Transcript Title Goes Here - Pain & Policy Studies Group

Pain in Cancer, AIDS, and NCDs,
with a Focus on
Opioid Analgesics
James Cleary, MD
Pain and Policy Studies Group
Uganda as a model!
• Uganda serves as a brilliant model, like
Wisconsin and Catalonia, for the importance
of an integrated government and community
non-governmental approach. Each one by
themselves in isolation, will not achieve
much.
Oxford Textbook of Palliative Medicine, 3rd Edition
Wisconsin Cancer Pain Initiative
• Dahl & Joranson (WI Pharmacy Board)
• US based: 1986
– WHO Demonstration Project.
– Role Model Initiative.
– Education
• Wisconsin Pain Initiative
– Alliance of State Pain Initiatives.
Pain and Policy Study Group
• 1996: Pain and Policy Study Group
– National
– International
• WHO Collaborating Center
– Cancer Control
– Access to Controlled Medications Program
• INCB Workshop Estimates; Dec 2009
• Close Ties with INCB
– Opioid Consumption Data
– Model Laws
– Estimates Process
Establishes a
Framework to:
1. Prevent abuse and
diversion, and
2. Ensure the
availability of drugs
for medical
purposes
Global Trend 1980 - 2008
10000
9000
Morphine ME
Total ME
8000
7000
6000
5000
4000
3000
2000
1000
0
19
80
19
81
19
82
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
Source: International Narcotics Control Board
By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2010
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
Total ME: High Income vs. Low and Middle Income Countries
9000
8000
High Income
LMICs
Global Total
7000
6000
5000
4000
3000
2000
1000
0
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
Source: International Narcotics Control Board
By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2010
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
2006 International Pain Policy Fellowship
Dr. Simbo Daisy
Amanor-Boadu
Dr. Henry Ddungu
Uganda/APCA
Nigeria
Prof. Snežana Bošnjak
Dr. Jorge Eisenchlas
Serbia
Argentina
Prof. Rosa Buitrago
Dr. Marta Ximena León
Republic of Panama
Colombia
Mrs. Nguyen Thi
Phuong Cham
Vietnam
Pain & Policy Studies Group
Supported by the
University of Wisconsin
Open Society Institute
October 2006 Madison, Wisconsin
Mr. Gabriel Madiye
Sierra Leone
2008 International Pain Policy Fellowship
Dr. Dingle Spence
Mrs. Verna WalkerEdwards
Dr. Hrant Karapetyan
Dr. Irina Kazaryan
Armenia
Jamaica
Dr. Pati Dzotsenidze
Mr. Mikheil Pavliashvili
Dr. Zippy Ali
Dr. Jacinta Wasike
Georgia
Kenya
Dr. Eva Rossina Duarte Juárez
Lic. Ana Lucía Arango
Espigares
Dr. Adrian Belîi
Republic of Moldova
Guatemala
Dr. Bishnu Dutta Paudel
Mr. Radha Raman Prasad Teli
Nepal
Pain & Policy Studies Group
Supported by the
University of Wisconsin
Open Society Institute
October 2006 Madison, Wisconsin
WHO Palliative Care Public
Health Model
Drug
Availability
Education
Policy
“the medical use of
narcotic drugs
continues to be
indispensable for the
relief of pain and
suffering… adequate
provision must be
made to ensure the
availability of
narcotic drugs for
such purposes.”
(Preamble, p. 13)
•
•
•
•
•
•
•
•
•
•
Measurement
Sustainable delivery systems
Tobacco, obesity, alcohol
Vaccination (HBV, HPV)
Dispel myths about cancer
Screening & early detection
Effective pain control
Training opportunities
Reduce health emigration
Improve cancer survival for all.
2020 Targets
• 7: Improve Access to Diagnosis, Treatment,
Rehabilitation and Palliative Care Access to
accurate cancer diagnosis, appropriate
cancer treatments, supportive care,
rehabilitation services and palliative care
will have improved for all patients
worldwide.
• 8: Effective pain control measures will be
available universally to all cancer patients in
pain
1274
27.5
Deaths from HIV & Cancer
Deaths by cause in the world (2005)
Noncommunicable diseases:
Infectious diseases:
HIV/AIDS 4.9%
Tuberculosis 2.4%
Heart disease
30.2%
Malaria 1.5%
Total:
58.2M
Cancer
15.7%
Diabetes
1.9%
Other chronic diseases
15.7%
(WHO, Chronic Disease Report, 2005)
Other
Infectious
Diseases
20.9%
Injuries 9.3%
Noncommunicable Diseases (NCDs)
• Responsible for up to 60% of all deaths,
• 80% are in low- and middle-income countries
• Major non-communicable diseases:
– Cardiovascular disease
Diabetes
– Cancer
– Chronic Respiratory disease
Cardiovascular
– Diabetes
Disease
Cancer
Chronic
Respiratory
Diseases
Other NCDs
• Shared preventable risk factors:
– Tobacco use
– Unhealthy diet
– Physical inactivity
– Harmful use of alcohol
Physical
inactivity
Obesity
Unhealthy
diets
Smoking
Harmful use
of alcohol
Noncommunicable diseases (2006-2015)
2005
Geographical
regions (WHO
classification)
2006-2015 (cumulative)
Total
deaths
(millions)
NCD
deaths
(millions)
NCD
deaths
(millions)
Trend: Death
from infectious
disease
Trend: Death
from NCD
Africa
10.8
2.5
28
+6%
+27%
Americas
6.2
4.8
53
-8%
+17%
Eastern
Mediterranean
4.3
2.2
25
-10%
+25%
Europe
9.8
8.5
88
+7%
+4%
South-East Asia
14.7
8.0
89
-16%
+21%
Western Pacific
12.4
9.7
105
+1
+20%
Total
58.2
35.7
388
-3%
+17%
WHO projects that over the next 10 years, the largest increase in
deaths from cardiovascular disease, cancer, respiratory disease and
diabetes will occur in low- and middle-income countries.
(WHO, Chronic Disease Report, 2005)
United Nations general assembly on
non-communicable diseases (NCD)
• For the first time ever, the United Nations
General Assembly held a Non-communicable
Disease (NCD) Summit involving Heads of
State, in September 2011, to address the
threat posed by NCDs to low- & middleincome countries (LMICs).
•
•
•
•
World Heart Federation
International Diabetes Federation (IDF)
International Union Against Cancer (UICC)
the International Union Against Tuberculosis and
Lung Disease
• Where was PAIN???
World Health Organization
Essential Medicines
16th edition (updated)
2010 WHO Model List
2. ANALGESICS, ANTIPYRETICS, NON-STEROIDAL ANTI-INFLAMMATORY MEDICINES (NSAIMs),
MEDICINES USED TO TREAT GOUT AND DISEASE MODIFYING AGENTS IN RHEUMATOID DISORDERS (DMARDs)
2.1 Non-opioids and non-steroidal anti-inflammatory medicines (NSAIMs)
acetylsalicylic acid
Suppository: 50 mg to 150 mg. Tablet: 100 mg to 500 mg.
Ibuprofen
Tablet: 200 mg; 400 mg. >3 months.
paracetamol*
Oral liquid: 125 mg/5 ml. Suppository: 100 mg. Tablet: 100 mg to 500 mg.
* Not recommended for anti‐inflammatory use due to lack of proven benefit to that
effect.
2.2 Opioid analgesics
Codeine
Morphine
Tablet: 15 mg (phosphate); 30 mg (phosphate).
Injection: 10 mg (morphine hydrochloride or morphine sulfate) in 1‐ml ampoule.
Oral liquid: 10 mg (morphine hydrochloride or morphine sulfate)/5 ml.
Tablet: 10 mg (morphine sulfate).
Tablet (prolonged release): 10 mg; 30 mg; 60 mg (morphine sulfate)
International Association of Hospice and Palliative Care
List of Essential Medicines for Palliative Care
(http://www.hospicecare.com/resources/pdf-docs/iahpc-list-em.pdf)
 Codeine,
 Fentanyl,
 Methadone,
 Morphine (immediate and sustained release),
 Oxycodone,
 Tramadol
NOTE: NO GOVERNMENT SHOULD APPROVE MODIFIED RELEASE MORPHINE,
FENTANYL OR OXYCODONE WITHOUT ALSO GUARANTEEING WIDELY
AVAILABLE NORMAL RELEASE ORAL MORPHINE.
WHO supports global effort to
relieve chronic pain
• The WHO co-sponsors the first Global Day
Against Pain, which seeks to draw global
attention to the urgent need for better pain
relief for sufferers from diseases such as
cancer and AIDS.
• The campaign, organised by the International
Association on the Study of Pain (IASP) & the
European Federation of the IASP Chapters
(EFIC), asks for recognition that pain relief is
integral to the right to the highest attainable
level of physical and mental health…
Report on AVAILABILITY
“The low levels of consumption of opioid
analgesics for the treatment of pain in many
countries, in particular in developing countries,
continue to be a matter of serious concern to
the Board.
The Board again urges all Governments
concerned to identify the impediments in their
countries to adequate use of opioid analgesics
for the treatment of pain and to take steps to
improve the availability of those narcotic drugs
for medical purposes…” (paragraph 97)
INCB, 2007 report
Opioid availability and cost: West Europe
Codeine Propox
HC/DHC
BuprPO
BuprTD
MoIR
MoCR
MoInj
OcIR
Finland
France
Norway
Austria
Portugal
Italy
Denmark
Israel
Netherlands
Cyprus
Greece
Germany
Luxemburg
Spain
Switzerland
UK
Belgium
Iceland
Turkey
Free
<25%
Cost
25-50%
Cost
50-75%
Cost
100%
cost
OcCR
Methad.
FentTD
FentTM
HmIR
HmCR
PethInj
Opioid availability and cost: Eastern Europe
Codeine
Propox HC/DHC
BuprPO BuprTD MoIR
MoCR
MoInj
OcIR
Czech R.
Croatia
Latvia
Rumania
Slovak R.
Hungary
Estonia
Serbia
Bulgaria
Moldova
Poland
Russia
Monten.
Maced.
Bosnia-H
Lithuania
Belarus
Albania
Georgia
Ukraine
Free
<25%
Cost
25-50%
Cost
50-75%
cost
100%
cost
OcCR
Methad. FentTD FentTM HmIR
HmCR
PethInj
Global Consumption of Morphine
High-Income vs. Low - and Middle - Income Countries, 2008
Population
Percent total
100
90
80
70
60
50
40
30
20
10
0
Consumption of Morphine
91%
83%
17%
9%
High Income (48)
Low- and Middle-Income (102)
Source: International Narcotics Control Board; United Nations Population Data, 2007; World Bank Income Classification, 2008.
By: Pain & Policy Studies Group, University of Wisconsin /WHO Collaborating Center, 2010.
Global Consumption of Morphine, 2008
Mg/capita
160
140
Austria
(166.9070 mg)
Uses morphine
for substitution
treatment
120
100
Global mean
5.9847 mg
Armenia
0.6945 mg
Georgia
1.338 mg
Guatemala
0.3561 mg
Jamaica
1. 3652 mg
Kenya
0.1292 mg
Nepal
0.0349 mg
Colombia
1.2390 mg
Panama
80
U.S.A
(66.5682 mg)
60
40
South Africa
(10.3011 mg)
Sierra Leone
Global Mean
(6.005 mg)
Poland
(6.4746 mg)
Italy
(3.4816 mg)
N/A
Serbia
0.6659
Vietnam
0.2193
Guatemala
Georgia
Armenia
Serbia
Kenya
Vietnam
Jamaica
20
0.5170
Colombia
Nepal
Panama
0
(158 Countries)
Source: International Narcotics Control Board; United Nations population data
By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2010
The means are calculated by adding the individual mg/capita statistics for all
countries and then dividing by the number of countries; data does not Include
information for countries from which the INCB did not receive a report
"We must not only stop the harm caused by drugs:
let's unleash the capacity of drugs to do good.
You think this is a radical idea? Look back to the
origins of drug control. The Preamble of the Single
Convention recognizes that … the medical use
of narcotic drugs continues to be indispensable for
the relief of pain… This is hardly the language of a
prohibitionist regime. Indeed, this noble goal of UN
drug policy, the freedom from physical pain,
demonstrates our over-riding commitment to health."
Antonio Costa, Exec Director,
UN Office on Drugs and Crime (UNODC)
March 2010