 Oct 2012.

  47. Pallium India, International Association for Hospice and Palliative Care, and the Pain & Policy Studies Group. A morphine manifesto. J Pain Palliat Care Pharmacother. 2012;26(2):144–5. doi:10.3109/15360288.2012.678475. Accessible at: http://informahealthcare.com/doi/abs/10.3109/15360288.2012.678475. Accessed 16 Oct 2012.

  48. Declaration of Miami, Joining forces for better pain treatment and promoting pain medicine all over the world. World Institute of Pain, Miami. 2012. Accessible at: http://www.wipfoundation.org/wp-content/uploads/2012/04/electronic-version-declaration-of-miami1.png. Accessed 19 Oct 2012.

  49. GAPRI: Global Access To Pain Relief Initiative, Union for International Cancer Control, s.l.a. Accessible at: http://www.uicc.org/sites/default/files/private/120806_eGAPRI_OnePager_Final.pdf. Accessed 17 Oct 2012.

  50. Radbruch L, et al. Access to opioid medication in Europe (Letter to the Editor). J Pain Palliat Care Pharmacother. 2012;26:200–1. Accessible at: http://informahealthcare.com/doi/abs/10.3109/15360288.2012.676614. Accessed 17 Oct 2012.

    Article  PubMed  Google Scholar 

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  1. Consultant – Medicines and Controlled Substances, Chemin du Lignolet 18A, 1260, Nyon, Switzerland

    Willem Scholten

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  1. Willem Scholten
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Correspondence to Willem Scholten .

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  1. Analgesics & Pain Research Ltd, Beckenham, United Kingdom

    Magdi Hanna

  2. Hildegard Hospiz, Basel, Switzerland

    Zbigniew (Ben) Zylicz

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Scholten, W. (2013). Access to Opioid Analgesics: Essential for Quality Cancer Care. In: Hanna, M., Zylicz, Z. (eds) Cancer Pain. Springer, London. https://doi.org/10.1007/978-0-85729-230-8_19

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