Access to opiates for pain relief and palliative care in India

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Published: 4 Dec 2013
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Dr James Cleary - University of Wisconsin School of Medicine and Public Health, Madison, USA

Dr James Cleary talks to ecancer at the 1st Indian Cancer Conference about the accessibility of pain medication in India versus the rest of the world.

In India, many problems come from governmental restrictions and lack of knowledge on what drugs are available in the country.

Read more on ecancernews here

A number of years ago the European Society of Medical Oncology, under the leadership of Nathan Cherny, did a research study looking at why there was such a difference in opioid access between Eastern Europe and Western Europe. And they actually confirmed what many of us knew is that a lot of countries in Eastern Europe did not have access to opioids for cancer pain relief and they also found that there were many policy restrictions stopping that. Based on that study, they’ve actually gone on and done this now and repeated it in Africa, the Middle East, Asia including India and also Latin America and the Caribbean. While we see that many countries actually have what we would consider essential opioids on formulary, we actually see that they’re not available consistently so that there are times where we say, ‘Yes, we have the drug,’ and India is a classic example, the drug is available but it’s only available occasionally.

There are also many policy restrictions which we have found: the laws in India at the moment are actually restricting the administration or the use of opioids. Part of these is the draconian penalties if in fact you don’t keep the right count; if one tablet goes missing you may end up in jail for two years because you’re not keeping the right count. Examples in the Philippines where you need a special prescription to write opioids, physicians have to pay for it and have to collect it in person and if you live in Manila and actually have to deal with people and get to an office to do that, you’re basically saying you’ll spend a day to get a prescription pad.

So there are multiple, multiple barriers like this but the reality is that most of the world’s population don’t have access to opioids and this is despite the fact that the 1961 Single Convention which was formed to ensure that we have access for medical and scientific purposes and to reduce their misuse, abuse and for other purposes, the world has not done a good job in making sure that we have access, that the whole community has access to these medications. The Commission of Narcotic Drugs has gone on to state in resolutions that in actual fact efforts to control or restrict should actually not interfere with access issues. So the police states type things that we look in, in Georgia you had to collect your own opioids from a police station, the Ukraine only had injectable morphine until recently and we see that in some Asian countries as well, but those efforts to actually restrict misuse and diversion should not interfere with ensuring access.

We’re working very hard so there’s coming up in the January World Health Organisation Executive Board, they’re working on a resolution with the support of Panama on palliative care and included in this is the whole access to opioids and this will be discussed at the World Health Assembly. But each country has to actually tackle this in their own situation. There are a number of organisations, the Union for International Cancer Control, ESMO, the European Society for Medical Oncology, the European Association for Palliative Care, our own group, the Pain Policy Studies Group, together with the WHO, the International Association for Hospice and Palliative Care, the World Palliative Care Alliance, I can go on and name… we’re all ready to work with countries to actually bring about this change.

The Pain and Policy Studies Group, which I direct at the University of Wisconsin, we have a programme called the International Pain Policy Fellowship where we work with clinical champions in country who find a government partner and they bring about together the changes. So it’s making sure that we change the policies, it’s making sure that we make drug available and it’s also educating clinicians. There has to be a concerted effort to do this. And it’s becoming equally important because in the non-communicable diseases strategies that have been developed, the UN has defined, together with the WHO, has defined that opioid consumption will be used as a marker for effective palliative care. So countries, I think we will see, are actually going to pay attention to this, realising that they can do all this good work for improving other aspects of palliative care but it comes back to a statement from the WHO. You can have palliative care in a country but you can’t have good palliative care in a country without good access to opioids.