Sunday 31 August 2014

Treat the Pain's Approach

American Cancer Society's TreatThePain.org has an outstanding approach towards resolution of the issue.

Here is an excerpt of their process (click the above link for more):

"More than 3.2 billion people worldwide lack access to adequate pain relief even though morphine, the most effective treatment for severe pain, is safe, effective, plentiful, inexpensive, and easy-to-use.

Legal and regulatory restrictions, cultural misperceptions about pain, inadequate training of healthcare providers, a poorly functioning market, generally weak health systems, and concern about diversion, addiction, and abuse create a web of barriers that force millions of people to live and die with treatable pain.

Access to pain treatment is particularly limited in low and middle-income countries where approximately 70% of cancer deaths and 99% of HIV deaths in the world occur, but just 7% of the opioid analgesics are consumed.

The problem can be addressed through several approaches, including a human rights focus, a policy focus, and a training focus.
Our preferred approach: mechanism of access:

We prefer to address the problem using a mechanism of access approach. Together with our partners, we've identified an 8-step framework to group challenges and interventions, called the Morphine Framework. It's a little hard to read here, so you can download a more detailed description of the framework here, or look at our recent article in Lancet Oncology, which describes the framework. (12)
Morphine framework

Cancer Pain: The Numbers

Cancer is undoubtedly a burden on a global scale. The number of cases expected to increase to 24 million by 2035 (was 12 million in 2012).
In developed countries, the incidence of cancer pain is in up to 85% of patients. Even in developed countries cancer pain is insufficiently treated in up to 50% of patients. Imagine this same issue in developing countries where analgesic medication shortages are common place.


“...the need for palliative care is considerable. Of the 45 million deaths that occur in developing countries, approximately 60 percent, or 27 million per year require palliative care for diseases such as AIDS and cancer.
Patients plagued by painful symptoms of these diseases benefit from palliative care when other treatment options have been exhausted.
For instance, morphine, which is essential to this care, is inaccessible in more than 150 countries.” (Freedom from Pain documentary)


"The ESMO-led Global Opioid Policy Initiative is the first and largest study of its kind, conducted in 79 countries and 25 Indian States, representing more than 5 billion people, i.e. more than half of the world’s population.
In the regions covered by this survey there are about 8 million new cases of cancer each year and upwards of 5 million cancer deaths.
Of those who die from cancer approximately 70-90% will suffer from severe pain." (GOPI)

"Current estimates suggest that upward of 80% of the world’s population lacks access to basic pain relief [6]. Paradoxically, those 80% are mostly in poorer countries, and their need for pain relief is heightened by a relative absence of curative care such as surgery, or treatment for both communicable and non-communicable diseases causing pain (e.g., HIV/AIDS, cancer)."


"We determined per capita need of strong opioids for pain related to three important pain causes for 188 countries. These needs were extrapolated to the needs for all the various types of pain by using an adequacy level derived from the top 20 countries in the Human Development Index. By comparing with the actual consumption levels for relevant strong opioid analgesics, we were able to estimate the level of adequacy of opioid consumption for each country. Good access to pain management is rather the exception than the rule: 5.5 billion people (83% of the world’s population) live in countries with low to nonexistent access, 250 million (4%) have moderate access, and only 460 million people (7%) have adequate access. Insufficient data are available for 430 million (7%). The consumption of opioid analgesics is inadequate to provide sufficient pain relief around the world. Only the populations of some industrialized countries have good access." (DrugWarFacts.org)


“Unlike so many global health problems, pain treatment is not about money or a lack of drugs, since morphine costs pennies per dose and is easily made. The treatment of pain is complicated by many factors, including drug laws, bureaucratic rigidity and commercial disincentives.” (Freedom from Pain documentary)




Cancer Pain Swept to the Wayside in Developing Countries

“...because of the bureaucracy a number of doctors do not want be bothered with prescribing morphine.”

If you are from a developed country, consider the above quote if you or a loved one was faced with moderate to severe pain as a result of cancer or some other debilitating diagnosis.

This issue was highlighted by an outstanding piece of journalism: "How can journalists help raise the profile of cancer and get it on the political agenda in countries where infectious diseases get most attention, reliable data are scarce, doctors are reluctant to talk and editors prefer cheery topics? Two award-winning reporters speak of the challenges they face."

Here are some excerpts that help the issue truly hit home:

“In a piece titled “Morphine kills pain but its price kills patients”, Bafana examined how in Zimbabwe, a country where diagnostic and treatment facilities for cancer are scarce, patients are dying in extreme pain before even receiving an oncology appointment. An effective supply of morphine would at least ease the suffering, but supply is short and the cost prohibitive.

Bafana talked to cancer patients about their experiences. Two daughters worked for two weeks selling enough of their chickens to raise the 18 dollars needed for a two-week supply of morphine for their mother, bedridden with stage 4 cancer of the cervix.

He wrote: “Pain is scrawled all over Ncube’s face as she narrates her tale: for six months now she has been on the waiting list to undergo radiotherapy at Mpilo Hospital. The radiotherapy machine has been broken for longer than she has been waiting and a new one is only now being installed. ‘The pain is unimaginable,’

Ncube told IPS in her home. Pointing to a white plastic bottle filled with paracetamol, a mild painkiller, she added, ‘That is all I could get from the hospital.’”

Bafana interviewed officials at the Bulawayo Island Hospice Service, which distributes limited supplies of donated morphine to its 300 patients, but is at risk of closure due to high operating costs and low donor support. He found out that in 2012 Zimbabwe used a total of 3.6 kilogrammes of morphine, despite having an allocation of 11.25 kilogrammes.

And he discovered that the cost of morphine could be brought down significantly if hospitals and pharmacies were allowed to stock morphine powder for making a liquid morphine preparation – which is cheaper and more convenient for severely ill patients to take.

“My article sought to capture that burden over the six months that I interviewed and followed patients in my home city of Bulawayo,” Bafana explained to Cancer World. “I have offered just the peak of a wider, complex problem and suffering that cancer patients and their families face in dealing with the disease.”




Is Unmanaged Pain Relief Really a Global Health Issue?

Without a doubt.

The number one medication in short supply in cancer treatment in developing countries is morphine! This is hard to imagine for someone from a developed nation with the myriad of pain treatments available. 
One minute can feel like an hour in pain to a patient in pain.

The mHealth solution from Opioid GPS would be focused in sourcing, delivering and then the proper use thereof of analgesics by patients and healthcare professionals.


***

“According to the Union for International Cancer Control (UICC), more than 3.3 million people with cancer are dying in pain, sometimes in agony, each year. Altogether, tens of millions of people are needlessly suffering pain, and a WHO estimate says that 600 million are going to suffer from untreated pain in their lifetime. The reason is simple: lack of access to basic, cheap and highly effective drugs, notably morphine. Around 70% of cancer deaths occur in low and middle-income countries, where just 6% of the opioid analgesics are consumed.


Source:


  • Fixing the holes in the opioid supply lines:
    • Patients are still dying in agony despite concerned efforts over many years to change attitudes towards the use and control of opiates. Could a new initiative, which works with NGOs, governments and policy makers to address practical problems, finally hit the spot?
http://www.cancerworld.com/Articles/Issues/48/May-June-2012/Spotlight-on/533/Fixing-the-holes-in-the-opioid-supply-lines.html 

***

"Opioid analgesics are critical to the effective relief of cancer pain. Effective treatment is predicated on sound assessments, individually tailored analgesic therapy, and the availability and accessibility of the required medications. In some countries, pain relief is hampered by the lack of availability or barriers to the accessibility of opioid analgesics." (1)
***
"For patients with cancer, and especially those with advanced and incurable cancer, adequate relief of pain is a central goal of care [1, 2]. Indeed, adequate relief of cancer pain is considered to be a human right by many organizations of health care professionals [310], but is not yet enshrined in human right conventions." (1)

Other Potential Partnerships

With excerpts from ESMO's Global Opioid Policy Initiative (GOPI):



"Major international efforts are underway to address the pandemic lack of availability and accessibility of opioids for the benefit of cancer patients (and other patients) in pain that affects the majority of the emerging economies and the developing world. The authors applaud recent progress on the global stage through inclusion of a specific target on access to essential medicines for cancer and other non-communicable diseases (NCDs) in the WHO Global NCD Action Plan 2013–2020. In addition, the WHO plan includes a specific indicator on morphine consumption in the associated Global Monitoring Framework (http://www.who.int/nmh/en/). Clearly, factors such as economic and social development are contributory; however, pilot projects in Uganda and Vietnam have demonstrated robustly that economic development is not an insurmountable barrier to the routine provision of pain medication for cancer patients suffering with severe pain."

"The Global Opioid Policy Initiative (GOPI) members are partnering with other key civil society and intergovernmental agency players in the global efforts that are underway to improve accessibility to opioids for patients with cancer pain. The EAPC, the WHO, and Help the Hospices are key partners in the Access to Opioid Medication in Europe (ATOME) project (www.atome-project.eu). The ATOME project is a multiyear collaborative project involving 10 organizations to improve access to opioids across Europe by identifying and removing barriers that prevent people from accessing medicines that could improve end-of-life care, to alleviate debilitating pain, and to treat heroin dependence. It focuses on 12 target countries: Bulgaria, Cyprus, Estonia, Greece, Hungary, Latvia, Lithuania, Poland, Serbia, Slovakia, Slovenia, and Turkey."

"The ‘Global Access to Pain Relief Initiative’ (GAPRI) is another major international effort led by the UICC (www.uicc.org/programmes/gapri). This ambitious collaborative project aims to contribute to the World Cancer Declaration target of universal access to essential pain medications by the year 2020."

"GAPRI is partnering with The Pain and Policy Studies Group at the University of Wisconsin to support and train clinical leaders in tandem with regulatory representatives from the same country through an International Pain Policy Fellowship Program [32]."

"Further, the American Cancer Society's ‘Treat the Pain’ campaign is implementing projects in Nigeria, Kenya, Uganda, India, and Haiti that are providing 2.8 million additional days of pain treatment."

"In addition to these three major multinational programs, critical contributions have been made by the International Palliative Care Initiative of the Open Society Foundation (OSF) led by Kathleen Foley and Mary Callaway (www.opensocietyfoundations.org), the Worldwide Palliative Care Alliance (WPCA) led by Stephen Connor (www.thewpca.org), the International Association for Hospice and Palliative Care (IAHPC) led by Liliana De Lima (http://hospicecare.com/home/), the Human Rights Watch Palliative Care Project led by Diederik Lohman (www.hrw.org/topic/health/palliative-care), Help the Hospices (www.helpthehospices.org.uk), and the National Institutes of Health (NIH) through the Center for Global Health of the National Cancer Institute (NCI) (www.cancer.gov/aboutnci/globalhealth) and the World Health Organization (WHO) (www.who.int)."




Global Health Pain Relief Initiatives

Initiatives that are already underway that could utilize the Opioid GPS platform:






Potential Key Partnerships

Collaborating Partner Organizations



 1
African Organisation for Research and Training in Cancer (AORTIC)
 2
African Palliative Care Association (APCA)
 3
Asia Pacific Hospice Palliative Care Network (APHN)
 4
Chinese Society of Clinical Oncology (CSCO)
 5
Foundation Akbaraly, Madagascar
 6
Help the Hospices
 7
Indian Association of Palliative Care (IAPC)
 8
International Association for Hospice & Palliative Care (IAHPC)
 9
Japanese Society of Medical Oncology (JSMO)
10
Latin American and Caribbean Society of Medical Oncology (SLACOM)
11
Latin American Association for Palliative Care (ALCP)
12
Malaysian Oncology Society (MOS)
13
Middle East Cancer Consortium (MECC)
14
Multinational Association of Supportive Care in Cancer (MASCC)
15
Myanmar Oncology Society
16
Open Society Foundations (OSF)
17
Worldwide Palliative Care Alliance (WPCA)

Source: 

References

A collection of some of the references we have utilized for background information:

References:


*Great approach: http://www.treatthepain.org/our_approach.html