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Global Outlook on Palliative Care in Cancer

Megan O’Brien, PhD
INTRODUCTION

Palliative care, and effective pain relief in particular, is a core component of cancer treatment. It’s been estimated that approximately 80% of people with advanced cancer require opioids to treat moderate or severe pain.1 However, access to medicinal opioids varies widely across the globe, with access generally proportional to a country’s gross income level.

Cancer and HIV are the 2 leading indications for opioid use. Low- and middle-income countries are home to 71% of cancer deaths2 and more than 99% of deaths from HIV,3,4 yet they consume less than 7% of the world’s medicinal opioids.5

Among the 175 countries that have data available on cause of death and opioid consumption, 60 consume a quantity of opioids that is not sufficient to meet even 10% of their need, with 40 of those countries in sub-Saharan Africa.

Worldwide, at least 2.4 million people die with untreated pain from cancer or HIV each year—lack of access to effective pain relief and palliative care is responsible for a tremendous amount of unnecessary suffering. Importantly, the high rate of stigma associated with these diseases results in turn in late presentation and poor treatment outcomes. For instance, in low-income countries, the majority of cancer diagnoses occur when patients’ disease is already advanced.6,7 While several factors contribute to delayed diagnosis—limited access to healthcare, limited diagnostic capacity of health systems, and inability of patients to afford even the most nominal costs associated with investigations—patients also present late because cancer, as a disease, is synonymous with unrelenting pain that grows worse each day. Patients fear the diagnosis and they do not expect hospitals to provide them with pain relief.

This suffering is unnecessary, because morphine is safe, effective, plentiful, inexpensive, and easy to use in resource-limited settings. Morphine has been designated an essential medicine by the World Health Organization (WHO)8 and is on almost all national essential medicines lists. Morphine and similar opioids are the only treatments for moderate or severe pain recommended by WHO in its pain treatment guidelines.9 Additionally, WHO has also developed a simple algorithm for pain treatment that is 80% to 90% effective: the analgesic ladder. The approach, which includes a 3-step algorithm for adults and a recently updated 2-step algorithm for treatment of pain in children, utilizes both opioid and non-opioid medicines.10

Derived from a plentiful plant source, morphine is off-patent, and thus quite affordable. An average weekly dose of treatment (67.5 mg per day)1 costs less than $1 (based on recent procurements in Uganda, Kenya, Swaziland, and Nigeria). The existence of an essential medicine that is so well suited to relieving pain in resource-limited settings makes the suffering caused by an inability to access the medicine both unnecessary and preventable.

BARRIERS TO ACCESS

The tremendous disparity in the lack of access to pain relief and palliative care is driven by several factors operating at different degrees in different settings.

In many countries, opioids such as morphine are not imported because ministries of health are structured around disease-specific units. Pain relief cuts across diseases (and accidents, childbirth, and postoperative care) in a way that causes it to fall between the cracks, not squarely in the mandate of any single department.

Pain relief is often given low priority within health ministries and particularly within oncology departments because of a cure-versus-care mentality that places higher value on interventions that have the potential to cure disease or extend survival; interventions that improve the quality of life are often considered optional and there is little precedence for their use in resource-limited settings.

Even when health ministries commit to making essential pain medicines available, they face a challenging global pharmaceutical market for opioids. Sixty-nine percent of opioids are sold in 4 countries: the United States, Canada, the United Kingdom, and Australia.5 In comparison, 140 low- and middle-income countries comprise less than 7% of the global opioids market and pharmaceutical companies are often unwilling to invest the time and cost required to register their products in these low-volume countries.

In settings where access to pain relief has been limited for decades, lack of education and experience in pain treatment in the medical community has led to high rates of misunderstanding and misperception and low levels of knowledge and experience.11,12 Health workers routinely overestimate the risk of side effects and adverse outcomes such as addiction, and are unable to differentiate addiction from physical dependence. Further, they routinely underestimate the effectiveness of opioids and underestimate pain levels in their patients. After years spent practicing medicine in the absence of effective pain relief, many health workers have simply become inured to their patients’ suffering, or may not consider pain relief their responsibility. Massive in-service training would be necessary to familiarize health workers with the assessment and treatment of pain and address out- dated perceptions and fears.

Just as is observed with other essential medicines, access to pain relief is also limited by weak health systems. For instance, sub-Saharan Africa has 24% of the global burden of disease but only 3% of the global healthcare force,13 forcing health workers to struggle to treat chronic diseases such as cancer in health systems that were built for acute care, not chronic disease management. Additionally, patients are often unable to access healthcare services because they cannot afford the time or cost of travel to reach them.

RESPONDING TO THE CRISIS

While no single intervention can solve the issue of limited access to pain relief and palliative care, several governments are making steady progress by systematically confronting the barriers described above. This is often done with technical assistance from international non-governmental organizations such as the American Cancer Society, which has a program called Treat the Pain that focuses on improving access to essential pain medicines in resource-limited countries.

In countries where opioids are unavailable, an essential rst step is for the ministry of health to assign responsibility to an internal department to improve access to pain relief. For example, the Nigerian Ministry of Health chose the Department of Food and Drug Services; Swaziland selected the National AIDS Program; and Ethiopia, the Medical Services Directorate. The responsible department is then tasked with developing a comprehensive plan to supply and distribute medicines and train health workers on appropriate use. Treat the Pain has collaborated with the ministries of health in these countries to support the addition of technical staff who can focus on expanding access to essential pain medicines.

The introduction of a locally produced oral morphine solution was a key breakthrough in sub-Saharan Africa—large-scale local production was pioneered by Hospice Africa Uganda after introducing small-scale production for their patients in the 1990s. The hospice obtains relatively cheap raw morphine powder from the open market, instead of from suppliers who have registered their products in Uganda. The morphine powder can be mixed with water, a preservative, and a colorant in a simple procedure that can be done safely using materials and equipment that can be bought locally. The oral solution has a 6-month shelf life and provides exible dosing for the treatment of adults and children.

In Uganda, after a prolonged shortage of opioids in the public sector in 2010, the government contracted with Hospice Africa Uganda to produce oral morphine for the whole country, including both the public sector and the private, not-for-profit sector. With some technical assistance from Treat the Pain, Hospice Africa Uganda upgraded its production system to meet the increased demand. The cost of this locally produced oral morphine solution is signicantly lower than the cost of imported morphine solution or tablets. Thus, as with other drugs in the essential medicines package, all Ugandan health facilities now have access to free morphine from the government.

Other countries have followed suit, adapting the model to their own situation. For example, the Nigerian Ministry of Health decided to create local morphine production hubs in 25 teaching hospitals around the country, while Swaziland created a central production hub at the national hospital. In Ethiopia, Epharm, a local pharmaceutical company, supplies oral morphine solution to the government.

Once an adequate supply of essential pain medicines has been secured, the next step is distributing the medicines to health facilities and training health workers to assess and treat pain. Coordination of these 2 elements is essential to prevent expiry of unused pain medication on the shelf, as has often been experienced. And if health workers are trained and then return to a work site that does not actually have the medicines available, they rapidly lose the new skills and knowledge and will require retraining.

To address this issue, the Treat the Pain program is partnering with governments in Nigeria, Ethiopia, Uganda, Swaziland, and Kenya to roll out a health worker training program called the Pain-Free Hospital Initiative. The Initiative targets large national referral and teaching hospitals to provide simple, accessible training for physicians, nurses, and pharmacists, to be delivered while staff are in service. The goal of the initiative is to equip staff to assess pain and provide high-quality first-line treatment. In Ethiopia, where morphine has been available only in the oncology department of 1 hospital, the Ministry of Health is implementing the Initiative in 9 hospitals this year while simultaneously making oral morphine available for the first time in those same hospitals. Nigeria is launching it in 4 teaching hospitals, and Swaziland in 12 hospitals.

The provision of high-quality pain relief is a core component of cancer treatment and of palliative care, but palliative care is more than just pain relief. Patients with advanced disease also need symptom management, psychosocial support, spiritual support, and assistance with end-of-life issues, including home-based care, legal assistance, and nancial assistance. These services, often modeled on the hospice programs that were created in the United Kingdom and the United States, are often limited in their size and scope, and rely on external donor funding. The challenge going forward will be to integrate these programs into public sector healthcare delivery and create sustainable funding bases for them. EBO
REFERENCES

1. Foley KM, Wagner JL, Joranson DE, Gelband H. Pain control for people with cancer and AIDS. In: Disease Control Priorities in Developing Countries. 2nd ed. New York: Oxford University Press; 2006:981-994.

2. GLOBOCAN 2012: estimated cancer inci- dence, mortality and prevalence worldwide in 2012. International Agency for Research on Cancer website. http://globocan.iarc.fr/Default. aspx. Accessed May 12, 2014.

3. Global Health Observatory Data Repository. World Health Organization website. http://apps. who.int/gho/data/node.main.623. Accessed May 12, 2014.

4. The World Factbook. Central Intelligence Agency website. https://www.cia.gov/library/ publications/the-world-factbook/. Accessed May 12, 2014.

5. International Narcotics Control Board. Data- set: opioid consumption statistics 2007-2012. Published 2014.

6. Kanavos P. The rising burden of cancer in the developing world. Ann Oncol. 2006;17(suppl 8): viii15-viii23.

7. Morhason-Bello IO, Odedina F, Rebbeck TR, et al. Challenges and opportunities in cancer control in Africa: a perspective from the African Organisation for Research and Training in Cancer. Lancet Oncol. 2013;14(4):e142-e151.

8. WHO Model List of Essential Medicines, Ed. April 2013. World Health Organization website. http://www.who.int/medicines/publications/ essentialmedicines/en/. Accessed March 20, 2015.

9. Ensuring balance in national policies on controlled substances: guidance for availability and accessibility of controlled medicines. World Health Organization website. http://www.who .int/medicines/areas/quality_safety/guide_ nocp_sanend/en/index.html. Published 2011. Accessed January 2, 2012.

10. WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. World Health Organization website. http://www.who.int/medicines/areas/quality_ safety/guide_perspainchild/en/. Published 2012. Accessed September 18, 2014.

11. Woldehaimanot T, Saketa Y, Zeleke A, Gesesew H, Woldeyohanes T. Pain knowledge and attitude: a survey among nurses in 23 health institutions in Western Ethiopia. Gaziantep Med J. 2014;20(3):254-260.

12. Eyob T, Mulatu, A, Abrha H. Knowledge and attitude towards pain management among medi- cal and paramedical students of an Ethiopian university. J Pain Relief. 2013;3(1).

13. World Health Report 2006: Working Together for Health. World Health Organization website. http://www.who.int/whr/2006/en/. Published 2006. Accessed March 20, 2015.
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