PPSG International News Alerts
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The Pain & Policy Studies Group (PPSG) of the University of Wisconsin Comprehensive Cancer Center invites you to a presentation and discussion titled, CANCER, PALLIATIVE CARE, AND MORPHINE USE IN INDIA by Dr. M.R. Rajagopal, Professor of Anesthesiology, Medical College of Calicut, India and Director, Pain and Palliative Care Society, Calicut. Dr. Rajagopal's presentation and discussion will be given on Monday, June 3 from 5:00 p.m. until 6:00 p.m. in the lower-level conference room of University Research Park’s 406 Science Drive location. Parking is plentiful and free. An informal reception will follow.
RSVPs for both the presentation and reception are appreciated by Wednesday, May 29, to Linda Gorman at 608-263-7662 or llgorman@wisc.edu.
The Pain & Policy Studies Group (PPSG)/World Health Organization Collaborating Center, would like to inform you of additions to its web site pertaining to international opioids policy and access to opioid analgesics.
(1) The World Health Organization’s 2000 publication, “Achieving Balance in National Opioids Control Policy: Guidelines for Assessment” is available in English, French, Italian, and Spanish. The Guidelines explain why national governments are obligated to ensure adequate availability of opioid analgesics, and provides 16 guidelines and a checklist that can be used by governments and health professionals to assess “balance” in the national opioids control policies of any country. Please see http://www.medsch.wisc.edu/painpolicy/publicat/00whoabi/00whoabi.htm.
(2) PPSG monographs are now available that present key resources as well as trends in opioid consumption: global, regional (Africa, Asia, Latin America, Europe) and selected countries. The monograph for Latin America is available in English and Spanish. A fact sheet on the availability of morphine in India is available. Go to http://www.medsch.wisc.edu/painpolicy/publicat/monograp/globaltrends.htm.
(3) The World Health Organization Collaborating Center's report about activities to improve cancer pain relief in the world during 2001 is available at http://www.medsch.wisc.edu/painpolicy/publicat/01report/intro.html. The report details the continuing progress of the WHO Demonstration Project in India; it reports on the Center’s assistance to the Italian Ministry of Health in developing a proposal in 2000 to reform national policy, including simplification of opioid prescribing requirements; and it reviews activities with national governments and non-governmental organizations in several countries in Europe and Asia. We also report on the activities of the global communications program, the centerpiece of which is the publication of Cancer Pain Release, a quarterly WHO newsletter.
The Pain & Policy Studies Group is pleased to announce that a new on-line issue of Innovations in End-of-Life Care regarding efforts to improve the availability of opioid analgesics in Latin America has just been published at http://www.edc.org/lastacts/
A Model for Improving Access to
Opioids: The Latin American Experience
January-February 2003, Vol. 5, No. 1
Read about the work of David Joranson, MSSW, and Liliana De Lima, MHA in this issue to understand how these leaders have worked with regulators, clinicians to begin to make opioid medications more available to patients in Latin America. Print friendly pdf versions are now available to download!
EDITORIAL
Opioid Availability in Latin America as a Global Problem: A New Strategy with
Regional and National Effects
by Liliana De Lima, MHA, of the International Association for Hospice and Palliative
Care
http://www2.edc.org/lastacts/editorial.asp
FEATURED INNOVATION
Improving Availability of Opioid Pain Medications: Testing the Principle of
Balance in Latin America by David E. Joranson, MSSW, of the Pain and Policy
Studies Group
http://www2.edc.org/lastacts/featureinn.asp
PERSONAL REFLECTIONS
Relieving Pain and Suffering in Colombia: One Regulator's Journey by Maria Cristina
Chirolla, JD
http://www2.edc.org/lastacts/reflections.asp
Visit many relevant links on the
Resources and Tools page at
http://www2.edc.org/lastacts/resources.asp
Find targeted references on the
Read More page at
http://www2.edc.org/lastacts/readmore.asp
The Pain and Policy Studies Group would like to draw your attention to a recent report which reaffirms the support of international narcotics regulatory officials for efforts to improve the availability of opioids for the relief of pain. The Report of the International Narcotics Control Board for 2002 states that the “Board welcomes the continued work of WHO…and supports the regional workshops on palliative care that have been organized by WHO. During 2002, such workshops were held in Africa, the Americas and Eastern Europe.” The Report noted the Congress of the Latin American Association of Palliative Care held in Guadalajara, Mexico in March 2002, which reviewed progress to improve opioid availability in Latin America. Previously, the INCB recognized WHO efforts to address regulatory impediments to opioid availability in India and Italy. The Board also endorsed the use by countries of the document “Achieving balance in national opioids control policy: guidelines for assessment.”
The WHO reports on regional palliative care and opioid availability workshops, as well as global and national opioid consumption trends, are available at: http://www.medsch.wisc.edu/painpolicy/publicat/monograp/globaltrends.htm
The 2002 INCB Report can be seen at http://www.incb.org/e/ind_ar.htm
The WHO guidelines are on-line at http://www.medsch.wisc.edu/painpolicy/publicat/00whoabi/00whoabi.htm
ITALY REFORMS NATIONAL POLICY FOR
CANCER PAIN RELIEF AND OPIOIDS
Blengini, C., Joranson, D. E. & Ryan, K. M.
An article describing recent steps taken to reform national narcotics and opioid prescribing policy in Italy was published in the March 2003 issue of the European Journal of Cancer Care. National experts have previously reported that cancer pain is inadequately treated and that opioids are underutilized. The International Narcotics Control Board expressed concern that the consumption of opioid analgesics in Italy is low compared to other developed countries in Europe, and that opioids may not be sufficiently available for the relief of pain in suffering cancer patients. The reasons include strict national requirements for prescribing, including the complex Special Prescription Form and limitation of prescriptions to an 8-day supply.
A working group appointed by Italy’s Ministry of Health (MOH), using technical assistance from the Pain & Policy Studies Group (PPSG) and the World Health Organization’s guidelines for achieving balanced opioids control policy, issued a proposal to reform national policy in 2000. The proposal was adopted by Italy’s Parliament in 2001. The new legislation included: revision of the prescription form so that it is similar to the standard form for reimbursable drugs; increase of the prescription quantity to a one month supply; ability to prescribe two drugs on a single prescription form; adding several pain medications to the list of reimbursable drugs in the national healthcare system; and allocating funds to improve physician education and public awareness of cancer pain management. If implemented by the government and health professionals, these changes can be important steps toward relieving cancer pain in Italy.
To view the article, please visit the Pain & Policy Studies Group web site at http://www.medsch.wisc.edu/painpolicy/publicat/03ejcc/index.htm
Dear Colleagues,
Cordial greetings from the Pain & Policy Studies Group in Madison, Wisconsin. We are happy to provide you with a link to a new section of our website that contains new educational resources about opioid consumption trends.
In June of this year, we sent you an update about activities since the February 2002 WHO workshop that a team from your country attended in Budapest, Hungary. At that time, we promised to send you opioid analgesic consumption statistics for each of the participating countries and also for the region. This information is available on the PPSG web site at http://www.medsch.wisc.edu/painpolicy/internat/E.Europe/Eastern_Europe.htm. Please have a look and let us know if it is useful information for you.
In this new Eastern Europe section of our website, you will also find the WHO Budapest Workshop report, including the country reports and action plans, as well as the detailed monograph that we presented at the workshop. You can view these materials, or download and print them. We will add more information in the next months. We hope that you can use the information in education programs for policy makers and your colleagues to emphasize the need to improve availability and patient access to pain relief.
We are very happy to receive your comments on this information, including how it can be improved. As always, please keep us informed of any progress or changes, and tell us how we may be of assistance. Karen Ryan can be contacted at kmryan2@wisc.edu.
The Pain & Policy Studies Group would like to announce the addition of a new section to our website about the work by our WHO Collaborating Center with governments and colleagues in Eastern Europe. The section contains opioid consumption statistics and trends for selected countries, as well as WHO Workshop reports, country reports, action plans, and detailed monographs. All are available for printing or downloading at http://www.medsch.wisc.edu/painpolicy/internat/E.Europe/Eastern_Europe.htm.
This section will be updated periodically, and new sections will be added for other regions of the world.
Availability of regulated pain medications in Europe and the former Soviet Union: East vs. West
The World Health Organization
continues to emphasize that opioid analgesics must be adequately available for
the relief of pain due to cancer.1-3
Patient access to pain relief is particularly important in low and middle income
countries where most cancer is not diagnosed until the late stages, when pain
is prevalent. Opioid analgesics are also needed for the relief of pain due to
HIV/AIDS.4,5 When
opioids are not available, the tremendous and growing burden of cancer and AIDS
is increased further by unrelieved pain and suffering. Improvements will occur
only if health system and regulatory barriers, including excessive restriction
of opioids, are identified and overcome.
Most governments are party to the 1961 Single Convention on Narcotic Drugs,
and thus are obligated to ensure the adequate availability of opioid analgesics
for the relief of pain and suffering. According to the International Narcotics
Control Board (INCB), many governments have yet to examine their laws and regulations
for unduly restrictive regulatory provisions.6
Examples include burdensome licensing requirements, punitive legal sanctions,
complex prescription regulations and limits on dose and prescription quantity.
Patients who need pain relief seldom receive the pain treatment that was recommended
by the WHO in 1986, almost 20 years ago.
A review of INCB statistical data reported by governments and controlled for
population reveals that, in 2001, Western European countries accounted for 88%
of all medical morphine consumed in the European region.a
The corresponding data for fentanyl, hydromorphone, oxycodone, and pethidine
are 85%, 100%, 99.6%, and 57%, respectively. In fact, consumption of opioid
analgesics in Western Europe has consistently exceeded that of the rest of the
region over the past 15 years. This persistent disparity, especially in light
of the increasing incidence of HIV/AIDS and cancer in Eastern Europe should
be addressed if European goals for palliative care are to be met.7
The University of Wisconsin Pain & Policy Studies Groupb
is developing a resource program to assist in the improvement of policies governing
the medical availability of opioid pain medication in Eastern Europe through
a grant from the Open Society Institute (see http://www.medsch.wisc.edu/painpolicy/internat/E.Europe/Eastern_Europe.htm).
For further information, contact Karen Ryan, Senior Policy Analyst, kmryan2@wisc.edu.
A valuable resource for additional information about palliative care in Europe
was published in 2002.8
a The European region is defined
as the member countries of the World Health Organization EURO region, which
includes Western, Central and Eastern Europe, and the former Soviet Union. A
complete listing of EURO member countries can be found at http://www.who.dk/countryinformation
b The Pain & Policy Studies Group is designated
a World Health Organization Collaborating Center for Policy and Communications
in Cancer Care.
Reference List
(1) World Health Organization.
National Cancer Control Programmes: Policies and Managerial Guidelines. Second
ed. Geneva, Switzerland: World Health Organization; 2002. (Available at http://www.who.int/cancer/nccp/nccp/en/).
(2) World Health Organization Cancer and Palliative Care Unit. Consultation
on Strategies to Improve and Strengthen Cancer Control Programmes. World Health
Organization; Geneva, Switzerland. Meeting held in Geneva, Switzerland; 25 -
28
November 2003. (Available at http://www.who.int/cancer/nccp/europeanconsultation/en/index.html).
(3) World Health Organization. Achieving Balance in National Opioids Control
Policy: Guidelines for Assessment. Geneva, Switzerland: World Health Organization;
2000. (Available at http://www.medsch.wisc.edu/painpolicy/publicat/00whoabi/00whoabi.htm).
(4) World Health Organization. Progress Report: Community Health Approach to
Palliative Care for HIV/AIDS and Cancer Patients in Africa. Geneva, Switzerland:
2002.
(5) World Health Organization HIV-AIDS. Palliative Care. Geneva, Switzerland:
World Health Organization; 2004. (Available at http://www.who.int/hiv/topics/palliative/care/en/).
(6) International Narcotics Control Board. Report of the International
Narcotics Control Board for 1995: Availability of Opiates for Medical Needs.
New York, NY: United Nations; 1996. (Available at http://www.incb.org/e/ind_ar.htm).
(7) Council of Europe. Recommendation (2003) 24 of the Committee
of Ministers to Member States on the Organisation of Palliative Care. Adopted
by the Committee of Ministers at the 860th meeting of the Ministers' Deputies;
12 November 2003.
(Available at http://www.coe.int/DefaultEN.asp).
(8) Clark D, Wright M. Transitions in End of Life Care: Hospice
and Related Developments in Eastern Europe and Central Asia. Buckingham, UK:
Open University Press; 2002. (Website for the International Observatory on End
of Life
Care is http://www.eolc-observatory.net/).
Dear Colleague,
1) WHO Cancer Control
Initiative, including palliative care and opioid availability: This is to inform
you that on 24 May 2004 the World Health Organization Executive Board will consider
a draft resolution on cancer prevention and control. In an unprecedented move,
the WHO calls for action to be taken in the face of the increasing burden of
disease caused by cancer and the availability of effective interventions adaptable
to different resource settings. WHO has made the document available for download
at http://www.who.int/gb/EB_WHA/PDF/EB114/B114_3-en.pdf.
(Our recent attempts to download this document have been unsuccessful; if you
need a fax or scan copy, please contact Ms. Jody Garthwaite (jgarthwaite@wisc.edu)
at the Pain & Policy Studies Group. The list of Member States and their
delegates to the Executive Board is available at http://www.who.int/governance/eb/eb_members/en/.
2) International Narcotics Control Board Opioid Availability Initiative: In
addition, we understand that the International Narcotics Control Board will
make a presentation to the WHO Executive Board about its concerns regarding
the continuing inadequate availability of opioids for medical purposes in many
low and middle income countries, including for pain and palliative care.
Cooperation between the international narcotics regulatory agency and the World
Health Organization
cancer control program is a most welcome development and will be followed closely.
Sincere regards,
David E. Joranson
Senior Scientist, Director
Pain & Policy Studies Group
World Health Organization Collaborating Center for Policy and Communications
University of Wisconsin Comprehensive Cancer Center
406 Science Drive, Suite 202
Madison, Wisconsin 53711-1068
tel 1 608 263 7662
fax 1 608 263 0259
email: joranson@wisc.edu
websites
http://www.medsch.wisc.edu/painpolicy
http://www.WHOcancerpain.wisc.edu
Guidelines for patients traveling with controlled substances
Periodically the Pain & Policy Studies Group is asked what should a patient know about traveling abroad with prescribed opioid analgesics? PPSG has placed on its website the answers provided by governments. See http://www.medsch.wisc.edu/painpolicy/internat/travel.htm
Patients need to consider two sets of law: 1) the law of the country they are in and 2) the law of the country or countries to which they are traveling. Links to two documents that explain the governmental requirements are provided: the U.S. Code of Federal Regulations and Guidelines from the International Narcotics Control Board.
Please consider forwarding this information to physicians, nurses, social workers and others who are involved in assisting patients to plan for travel.
On Monday, October 11, the World Health Organization will sponsor a Global Day Against Pain, organized by the International Association for the Study of Pain (IASP) and the European Federation of the IASP Chapters. This global day campaign urges that pain relief be viewed as a human right, and asks people to recognize pain as a pressing problem and to act now to relieve suffering. The conference will include presentations and discussions by numerous experts in the pain field and can be viewed by live web broadcast.
To find out more information, you can visit the IASP's website at http://www.iasp-pain.org/Global%20Day.html or through the home page of the Pain & Policy Studies Group website.
The University of Wisconsin Pain & Policy Studies Group (PPSG) recently hosted a 5-person delegation from Romania to examine and recommend changes in the Romanian regulatory system. The purpose of this project is to make opioid analgesics more accessible to patients for pain relief and palliative care. The delegation included regulatory experts from the Ministry of Health, as well as representatives of oncology, palliative care, pharmacology and pharmacy.
In 2003, PPSG worked with a Palliative Care Commission in Romania to recommend changes to the national narcotics control law. This law dates from the Communist era, and severely limits the use of opioid analgesics in today’s hospice and palliative care programs. During this recent visit, PPSG worked with the delegation to draft a regulation that will implement the new law and the simplified prescription system.
Click here to see an article (PDF) that explains more about the situation in Romania and the objectives of this project.
For further information about our work in Romania and Eastern Europe, please visit: http://www.medsch.wisc.edu/painpolicy/internat/E.Europe/Eastern_Europe.htm
Dear Colleagues
The Pain & Policy Studies Group would like to call your attention to materials it prepared for the 2nd Global Summit for Hospice and Palliative Care Associations and the 6th Asia Pacific Hospice Conference held recently in Seoul, Korea. The following materials can be found at http://www.medsch.wisc.edu/painpolicy/internat/conferences.htm:
1) Selected Resources about Opioid
Availability (monograph),
2) Resources for Addressing Barriers to Pain Relief in the World, and
3) individual graphs of morphine consumption for the participating countries,
including
The
2000 WHO Guidelines are now also available in Turkish and Mongolian 10/18/05 |
Dear International Colleagues,
This is to inform you that the 2000 World Health Organization guidelines, “Achieving Balance in National Opioids Control Policy” are now available via our public access website in Bulgarian, German, Lithuanian, Polish, and Ukrainian as well as English, French, Italian, Romanian, Russian, and Spanish. As you may know, WHO designed these guidelines for governments and healthcare professionals to assess national opioids control policies and their administration to determine if they contain the provisions, administrative procedures and cooperation that are necessary to ensure availability of opioid analgesics for pain relief and palliative care. These guidelines are an essential tool in our ongoing work in Eastern Europe to improve patient access to pain medications.
The WHO guidelines, now available in all 11 languages, can be found at http://www.medsch.wisc.edu/painpolicy/publicat/00whoabi/00whoabi.htm
We are grateful to the Open Society Institute for its ongoing support of work in Eastern and Central Europe and the Former Soviet Union countries. For more information, please contact Karen Ryan at kmryan2@wisc.edu.
The Pain & Policy Studies Group
is pleased to announce publication of “Improving
Cancer Pain Relief in the World: Report for 2004.” The report describes
the work accomplished by the World Health Organization Collaborating Center
for Policy and Communications in Cancer Care (the Center), which is sponsored
by the Pain & Policy Studies Group at the University of Wisconsin Comprehensive
Cancer Center.
Highlights of the report include:
Policy research and development projects in India with state governments and
palliative care professionals to improve access to opioid analgesics for treating
cancer pain.
Reform of narcotic control policies in Romania, which included visits to the
country to study the Romanian health and regulatory system for making opioid
analgesics available for pain relief, and a study visit to the Center by a team
from the Romanian Ministry of Health to draft new national opioid regulations.
A monograph is available at http://www.medsch.wisc.edu/painpolicy/publicat/monograp/romania04.pdf.
Assistance to the Middle East Cancer Consortium (MECC) sponsored by the United
States National Cancer Institute. A presentation about improving access to opioid
analgesics for pain relief in the Middle East was given at a workshop in Cyprus
for the countries of Cyprus, Egypt, Israel, Jordan, and Turkey. A monograph
of opioid consumption trends for the Middle East, highlighting the participating
countries, can be accessed at http://www.medsch.wisc.edu/painpolicy/publicat/monograp/cyprus04.pdf.
A Spanish-language monograph was prepared for the 2nd Latin American Congress
of Palliative Care in Montevideo, Uruguay and is available at http://www.medsch.wisc.edu/painpolicy/publicat/monograp/uruguay04.pdf.
The brief monograph contains a table of the 2001 milligrams per capita consumption
of certain opioids for all of the countries participating in the Congress.
A pdf version of the full report can be seen at http://www.medsch.wisc.edu/painpolicy/publicat/04report/04report.pdf.
Comments, suggestions and questions are welcome.
Dear Colleague,
As 2005 comes to a close, I would like to extend my best personal wishes to you for a healthy and successful New Year--and offer a few reflections on the year past and ahead.
In the US, 2005 was characterized by a mix of policy setbacks, new information about the source of abused pain medications, and an important transition. Following the US Drug Enforcement Administration’s (DEA) abrupt withdrawal from the interdisciplinary and balanced pain and regulatory education initiative known as the “FAQ”, DEA reversed its own long-standing policy on issuing Schedule II prescriptions and communicated a new aggressive tone about investigations. These actions precipitated a nationwide retrenchment in care of pain patients and law-abiding physicians’ concerns about being investigated have escalated. DEA requested comments on its actions; hundreds of comments were filed from healthcare professionals, associations, regulators and law enforcement officials all over the country; DEA’s response is due early in 2006. We hope that DEA’s statement will include a recommitment to a balanced approach to diversion control that specifically avoids interfering in medical practice and patient access to pain management, assurance to practitioners that DEA agents will use diversion indicators that cannot be confused with legitimate medical practice, clarification of the increasingly blurred lines between professional practice, unprofessional conduct and criminal conduct, reaffirmation that a series of original prescriptions for Schedule II medications is legal, endorsement of the Federation of State Medical Board Model Policy, and establishment of communication mechanisms that will allow, as years past, communication between DEA and practitioner, law enforcement, regulatory and patient groups. http://www.medsch.wisc.edu/painpolicy/DEA/index.htm
In 2005, the PPSG published preliminary
first-of-a-kind quantitative data about the amount of diversion of prescription
drugs including opioid analgesics. We obtained data from federally-required
reports which showed that in the last four years approximately 28 million dosages
of prescription controlled substances were unlawfully diverted from the US drug
supply chain into channels of illicit distribution and abuse. This tremendous
quantity was based on reports from only 22 states; in 2003 alone, 5.8 million
dosages of prescription opioid analgesics were diverted in this manner. Clearly,
the reported increase in abuse of “prescription opioids” does not
necessarily mean the opioids came from prescriptions. Twenty years ago, pharmacists
terrorized by armed robberies convinced Congress to make theft of controlled
substances from DEA-registered pharmacies a federal felony. Yet today, we know
that thousands of incidents of theft and robbery resulting in diversion continue
to occur every year, and we know nothing about the law enforcement response.
A fair and balanced federal approach to prescription drug abuse must take into
consideration all sources of diversion, including those criminal activities
for which DEA-registered pharmacists and physicians are not responsible.
http://www.medsch.wisc.edu/painpolicy/publicat/05jpsm/05jpsm.pdf
2005 was also a year for important transitions. Patricia Good retired from the DEA. She understood pain management and was a clear voice within DEA for balanced law enforcement approaches to drug diversion and cooperation with the pain and palliative care fields. She will be missed.
In contrast with the confusion in Washington, the States continued to make steady progress to achieve more balanced policies governing the medical use of controlled substances for pain. We have previously reported that a number of states have adopted, amended or repealed policies sufficient to improve their grade for balanced pain policy. http://www.medsch.wisc.edu/painpolicy/publicat/05hlthpol/05hlthpol.pdf In 2005, PPSG policy evaluation tools continue to be used by a number of organizations as road maps for achieving more balanced state pain policies.
On the international side, 2005 has been a year of important progress. The United Nations adopted new resolutions to address inadequate relief of pain in cancer and HIV/AIDS; all national governments have been asked to examine their laws and regulations for barriers to opioid availability; the World Health Organization and the International Narcotics Control Board have been requested to explore development of an assistance mechanism to support the work necessary to improve patient access to essential medicines, in particular the opioid analgesics. http://www.un.org/docs/ecosoc/documents.asp?id=863
A collaborative project with the Ministry of Health Palliative Care Commission in Romania is coming to fruition. The project began in 2002 with a WHO workshop to assist Eastern European countries to identify and remove regulatory barriers to patient access to opioid pain medications. In November 2005, the Romanian Parliament adopted a new and modern drug control law replacing the laws of the Ceausescu regime which for decades restricted physicians from prescribing more than a 3-day supply of opioids; 10-15 day supplies were possible for cancer patients but only if they were “incurable,” and not at all for patients with HIV/AIDS. Within six months the Ministry will adopt new regulations to implement the new law; the regulations have already been drafted by a team of Romanian experts during a visit to the PPSG. We are excited that 2006 may bring a new national drug policy that will strike a balance between control and availability, allow modern pain control practices in Romania and be an example for Eastern Europe and the Former Soviet Union. Look for a journal article soon.
2006 will mark the tenth anniversary for the PPSG. We look forward to announcing plans to expand our policy research and communications programs in the US and internationally, including improvements to the PPSG website at www.medsch.wisc.edu/painpolicy. We will continue to email you periodic updates and, as always, would look forward to comments you may have as we work toward our collective vision of relieving pain and suffering.
Best wishes for the New Year
David E. Joranson, Senior Scientist
Director
Pain and Policy Studies Group
University of Wisconsin Comprehensive Cancer Center
WHO Collaborating Center for Policy and Communications in Cancer Care
Dear International Colleagues,
This is to inform you that the 2000 World Health Organization guidelines, “Achieving Balance in National Opioids Control Policy” are now available via our public access website in Mongolian, Serbian, and Turkish as well as Bulgarian, English, French, German, Italian, Lithuanian, Polish, Romanian, Russian, Spanish, and Ukrainian. As you may know, WHO designed these guidelines for governments and healthcare professionals to assess national opioids control policies and their administration to determine if they contain the provisions, administrative procedures and cooperation that are necessary to ensure availability of opioid analgesics for pain relief and palliative care. These guidelines are an essential tool in our ongoing work in Eastern Europe to improve patient access to pain medications.
The WHO guidelines, now available in all 14 languages, can be found at http://www.medsch.wisc.edu/painpolicy/publicat/00whoabi/00whoabi.htm
We are grateful to the Open Society Institute for its ongoing support of work in Eastern and Central Europe and the Former Soviet Union countries and to Dr. Odontuya Davaasuren for providing the Mongolian translation. For more information, please contact Karen Ryan at kmryan2@wisc.edu.
The Pain & Policy Studies Group (PPSG) would like to inform you of a recent Spanish-language report which provides information about the availability of opioid analgesics in the world and for countries in the region of Latin America. Titled "Descripción De La Disponibilidad De Opioides in América Latina," it was prepared for presentation at the 3rd Congress of the Latin American Association of Palliative Care in Isla Margarita, Venezuela. The report can be accessed on the PPSG website at http://www.medsch.wisc.edu/painpolicy/publicat/monograp/venezuela06.pdf.
Dear Colleagues,
There are now 21 translations of the 2000 World Health Organization guidelines document, “Achieving Balance in National Opioids Control Policy,” available on the Pain & Policy Studies Group’s public access website. Seven new translations have been added, including:
All 21 translations can be found at http://www.medsch.wisc.edu/painpolicy/publicat/00whoabi/00whoabi.htm.
Our sincere thanks to Willem Scholten, PharmD, MPA, Technical Officer of the World Health Organization’s Department of Medicines Policy and Standards for his support and assistance in obtaining these translations.
NEW PAIN POLICY FELLOWSHIP ANNOUNCED
The International Palliative Care Initiative
of the Open Society Institute
and the Pain & Policy Studies Group of the
University of Wisconsin Comprehensive Cancer Center
is pleased to announce the International Pain Policy Fellowship
Program. The overall goal of the fellowship program is to
improve the availability of opioid analgesics for pain management in developing
countries for patients with pain from cancer, HIV/AIDS, or other chronic diseases.
The two-year fellowship program will include training, mentoring, and an in-country pain policy project. A salary stipend covering up to 20% of each fellow’s professional salary will be given. Applications will be accepted from mid-career physicians, health care administrators, policymakers, or lawyers from a health care facility, policy center, or university from low- or middle-income economies (as classified by the World Bank's GNI per capita method--see World Bank GNI Data Country Classification on the web). Applicants must have a sincere interest in improving access to opioid analgesics for pain management through drug policy advocacy.
Fellows are required to participate in a five-day learner-centered training program at the University of Wisconsin in Madison, Wisconsin from 23 October to 27 October, 2006. The training program will cover the relationships between disease, pain, palliative care, and inadequate opioid availability, and will use WHO Guidelines to examine regulatory barriers and resources for evaluating national policy, as well as examples of their use. Each fellow will be responsible for outlining their drug availability project plan and timeline during the training program in Madison, and then incorporating it into their in-country pain policy project.
For more information and the application form, please visit http://www.soros.org/initiatives/health/focus/ipci/grants/palliative/guidelines.
Click here for printer-friendly (PDF) version of this announcement
The June 24, 2006 issue of the Lancet includes an article co-authored by Dr. Daniela Mosoiu, director of Hospice Casa Sperantei in Romania, and members of the Pain & Policy Studies Group (PPSG). The article details a 3-year collaborative project to identify and remove regulatory barriers to pain relief by using the WHO guidelines to evaluate the Romanian anti-narcotics law that had been adopted in 1969 during the Ceausescu regime. A commission of Romanian pain and palliative care experts recommended changes to the law and prescribing regulations, with assistance from the PPSG. As a result, the Romanian Parliament has adopted a new law, and the Ministry of Health is currently finalizing new, simplified, regulations with approval expected later this year.
The Pain & Policy Studies Group (PPSG) is pleased to announce
the selection of eight Fellows for its new International Pain Policy Fellowship
program. This two-year project is funded by a grant from the Open Society Institute’s
(OSI) International Palliative Care Initiative.
The purpose of the Fellowship is to assist low and middle income countries to improve patient access to pain medicines recommended by the World Health Organization (WHO) for pain of cancer, HIV/AIDS and other diseases. United Nations agencies, including the WHO and the International Narcotics Control Board, have expressed concern about the low consumption of controlled pain medicines in the world, especially in developing countries.
Fellows will train with the PPSG and other international experts in Madison, Wisconsin, USA during the week of 23-27 October 2006. They will develop action plans to improve opioid availability during the next two years with technical support from the PPSG and grant support from the OSI.
The eight selected Fellows are:
1. Dr. Simbo Daisy Amanor-Boadu, MBBS, FMCA Nigeria
2. Prof. Snežana Bošnjak, MD, PhD Serbia
3. Prof. Rosa Buitrago, BS, MCPh Panama
4. Mrs. Nguyen Thi Phoung Cham, Pharm Vietnam
5. Dr. Henry Ddungu, MB ChB, M.Med Uganda
6. Dr. Jorge Eisenchlas, MD, MSc Argentina
7. Dr. Marta Ximena León, MD Colombia
8. Mr. Gabriel Madiye, DPH Sierra Leone
Country Profiles on Opioid Availability Now Available
The Pain & Policy Studies Group (PPSG) announces enhancements to the international
section of its website that may be useful for individuals and organizations
interested in improving availability and access to essential opioid medications.
The PPSG website (www.painpolicy.wisc.edu)
now offers Country Profiles that provide standardized information about opioid
availability and key policy-related indicators for every country in the world.
Each Country Profile contains graphs that portray the trend in reported national
consumption of principal opioids as an indicator of opioid availability. Key
policy-related indicators are provided, including whether the country is a Party
to the international conventions which require governments to estimate their
medical requirements for opioids and to report consumption statistics to the
International Narcotics Control Board. Information on how to contact the national
Competent Authority, which is responsible for administering these important
government functions that supports opioid availability is provided, as well
as access to the WHO Guidelines, “Achieving Balance in National Opioids
Control Policy: Guidelines for Assessment (2000)” now available in 22
languages. Links to national resource documents regarding opioid availability
for pain relief and palliative care will be added as the PPSG learns about them.
Additional enhancements are being developed and will be announced here. Suggestions
for national resource documents are welcome. The Country Profiles can be accessed
directly at http://www.painpolicy.wisc.edu/internat/countryprofiles.htm
or from the PPSG home page.
2007 INTERNATIONAL PAIN POLICY FELLOWSHIP ANNOUNCED
The Pain & Policy Studies Group is pleased to announce the 2007 International Pain Policy Fellowship. Currently in its second year, the goal of the Fellowship Program is to improve the availability of opioid analgesics for pain management in patients with cancer, HIV/AIDS, or other chronic diseases.
Applications will be accepted from mid-career level physicians, pharmacists, health care administrators, policy makers, social workers or lawyers from a health care facility, policy center, or university in low or middle income countries. The Fellow must commit to spending 20% of his/her professional time on the project. Preference will be given to applications that demonstrate a willingness of the Ministry of Health to participate in the Fellowship.
The two-year Fellowship program will include training, mentoring, and an in-country pain policy project. A salary stipend will be provided to cover a portion of each fellow’s professional salary. Applicants must have a sincere interest in improving access to opioid analgesics for pain management through drug policy advocacy.
Fellows are required to participate in a five-day learner-centered training program at the University of Wisconsin in Madison, Wisconsin from 22 October to 26 October, 2007. The training program will cover the relationships between disease, pain, palliative care, and inadequate opioid availability, and will use WHO Guidelines to examine regulatory barriers and resources for evaluating national policy, as well as examples of their use. Each Fellow will be responsible for outlining their drug availability project plan and timeline during the training program in Madison, and then incorporating it into their in-country pain policy project.
The deadline for receipt of completed applications is Friday, 15 June 2007.
This program is funded by the International Palliative Care Initiative of the Open Society Institute and directed by the Pain & Policy Studies Group of the University of Wisconsin Comprehensive Cancer Center.
For more information and the application form, please visit http://www.soros.org/initiatives/health/focus/ipci/grants/palliative.
Leadership Transition at PPSG
The
University of Wisconsin Pain & Policy Studies Group (PPSG) is pleased to
inform you of recent transitions in leadership.
We would like to announce that Mr. David Joranson, MSSW, Director and Distinguished Scientist, has retired. Mr. Joranson is remaining with the PPSG in an advisory capacity and is working on special projects.
The work of the PPSG will continue under the capable leadership of Co-Directors: Aaron M. Gilson, Ph.D., Director of U.S. Policy Research, and Karen M. Ryan, MA, Director of International Policy Research. We encourage you to contact Dr. Gilson or Ms. Ryan if you have questions regarding U.S. and international matters, respectively.
Please update your records for the PPSG accordingly:
Dr. Aaron Gilson, Director of U.S. Policy Research
amgilson@wisc.edu
Ms. Karen Ryan, Director of International Policy Research
kmryan2@wisc.edu
Mr. David Joranson, Distinguished Scientist, Founder
joranson@wisc.edu
Pain & Policy Studies Group
Paul P. Carbone Comprehensive Cancer Center
University of Wisconsin School of Medicine and Public Health
World Health Organization Collaborating Center for Policy and Communications
in Cancer Care
406 Science Drive, Suite 202 Madison, Wisconsin 53711-1068
www.painpolicy.wisc.edu
We remain committed to our mission of pain policy reform and access to essential pain relief medicines, which are long-term problems requiring a sustained policy and systems response.
New 2005 Global and Regional opioid consumption
statistics
PPSG website users can now find global and regional consumption data for fentanyl,
hydromorphone, methadone, morphine, oxycodone, and pethidine from each Country
Profile page on the PPSG international website. These can be accessed at http://www.painpolicy.wisc.edu/internat/countryprofiles.htm
or from the PPSG homepage under International Resources.
We hope you find this information useful in addressing patient access to essential
opioid pain medications throughout the world. Please contact us if you have
any questions about this new resource.
Policy Evaluation Resources for the Practitioner
An article, titled "Improving state pain policies: Recent progress and
continuing opportunities," was published in CA: A Cancer Journal for
Clinicians. This article presents recent results from the PPSG's national
policy evaluation project, and describes how practitioners can use each state's
findings to inform and guide state-level efforts to improve policies affecting
appropriate pain management and patient care. Although the policy evaluation
resources are specific to the U.S., the criteria used to evaluate policy also
have international relevance because similar requirements or restrictions can
be found in drug control and professional practice laws in other countries.
The article is available at http://caonline.amcancersoc.org/cgi/reprint/57/6/341.
2006 Global, Regional, and National opioid consumption statistics now available through PPSG's Country Profiles
The Pain & Policy Studies Group (PPSG) now provides 2006 global, regional, and national consumption data for fentanyl, hydromorphone, methadone, morphine, oxycodone, and pethidine through the Country Profiles section of the PPSG's international website.
A review of the 2006 INCB morphine data reported by governments reveals that
7 high-income countries (United States, France, Canada, United Kingdom, Germany,
Austria, and Australia) accounted for nearly 84% of medical morphine consumed
in the world, but comprise less than 12% of the world's population. These figures
point to the large and continuing disparity in morphine consumption among countries,
and provide further evidence of the inadequate global treatment of pain, especially
in low- and middle-income countries.
The Country Profiles can be accessed at http://www.painpolicy.wisc.edu/internat/countryprofiles.htm
or from the PPSG homepage under International Resources.
PPSG International Pain Policy Fellowship
Dear Colleague:
The Pain & Policy Studies Group (PPSG) is very pleased to announce the selection of nine Fellows for its 2008 International Pain Policy Fellowship (IPPF) program. Due to the success of the IPPF 2006, the Open Society Institute’s (OSI) International Palliative Care Initiative is funding a second class of Fellows for a two-year project.
The purpose of the Fellowship is to assist low and middle income countries to improve patient access to pain medicines recommended by the World Health Organization (WHO) for pain of cancer, HIV/AIDS and other diseases. United Nations bodies, including the WHO and the International Narcotics Control Board, have expressed concern about the low consumption of controlled pain medicines in the world, especially in developing countries.
Fellows will train with the PPSG and other international experts in Madison, Wisconsin, USA during the week of 16-20 June 2008. They will develop action plans to improve opioid availability that they will implement during the next two years with follow-up technical support from the PPSG and grant support from the OSI. Fellows will be accompanied to Madison by a Ministry of Health representative, which demonstrates their government’s willingness to support efforts to improve opioid availability for pain management in their respective country.
The nine selected Fellows are:
Zipporah Ali, MD, MPH, Dip. Palliative Care, Kenya
Adrian Belîi, MD, PhD, Republic of Moldova
Eva Rossina Duarte Juárez, MD, MA, Guatemala
Pati Dzotsenidze, MD, Georgia
Hrant Karapetyan, MD, PhD, Republic of Armenia
Irina Kazaryan, PharmD, PhD, MSc, Republic of Armenia
Bishnu Dutta Paudel, MD, MBBS, Nepal
Margaret Dingle Spence, BSc, MBBS, Dip. Pall. Med., FRCR, Jamaica
Verna Walker-Edwards, BSc, Pharmacy, Jamaica
Philippine news coverage from 3-country workshop
Last month, the Pain & Policy Studies Group (PPSG) sponsored an opioid availability workshop for the Philippines, Thailand, and Indonesia. The Philippine Health Secretary welcomed the participants and announced the availability of 10 million Pesos (approximately USD 231,000) for the purchase of opioids (such as morphine) to alleviate the pain of poor cancer patients throughout the country. See story below.
Funded by the Open Society Institute and hosted by the Pain Society of the Philippines, the workshop took place over 3 days on Boracay Island, Philippines. The workshop was similar in design to others held since 2000 in Latin America, Eastern Europe and sub Saharan Africa: teams of healthcare practitioners, government and drug regulatory officials from each country convened to learn about the global epidemic of untreated pain, the causes of under-treatment, the role of regulatory and system barriers that interfere in opioid availability and access, and methods to address these barriers. They spent part of the meeting drafting Action Plans for their country. PPSG will provide follow-up technical assistance as they implement these objectives.
For more information about opioid availability in these countries, see http://www.painpolicy.wisc.edu/publicat/monograp/philippines08.pdf.
Last week (16 May 2008), the Philippine Daily Enquirer published the first of a 4-part series regarding this workshop and the status of unrelieved pain in the Philippines. We are pleased with this coverage of a very important topic. The article can be found at: http://showbizandstyle.inquirer.net/lifestyle/lifestyle/view_article.php?article_id=137034
DoH allots P10M to purchase opioids for poor cancer patients
By Cesar Mangawang
Philippine Daily Inquirer
First Posted 08:07pm (Mla time) 05/16/2008MANILA, Philippines - Health Secretary Francisco Duque announced the availability of P10 million for the purchase of opioids (such as morphine) to alleviate the pain of poor patients suffering from cancer all over the country.
Duque made the announcement during the “Workshop on Assuring Availability and Accessibility of Opioids Analgesics for Pain and Palliative” held last month at the Boracay Regency Hotel in Boracay Island, Aklan.
He said “the Department of Health is grateful for every opportunity to review the country’s progress in our pain control efforts, to confront the ever-present challenges that come our way, and to embark on a renewed, collective effort with our partners as we map out our national strategies on pain control as well as our part in the global pain control efforts.”
According to him, the relief and management of cancer pain in the Philippines is benchmarked on the World Health Organization’s Three-step Ladder of Cancer Pain Management. The medical profession, he said before delegates from Indonesia, Thailand and the Philippines, has long recognized the unnecessary pain suffered by many patients but pain control has been a low priority issue in health care.
Necessary for pain relief
Duque said international policies and cancer pain guidelines also recognized that opioids are necessary for the relief of pain, and that national and local governments must ensure that these pain relief drugs are adequately available to meet the requirements.
Since cancer affects at least 200,000 Filipinos daily, he said the DoH has made pain control a part of its mission, laying the foundation for a prominent role in national pain control collaborations and partnerships.
According to him, the DoH has initiated three phases for the national program on cancer pain control.
• It targeted different stakeholders which resulted in top-line meetings and partnerships with various groups.
• Cancer pain control capability building workshops were conducted at the DoH regional level.
• A consultative workshop addressed the multisectoral concerns on morphine inaccessibility and other pain relief misconceptions.
Minimal use of morphine
Duque said morphine use in the Philippines was deemed minimal at only 0.14 kilogram per million population or a daily dose of only seven milligrams per day, as reported by the International Narcotic Control Board in 2004. He said that although there is no shortage of the need for morphine use, “we lagged behind advanced countries and even from our Southeast Asian neighbors such as Thailand (12 mg per day), Singapore (31 mg per day) and Malaysia (18 mg per day).
Duque attributed such minimal showing to various factors like multisectoral barriers posed by physicians, patients and suppliers combined. He cited the underlying issues as morphine inaccessibility due to opioids regulatory issue, existence of morphine misconceptions at different levels, coordination issues between the stakeholders at the service level, etc.
The health secretary also enumerated the following reasons:
• Many physicians remain uncomfortable with the use of opioids apparently due to fear of drug addiction and other side effects.
• There is also a perception that these drugs are to be used as “last resort” only and some of our doctors prefer weaker drugs.
• A good number of physicians are barred by technicalities such as incomplete prescription details and lack of authorized licenses to prescribe the drugs.
• Majority of physicians, who believe these pain relief drug are effective, do not have the required S2 licenses and yellow prescriptions.
• Patients have their share of misgivings about pain drugs for fear of addiction and side effects as well as propelled by our tolerance of pain.
• Availability of morphine is a significant problem, which is related to low demand and limitation of the so-called yellow prescriptions.
• Pharmacies and drug stores have perceived dispensing of drugs as a tedious requirement leading to inconsistent filling and refilling of prescriptions.
Filipino pain advocates
Duque said the emergence and fast-growing eminence of Filipino pain advocates such as the Pain Society of the Philippines and other working at the forefront of pain is a welcome.
“In the last few years we have seen the steady growth, not only in the ranks of pain advocates but more important, on the impact that they bring to the lives and consciousness of Filipinos in terms of pain control and management,” he said.
(First of four parts)
The Pain & Policy Studies Group is pleased to announce our new on-line course,
Increasing Patient Access to Pain Medicines around the World:
A Framework to Improve National Policies that Govern Drug Distribution
This course is about the relationship between government policies that affect the medical availability of opioid analgesics and patients who experience moderate to severe pain. It is critically important for health care professionals, government drug regulators, and advocates involved in palliative care and pain relief to understand the government policies that control opioid analgesics and how they can block or ensure patient access to opioid analgesics.
It was designed to provide a synthesis of the critical background material and current methods that have been developed to improve national policies governing medical availability of essential pain medicines for cancer and HIV/AIDS patients. It is intended for an international audience of health care professionals, local and national policy makers, palliative care advocates, government drug regulatory personnel, national health policy advisors, and health policy scholars with an interest in pain management or palliative care.
The course is accessible at no cost and is self-paced so that it can be taken at any time that is convenient for the learner. It has 7 lessons each with required readings. Upon successful completion of the course the learner will receive a certificate.
Lesson 1: Understanding the Relationship between Pain and Drug Control Policy
Lesson 2: The Role of International and National Law and Organizations
Lesson 3: Barriers to Opioid Availability and Access
Lesson 4: WHO Guidelines to Evaluate National Opioids Control Policy
Lesson 5: WHO Guidelines to Evaluate National Administrative Systems for Estimating Opioid Requirements and Reporting Consumption Statistics
Lesson 6: WHO Guidelines on Procurement and Distribution Systems for Opioid Analgesics
Lesson 7: How to Make Change in your Country
The development of this course was supported by the National Hospice and Palliative Care Organization and the Foundation for Hospices in Sub-Saharan Africa.Please find attached a PowerPoint slide with the course information for your use in presentations, if you wish.
For more information, and to access the course, please visit: http://www.painpolicy.wisc.edu/on-line_course/welcome.htm
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