UICC World Cancer Congress 2006

Pain due to cancer, HIV/AIDS and other chronic diseases is a public health problem that is receiving increased attention by United Nations bodies, governments and the global health community. There is a growing recognition that pain management and palliative care are essential elements of a rational national response to needless suffering. Unfortunately, the relief of severe pain is often blocked by strict government drug control policies that interfere with the availability and medical use of essential medicines like morphine. This situation makes it necessary for the health care community to work outside of its usual comfort zone to understand the drug regulatory system and learn how to work with government to achieve balanced policies that permit drug control as well as drug availability.

In 2000, WHO developed Guidelines for Achieving Balance in National Opioids Control Policy to improve patient access to opioid pain medications. The Pain and Policy Studies Group has been developing methods, tools and projects to address regulatory barriers. PPSG evaluates national policies and drug distribution systems using a model that is familiar to health professionals: examination; diagnosis; treatment; monitoring; evaluation. In consultation with the WHO, PPSG has developed several collaborative projects that have resulted in policy change, including India and Romania.

In India, a 1985 anti-narcotics law almost completely erased the use of morphine; a generation of doctors was educated without its availability. Today, after a decade of effort by palliative care leaders working closely with their national and state governments, a number of policy changes have been made. The journey to make opioid analgesics accessible for palliative care has begun. In the state of Kerala, population 32 million, the narcotics rules have been simplified. Community-based palliative care programs now have continuous access to inexpensive oral morphine and are spreading across the state. An evaluation demonstrated that increased access to morphine has not led to diversion and misuse.

With grant assistance from the Open Society Institute (OSI) and the National Hospice and Palliative Care Organization (NHPCO), the PPSG is developing new tools to improve access by advocates to pain policy resources. These tools include an internet course in basic pain policy and how to approach policy change, an international fellows program for those who want to develop national projects, and technical assistance to experts.

PPSG has also begun a major new project to improve access to opioid pain medications in Sub Saharan Africa, in partnership with NHPCO, the African Palliative Care Association, the Foundation for Hospices in Sub Saharan Africa and OSI.

Selected Resources

Blengini C, Joranson DE, Ryan KM. Italy reforms national policy for cancer pain relief and opioids. European Journal of Cancer Care. 2003; 12(1):28-34. (http://www.medsch.wisc.edu/painpolicy/publicat/03ejcc/index.htm).

Jagwe JGM. The introduction of palliative care in Uganda. Journal of Palliative Medicine. 2002;5(1):160-163.

Joranson DE. Improving availability of opioid pain medications: Testing the principle of balance in Latin America. Innovations in End-of-Life Care. 2003; 5(1). (http://www2.edc.org/lastacts/archives/archivesJan03/featureinn.asp).

Joranson DE, Rajagopal MR, Gilson AM. Improving access to opioid analgesics for palliative care in India. Journal of Pain and Symptom Management. 2002; 24(2):152-159. (http://www.medsch.wisc.edu/painpolicy/publicat/02jpsm3/index.htm).

Mosoiu D, Ryan KM, Joranson DE, Garthwaite JP. Reforming drug control policy for palliative care in Romania. Lancet. April 11, 2006;

Pain and Policy Studies Group. Availability of Opioid Analgesics in Africa and the World (Monograph) 2002 http://www.medsch.wisc.edu/painpolicy/publicat/monograp/afmono02.pdf

Rajagopal MR, Joranson DE, Gilson AM. Medical use, misuse, and diversion of opioids in India. Lancet. 2001; 358(9276):139-143. (http://www.medsch.wisc.edu/painpolicy/publicat/01lancet/contents.htm).

United Nations Economic and Social Council. Treatment of Pain Using Opioid Analgesics; Resolution 2005-25. Report on the forty-eighth session of the Commission on Narcotic Drugs E/2005/28; 19 March 2004 and 7-11 March 2005; issued 22 July 2005. (http://www.un.org/docs/ecosoc/documents/2005/resolutions/Resolution%202005-25.pdf).

World Health Organization. Achieving Balance in National Opioids Control Policy: Guidelines for Assessment. Geneva, Switzerland: World Health Organization; 2000. (http://www.medsch.wisc.edu/painpolicy/publicat/00whoabi/00whoabi.htm).