Opioid Analgesics for Cancer Pain Relief: Asia

OPIOID ANALGESICS FOR CANCER PAIN RELIEF: A REVIEW OF CONSUMPTION TRENDS AND THE LITERATURE RELATING TO ASIAN COUNTRIES

PURPOSE:

This monograph is a review of opioid analgesic consumption trends and published literature about the subject of opioid availability for cancer pain relief. It has been prepared especially for participants in the 9th Study Programme for Overseas Experts on Drug Abuse and Narcotic Control. It has two purposes: 1) to share information throughout the region, and 2) to encourage further study and discussion of ways to improve the availability of opioid analgesics to cancer patients for the relief of pain, while preventing diversion and abuse. Comments on the usefulness of this report and suggestions for improvement are welcome.

THIS MONOGRAPH MAY BE QUOTED, REPRODUCED OR TRANSLATED IN WHOLE OR IN PART. ACKNOWLEDGMENT IS APPRECIATED:

Joranson DE, Gilson AM, Krchnavek, K. Opioid analgesics for cancer pain relief: A review of consumption trends and the literature relating to Asian countries. The University of Wisconsin Pain Research Group/WHO Collaborating Center for Symptom Evaluation: Madison, Wisconsin, 1994. (Monograph)

The authors are grateful for Amy Harmon's assistance in preparing this monograph, and for the statistical information provided by Mr. Koli Kouame, Chief of the Narcotics Control Unit of the International Narcotics Control Board.

TABLE OF CONTENTS

Part A. Opioid Analgesic Availability
Introduction and overview
Section I: Access to essential drugs (1986-87)
Section II: Consumption of morphine and pethidine in the world
Section III: Consumption of morphine and pethidine in individual countries
Section IV: Comparison of estimated need vs. reported consumption of morphine in individual countries
Part B. Review of Literature
Introduction and purpose
Section I: International opioid policy
Section II: Cancer pain relief and opioid availability in Asia
Section III: Drug abuse and diversion in Asia

PART A

OPIOID ANALGESIC AVAILABILITY

Introduction and overview

The purpose of Part A is to acquaint readers with the information that is available concerning the consumption of opioid analgesics (narcotics) for medical purposes in individual countries. Additional information and discussion about these data may be found in the resource articles that are summarized in Part B of this report. These data may be useful to health care professionals, government regulators and pharmaceutical industry representatives as they endeavor to improve the availability of opioid analgesics for the treatment of cancer pain, while preventing diversion and abuse.

Section I is a table that estimates the extent to which "essential drugs" are believed by the World Health Organization (WHO) to be accessible to the general population in selected countries. Essential drugs are medicines that have been designated by the WHO as essential to the prevention and treatment of disease and should be made available to as many of the population in a country as possible. This estimate is made by the WHO in a publication called "The World Drug Situation" and is for the period 1986-1987. A more recent estimate is being prepared for publication.

A number of opioid analgesics are essential drugs, such as codeine and morphine, and have been included in the WHO three-step analgesic ladder. Opioid analgesics such as codeine and morphine are considered the cornerstone of analgesic therapy for cancer pain. Although listed as an essential drug, pethidine's use may be limited due to short duration of action and toxicity due to accumulation of a metabolite. It is recognized that opioid analgesics may be less available than other essential drugs in many countries.

Section II contains a graph that describes the consumption trend of morphine in the world. In this case, "consumption" refers to the amount of a drug that was distributed to pharmacies and hospitals for medical use. The WHO uses morphine consumption as an indicator of progress to improve the relief of cancer pain. (Consumption of codeine is not used as an indicator because codeine is used for other medical purposes in addition to pain management.)

The ten countries that have consumed the most morphine over the last 20 years are developed countries, including Australia, Canada, Denmark, Iceland, Ireland, New Zealand, Norway, Sweden, the United Kingdom and the United States.

Pethidine is widely used in the world for both acute and chronic cancer pain management; one graph compares its global consumption trend with that of morphine.

Section II also has a table that shows changes in the consumption of morphine that are adjusted for population in individual countries for two overlapping time periods, as calculated by the International Narcotics Control Board (INCB). The statistic in this table is the Defined Daily Dose, or DDD. The DDD is calculated by using the following formula:

DDD of a country = annual consumption in kilograms/365 days/estimated daily dose/population of the country.

The DDD represents a country's average consumption for the period per million inhabitants. The uses of this formula and its limitations are discussed in the international opioid policy publications in Part B.

Finally, Section II contains a graph that compares the consumption (DDD) of morphine and pethidine for countries in Asia.

Section III contains graphs that describe the morphine and pethidine consumption trends for individual countries. On some graphs there is a no data for certain years. Please refer to the tables of data that follow these graphs. In these tables (which were used to generate the graphs), the symbol (--) means that consumption was reported as less than one kilogram; the symbol (?) means that data was not available, usually meaning that the national government did not submit a report for that year to the International Narcotics Control Board. The source of these data are annual reports from national governments. These reports are required by the Single Convention on Narcotic Drugs and are published by the United Nations International Narcotics Control Board annually. See "Narcotic Drugs: Estimated World Requirements and Statistics, United Nations publication, ISBN No. 92-1-048057-0." The countries of Laos and Vietnam are not represented by graphs in this section; Laos' consumption trend is less than one kilogram per year, and Vietnam does not supply data to the INCB because it is not a member of the Single Convention on Narcotic Drugs.

Section III also contains two graphs that compare morphine consumption data for the Asian countries in which there are sufficient data to examine trends.

The use of opioids such as morphine has begun to increase in a number of less developed countries, in response to cancer pain relief initiatives. A discussion of global opioid trends can be found in articles listed in the section on international opioid policy in Part B.

Section IV contains graphs that compare national governments' official estimate of medical need for morphine with the amount of morphine that was reported to have been consumed. A graph for Vietnam is not presented because it does not supply data to the INCB.

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Section I: Access to essential drugs

Access to Essential Drugs

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Section II: Consumption of morphine and pethidine in the world

Global Consumption of Morphine
Global Consumption of Morphine and Pethidine
Defined Daily Doses of Morphine
Average Daily Consumption of Defined Daily Doses (DDD)

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Section III: Consumption of morphine and pethidine in individual countries

Section IV: Comparison of estimated need vs. reported consumption of morphine in individual countries

PART B

REVIEW OF THE LITERATURE

Introduction and purpose

The purpose of Part B is to provide readers with a guide to articles and reports that have been published on the topic of opioid availability for cancer pain relief and drug abuse and diversion. Although this review is not comprehensive, it provides a starting point for those who may not be familiar with this literature. This is the body of knowledge about law and public policy that is necessary to successful efforts to make opioids available for medical purposes while preventing their abuse and diversion.

Readers may request a single copy of any article in this section by writing to the Pain Research Group at the address which appears at the front of this publication. In addition, readers are invited to provide additional articles for inclusion in subsequent printings of this booklet.

Section I lists and summarizes publications about international opioid policy. This section contains articles that discuss international law, guidelines for regulating health care professionals, recent trends in opioid use, methods for assessing and addressing barriers to opioid availability, and the risk of diversion.

Section II summarizes articles that discuss many aspects of palliative care in Asia, focusing particularly on the availability of opioids for cancer pain relief. It should be noted that these summaries focus primarily on opioid availability issues, although some articles discuss the broader area of palliative care.

Section III summarizes articles that deal with drug abuse and diversion of opioids in Asia. Although these articles are by no means comprehensive, they represent the need to achieve a balance between assuring availability of opioids and preventing their abuse and diversion.

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Section I: International Opioid Policy

Angarola, R. T. National and international regulation of opioid drugs: purpose, structures, benefits and risks. Journal of Pain and Symptom Management 1990; 5(2) (Suppl.) February: S6-S11.

SUMMARY: This article summarizes the history and structure of the international drug control system for the regulation of opioids. Prior to 1961 there were nine different treaties regulating opioids worldwide. With the establishment of the Single Convention on Narcotic Drugs in 1961, these treaties were replaced with a comprehensive agreement. The author reviews the main components of the treaty, including the creation of the International Narcotics Control Board (INCB), which monitors the movement of opioids worldwide through government reports, and works with national authorities to prevent diversion of narcotics into illicit channels. The INCB also monitors the global supply of opioids and endeavors to assure that the supply meets the need for opioids for medical and scientific purposes. The international drug control system is working well to prevent the illicit diversion of opioids. However, in recent years it has become evident that one of the purposes of the treaty is not being met - the sufficient availability of opioids for medical use. The author states that national drug control systems "have fostered concepts and attitudes that have limited access to opioid drugs, which the international treaties recognize are indispensable for the reduction of pain and the treatment of other conditions. Patients who have a legitimate need for the relief that these drugs can provide have become the unintended victims of the national drug control systems." The author offers evidence for this through examining opioid consumption statistics of several countries which illustrates the underuse of opioids for medical purposes. The author also specifies examples of overly restrictive regulations which decrease opioid availability. Fortunately both the WHO and the INCB have recognized this problem and are taking steps to improve the availability of opioids for legitimate medical purposes, such as for cancer pain relief.
Joranson, D.E. Availability of opioids for cancer pain: recent trends, assessment of system barriers, new World Health Organization guidelines, and the risk of diversion. Journal of Pain and Symptom Management 1993; 8(6):353-360.

SUMMARY: This article presents information on the increasing global use of morphine along with the most recent statistics for most countries. Barriers to opioid availability are discussed. It is recommended that health care professionals assess the barriers to effective pain control, and develop an action plan to overcome these obstacles. The article includes a survey which can be used to develop an action plan to address them. The WHO Guide to Opioid Availability is summarized, including information about international and national drug control systems, the regulation of health care workers, ensuring patient access, medical decision making and the low risk of addiction. Data is presented showing that an increase in opioid availability for medical purposes does not increase diversion into illicit channels if handled properly, according to recommendations of the WHO and the INCB. Tables and graphs in the article present data regarding morphine consumption, including global consumption of morphine from 1972-1991, countries with an increase in morphine consumption between 1984-91 and countries with a decrease in consumption during the same time period. Statistics describing increasing morphine consumption compared to a low rate of diversion in Wisconsin are presented.
International Narcotics Control Board. Demand for and Supply of Opiates for Medical and Scientific Needs. New York: United Nations, 1990.

SUMMARY: This report was prepared as a result of Economic and Social Council resolution 1989/15 of 22 May 1989 which requested that the International Narcotics Control Board (INCB), "assess legitimate needs for opiates in various regions of the world hitherto unmet because of insufficient health care, difficult economic situations or other conditions." This INCB report was prepared in conjunction with the World Health Organization. The report indicates that the need for opiates for legitimate medical purposes is not being met. The report provides an overview of the production of opiate raw materials and global consumption. It describes the requirement that each national government complete a thorough assessment of their annual need for opiates, and the criteria by which this should be accomplished. Impediments to the medical availability of opiates are reviewed; they are associated with problems in health care systems, legislation and drug administration, as well as behaviors of health care providers. The report concludes with recommendations for governments, the WHO, and professional associations and medical instructors to overcome these barriers, and thus fulfill the medical need for opiates, particularly in regard to cancer pain treatment.
Stjernsward, J., Teoh, N. Current status of the global cancer control program of the World Health Organization. Journal of Pain and Symptom Management 1993;8(6):340-347.

SUMMARY: The authors provide an overview of the Global Cancer Control Program, related primarily to pain control and palliative care. Measures regarding the implementation of national cancer pain relief programs are reviewed: the existence of a national policy, education, and drug availability. Global morphine consumption figures are noted, and the pros and cons of using morphine consumption as a indicator of access to pain control is discussed. Structural components of the WHO program are indicated through the appendices: publications, list of essential drugs, collaborating centers, and WHO member states. Additionally, countries with national policies on pain, cancer pain, and terminal care are listed.
World Health Organization. Cancer Pain Relief: A Guide to Opioid Availability. Madison, WI: Pain Research Group, World Health Organization Collaborating Center for Symptom Evaluation in Cancer Care, 1993 (also in Spanish).

SUMMARY: This Guide has been prepared by the WHO Expert Committee on Cancer Pain Relief and Active Supportive Care for health care professionals and drug regulators to explain the system through which morphine and other opioids can legally be made available to patients for the treatment of pain. Opioids are unavailable in many places in the world, in part due to overly restrictive narcotics laws. It is important for health care professionals to understand how the international regulatory system for opioids affects national laws governing opioid availability.

The Guide explains the Single Convention on Narcotic Drugs and the drug distribution system, emphasizing the need for regulators and the pain management community to work together to ensure sufficient medical availability of opioids while preventing diversion. International health and drug regulatory authorities have recognized that the medical need for opioids is not being fully satisfied--in particular for the treatment of cancer pain.

The Guide recommends principles to regulate health care professionals who provide opioids to patients. These principles include legal ability; accountability; requirements of prescriptions; ensuring patient access; non-regulation of medical decisions; and recognition that physical dependence is not the same as addiction. National laws and regulations should be consistent with the intent of the Single Convention, which balances the goal of preventing diversion with the responsibility of ensuring opioid availability for medical purposes.
World Health Organization. Cancer Pain Relief and Palliative Care (Technical Report Series 804). Geneva: WHO, 1990.

SUMMARY: This report reviews the WHO method of relieving cancer pain through the "three-step analgesic ladder." Topics covered include palliative care, cancer pain, opioid availability, common symptoms of cancer patients, psychosocial aspects, spiritual aspects, ethical considerations, education and training, implementation of palliative care at the national level and WHO recommendations for national policy. A brief overview of global morphine consumption is presented, as well as an explanation of the International Narcotics Control Board and the background of the drug control and distribution system related to the international treaties. The report discusses the risk of diversion of medically prescribed opioids (which if properly regulated is low), and the importance of facilitating opioid availability for medical purposes. Specific principles are advocated to provide a framework for drug legislation and administrative requirements for national, provincial and/or state policies.
World Health Organization. Guiding principles for small drug regulatory authorities. WHO Drug Information. 1989;3(2):43-50.

SUMMARY: The article summarizes issues which small national drug regulatory authorities need to address in their provisions. The authority must be operating within a defined context which indicates the scope of drug control. The article also indicates the basic responsibilities which authorities must fulfill. Basis of authority, powers of enforcement, licensing functions and overall procedures, are some of the major areas discussed within the document.

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Section II: Cancer Pain Relief and Opioid Availability in Asia

Ba Duc, N. Vietnam: status of cancer pain and palliative care. Journal of Pain and Symptom Management 1993;8(6):440-442.

SUMMARY: Compared to developed countries, Vietnam has a low incidence of cancer. However, when patients are diagnosed, it is typically during the advanced stage of the disease. Efforts to control cancer are limited, but national efforts are beginning. These efforts are generally related to cancer prevention, detection, and treatment. Since 1988, a cancer pain relief program has been operating in Vietnam with the assistance of WHO. The monograph, Cancer Pain Relief, has been translated into Vietnamese. Additionally, the WHO three-step ladder, and the Brief Pain Inventory, are also in use. Since 1991, the Vietnam Traditional Medical Institute and the National Cancer Institute of Hanoi have been working together to evaluate pain relief by LASER acupuncture. The Ministry of Health is making the alleviation of cancer pain a priority, and has delineated several goals to attain this end. The goals include an increase in training, and increase in availability of both narcotic and non-narcotic methods of pain control, establishment of cancer pain units in hospitals, public education, and a review of national drug regulations.
Burn, G. A personal initiative to improve palliative care in India. Palliative Medicine. 1990; 4: 257-259.

SUMMARY: This is a personal account of the author's professional education tour of India. She briefly discusses opioid availability, indicating that oral morphine was first made available in India in 1988. The article indicates that India now manufactures some oral morphine tablets at a very low cost. The author states: "It only remains for legislation to be amended in the different states and for all those involved in the care of cancer patients to become aware of the drugs available for pain and symptom relief, and to gain the knowledge required for their correct use. There is also a need to change attitudes towards caring for cancer patients and to alter the entrenched fear of addiction when using opiates." The article also describes the need for primary care and a multi-disciplinary approach which would enable better management of cancer pain.
Chaudakshetrin, P. Thailand: status of cancer pain and palliative care. Journal of Pain and Symptom Management 1993;8(6):434-436.

SUMMARY: Cancer is the second leading cause of death in Thailand. It is estimated that 18,000 people die of cancer every year, and that about 13,000 of these people die in pain without drug management. Some of the impediments to pain control are: lack of education and resources, the restrictiveness of regulations due to the "war on drugs", and physicians' reluctance to prescribe opioids due to fear of addiction in their patients. As a result, acetaminophen is used to treat pain instead of opioids. Drug policy restricts use of narcotics through bureaucratic paperwork, and restricted access to morphine. Government hospitals were only allowed access to 200 grams of morphine per year, whereas private hospitals were only allowed 20 grams. This has recently been increased to 400 grams, and 40 grams, respectively. "The delay to supply morphine from the pharmacy is a common cause of under-utilization in large government hospitals. In the district hospitals, drug legislation and fear of burglaries by drug addicts usually prevent the stocking of opioids for medical purposes." Morphine consumption in 1990 was 5 kg, and rose to 7 kg in 1991 due to a donation of slow-release tablets by the Purdue Frederick Company. The main barriers to cancer pain relief are lack of trained health care professionals, financial resources, and education. However, some progress is being made, particularly in terms of education. The WHO newsletter Cancer Pain Release and the IASP newsletter are being distributed to professionals. The monograph Cancer Pain Relief has also been made available. A national chapter of IASP has been formed, and a local newsletter is now being published. Workshops, seminars, and meetings on pain have been occurring over the last two years. These events have encouraged work on drug policy changes and continued dissemination of information, such as the development of a speakers bureau on cancer pain. A local preparation of morphine tablets is being quality tested. The WHO model of cancer pain treatment is being advocated in conjunction with all of these activities. The author concludes by indicating that Thailand has just reached the first phase of providing cancer pain and palliative care in the country. An action plan is being developed related to national legislation, education, and opioid availability.
Cleeland, C.S., Ryan, K.M. Pain assessment: Global use of the brief pain inventory. Annals, Academy of Medicine, Singapore. 1994;23(2):129-138.

SUMMARY: Poorly controlled cancer pain is a significant public health problem throughout the world. There are many barriers that lead to undertreatment of cancer pain. One important barrier is inadequate measurement and assessment of pain. To address this problem, the Pain Research Group of the WHO Collaborating Center for Symptom Evaluation in Cancer Care has developed the Brief Pain Inventory (BPI), a pain assessment tool for use with cancer patients. The BPI measures both the intensity of pain (sensory dimension) and interference of pain in the patient's life (reactive dimension). It also queries the patient about pain relief, pain quality, and patient perception of the cause of pain. This paper describes the development of the Brief Pain Inventory and the various applications to which the BPI is suited. The BPI is a powerful tool and, having demonstrated both reliability and validity across cultures and languages, is being adopted in many countries for clinical pain assessment, epidemiological studies, and in studies of the effectiveness of pain treatment.
De Souza, L.J., Lobo, Z.M.F. Symptom control problems in an Indian hospice. Annals, Academy of Medicine, Singapore. 1994;23(2):287-291.

SUMMARY: "Symptom control is the essence of palliative care but is not without problems, especially in the difficult socio-economic conditions of a developing country. We present our experience with over 2000 hospice admissions over six years in India's first hospice, to highlight our problems and the measures we have taken to solve them. The prevalent habit of tobacco smoking and chewing in India gives rise to a high incidence of head and neck cancers which form 50% of our admissions. Another 24% is formed by breast and gynecological cancers. The difficult symptoms in head and neck cancers are pain, dysphagia, fungation and trismus. Almost 25% of our head and neck cancers have feeding tubes, which we feel are justified and most useful for medication and basic nutrition. Difficult problems in gynecological cancers are pain, chronic blood loss, ulcerations and fistulae. The inadequate or sporadic availability of oral and injectable morphine adds to our problems in pain control. Non-compliance of patients to take adequate medications and the resistance from relatives make it sometimes difficult to achieve optimum symptom control. India has man systems of alternate and unorthodox medicine. We find that these are best tried outside the hospice unless they are in fully-studied clinical trials. In the end there is always the difficult choice of either remaining in the hospice for optimal symptom control or going back to their homes, where this may not be available." (taken from abstract)
Goh, C.R., Shaw, R.J. Evolution of a Hospice Home Care Service in Singapore. Annals, Academy of Medicine, Singapore 1994;23(2):275-281.

SUMMARY: "The hospice movement in Singapore was started in 1985 when St Joseph's Home opened its doors to terminally ill patients by setting aside 16 beds for hospice care. A newspaper article about this work brought together a group of volunteers who started a hospice home care service under the auspices of the Singapore Cancer Society in 1987. This service was originally entirely staffed by volunteers until a charitable foundation made possible the employment of a nurse coordinator in 1988. Nearly two years later, in December 1989, the Hospice Care Association, a new charitable organization specifically devoted to the promotion and provision of hospice care, was formed. With charitable funding from the community, the new organization built on the experience of the volunteer-run hospice home care service and developed it into one in which professionals provide most of the care, supported by volunteers. Full-time staff were responsible for the day-to-day running of the service, providing for reliability and setting and maintaining of standards, while the role of volunteers changed to that of supporting, supplementing and enhancing the quality of the care given to patients. This paper chronicles the evolution of this service and describes its present functioning." (taken from abstract)
Goh, C. Singapore: status of cancer pain and palliative care. Journal of Pain and Symptom Management. 1993; 8(6); 431-433

SUMMARY: "In Singapore, cancer pain relief and palliative care have not met with problems of drug availability. Morphine for cancer pain relief has been freely available. The pioneers of the hospice movement have early on received support from pharmacists and the drug administration division, who have made oral morphine preparations available for cancer pain relief. Funding through charitable donations for hospice services has also not been a problem. The public shows great appreciation and support for such projects. Government funding, however, has not been forthcoming and palliative care has not been and still is not a priority in health care provision and planning. The government has only recently begun to look into recognizing it for funding, and it has yet to be incorporated into a national plan for dealing with cancer. Personnel provision for palliative care presents some difficulties. There is a lack of medical personnel, previously because the specialty was entirely unknown. More recently, some of the younger doctors have shown an interest in going into the specialty, but trained medical personnel are very scarce. Nursing personnel are a problem in that Singapore currently suffers a national shortage of 1000 nurses for all services. However, palliative care is an attractive field for nurses, and it is encouraging that more and more nurses with the requisite experience are expressing interest to work in the field."
Laudico, A.V. Development of Cancer Pain Relief and Palliative Care in the Philippines. Annals, Academy of Medicine, Singapore. 1994;23(2):292-295.

SUMMARY: "The article describes the development and progress of cancer pain relief and palliative care in the Philippines from 1986 onwards. The strategy employed was a stepwise progression that began with the establishment of government policy, followed by measures to improve availability and accessibility to oral morphine, and finally, continuing nationwide professional education. Key elements to successful implementation were the presence of a national cancer control programme; the active participation of the World Health Organization, the Department of Health, the Philippine College of Surgeons, and the Philippine Cancer Society Inc; and research development and utilization. Data from three clinical studies are also presented, which showed the efficacy of the WHO Method of Cancer Pain Relief among samples of Philippine patients, and that cancer pain relief alone did not significantly improve overall quality of life, demonstrating the need for comprehensive palliative care." (taken from abstract)
Laudico, A.V. The Philippines: status of cancer pain and palliative care. Journal of Pain and Symptom Management 1993;8(6):429-430.

SUMMARY: Since 1987, the Philippine government has made cancer pain control a priority. Significant progress has been made. The author states: "Today, the Philippines is one of only four countries in the Western Pacific Region wherein all of the basic infrastructure needed for implementation of the WHO method is present. Together with Japan, Australia, and Singapore, we have a national policy and commitment, availability, and accessibility of oral morphine, and an aggressive professional education program." Research done in 1989-90 showed that there was significant undertreatment of pain in the country. However, with the adoption by the government of the Philippine Cancer Control Program; the use of the "two-step ladder" method of pain control (adapted from the WHO three-step approach ); and the provision of seminars and workshops in palliative care, the Philippines is making gains in providing pain relief to its cancer patients.
Lickiss, L.N. Indonesia: status of cancer pain and palliative care. Journal of Pain and Symptom Management. 1993;8(6);423-424.

SUMMARY: Indonesia is a country of 180 million people with a fast-growing economy and "carefully planned growth of health care facilities." As a result of WHO's cancer control program, awareness of cancer pain relief increased in Indonesia during the 1980's. A 1990 meeting in Australia on cancer pain management, which was attended by an Indonesian Ministry of Health official and a pharmacist from a teaching hospital, was the impetus to spur development of cancer pain relief efforts and programs in Indonesia. The National Cancer Committee was established by the Minister of Health in September of 1990. This committee has been instrumental in developing a National Cancer Control Program in Indonesia. The main elements of the plan are delineated in the article. Since 1990 this program has focused on physician and health care professional education on palliative care, the formulation of palliative care guidelines, and adjustment in government policies regarding the use of oral morphine. A national symposium held in October of 1992 advanced the process through discussion of policies and programs regarding the availability of opioids for pain relief. Also at this symposium, a decision was made to allow oral morphine to be used by patients in the home, not just in the hospital. The author states: "In 1992, Indonesia was importing less than 1 kg. of morphine per year for medical use, but the commitment was clear to increase availability of the drug on a pilot basis." Demonstration programs are beginning in Indonesia focused on cancer pain relief, which will increase the supply of morphine on a gradual basis, with the intent of incorporating palliative care into mainstream health care.
Sham, M.K., Wee, B.L. The first year of an independent hospice in Hong Kong. Annals, Academy of Medicine, Singapore. 1994;23(2):282-286.

SUMMARY: "Two hundred and ninety-nine patients admitted to the Bradbury Hospice, Hong Kong, during the period from 1 June 1992 to 31 May 1993 were studied. While a majority of the patients held realistic expectations of the hospice service, a small percentage expected cure, prolongation of life or even euthanasia. Physical symptoms were the main concern in a vast majority of patients, the commonest being pain. Only 1.7% regarded psycho-social problems as their main distress. Morphine was widely used for pain control, although 68% of patients required co-analgesics or palliative radiotherapy as well. Morphine was also the mainstay of treatment for dyspnoea. It might be worthwhile for hospices to be equipped with oxygen, as approximately 71% of our patients with dyspnoea as their main distress benefitted from oxygen therapy. Many patients expressed fear of death; more worried about suffering. While 17.7% were assessed to be in the stage of acceptance on admission, 14.7% expressed self-pity when their search for meaning failed. Although many patients were atheists, a majority of patients with religious beliefs found that they could get support from their faith. A significant number of patients believed in Shumei. Increased knowledge of this religion would be helpful in taking care of these patients." (taken from abstract)
Sun, Y. China: status of cancer pain and palliative care. Journal of Pain and Symptom Management. 1993;8(6):399-403.

SUMMARY: Cancer is one of the main causes of death in China, and detection of the disease usually occurs in the advanced stage of the disease. During the past few years, the WHO has begun to work with China's Ministry of Public Health to develop a national cancer pain and palliative care program. This is being accomplished through numerous training workshops which have been occurring throughout the country since 1990. WHO literature on pain control has been translated into Chinese and is being disseminated. In major hospitals, oral morphine is available in 5 mg. and 10 mg. tablets in limited quantities. Also, a few other opioids are being tested, including codeine and dihydroetorphine tablets. Cancer pain research is being done which include studies on the degree of pain patients experience at different stages of the disease, the effect of different treatment methods and drugs on pain and quality of life indicators. China is also involved in testing several drugs for the relief of pain including Qiang Tong Ding (AP-237), Lappaconine, Acetaminophen-codeine, and Dihydroetorphine.
Takeda, F. Recent progress in cancer pain management and palliative care in Japan. Annals, Academy of Medicine, Singapore. 1994;23(2):296-299.

SUMMARY: One out off every four deaths in Japan is due to cancer, so that health-care workers and the lay public have gradually become aware of the importance of cancer pain relief and palliative care in recent years. In 1984, the feasibility and effectiveness of the WHO method for relief of cancer pain was demonstrated in Japanese cancer patients. Thereafter, information on the latest knowledge and skills in cancer pain relief and palliative care has been disseminated through medical meetings, publications and mass communication networks. The national government published manuals of care for terminally ill cancer patients and amended narcotics regulation in order to improve the accessibility of opioid analgesics, especially morphine, to cancer patients with pain. These activities resulted in a 35-fold increase in the annual consumption of morphine preparations for medical purposes between 1979 and 1992. However, the annual consumption per capita is still much smaller than that in other developed countries, indicating the need for further information dissemination and professional education in the implementation of palliative care programs.
Takeda, F. Changing attitudes towards narcotic use in cancer pain management in Japan. Postgraduate Medical Journal 1991;67(Suppl. 2):S31-S34.

SUMMARY: Morphine consumption for medical purposes has increased in Japan seventeen-fold between 1979 and 1989, with no increase in diversion during this time. The change in attitude and regulations which fostered this increase is due to the WHO Cancer Pain Relief Programme. Additionally, the media was a strong change agent to change attitudes about narcotics, both among medical professionals and the public. By the end of the 1980s, the Ministry of Health and Welfare of the Japanese Government was committed to the promotion of palliative care and pain control. Education and training in palliative care is now a priority, and there has been an increase in the types of opioids available in the country. A table lists the opioids available by method of administration. However, regulations in Japan are still quite strict. In Japan the regulation "encompasses the entire process from manufacture/import to consumption of the narcotic drugs for medical aims." The article briefly describes some of the regulations, particularly related to prescription. It also describes regulations which have been revised. In 1990 an advisory panel "drafted a set of guidelines on regulation, prescription and dispensation of morphine preparations for cancer pain management for use in each hospital, clinic, and pharmacy. [The titles of the manuals are listed]. The legalization of 10 mg and 30 mg slow-release morphine (MS Contin) alone has increased morphine consumption 1.5 fold between 1988 and 1989. Despite all of these changes, there is still undertreatment of pain. The per capita amount of morphine consumed in Japan is still "about one-fourth and one-eighth as much as those consumed in the United States and the United Kingdom, respectively."
Takeda, F. Japan: status of cancer pain and palliative care. Journal of Pain and Symptom Management. (1993): 8(6); 425-426.

SUMMARY: As a result of the WHO Cancer Pain Relief Program, morphine consumption in Japan has increased dramatically over the past several years. The article indicates that there has been a "25-fold increase in the medical use of morphine preparations between 1979 and 1991, without an increase in diversion." In 1979 morphine consumption was only 11 kg, whereas in 1991 it rose to 280 kg. In the last few years national policies and regulations have been reviewed to enable greater accessibility to opioids for medical use, including cancer pain management. Further, various dosages and modes of morphine administration have become more available in Japan. "In 1989, the Ministry of Health and Welfare legalized the use of 10-mg tablets of slow-release morphine tablets (MS Contin) and, in 1990, the 30-mg tablet was approved. In 1992, the ministry approved field tests of both the 60-mg tablet of slow-release morphine and the 5-mL (50 mg) ampules of injectable morphine hydrochloride." Narcotic supply is now unlimited for both hospital and medical settings at the community level, provided that proper regulatory procedures are utilized. There has also been emphasis on both professional and public education on pain management. Despite all of this progress, the author states, "at present the amount of morphine consumed per capita in Japan is still less than one-fifth as much as the amounts consumed in the United States and in the United Kingdom, which means that many doctors are still reluctant to prescribe morphine to control cancer pain and that there are still many cancer patients with unrelieved pain."
Vijayaram, S. India: status of cancer pain and palliative care. Journal of Pain and Symptom Management 1993;8(6):421-422.

SUMMARY: It is estimated that there are approximately 1.5 million cancer cases in India at any given time. About .5 million new cases are added each year. There are 12 regional cancer centers in India. Oral morphine is only available at the following centers: Bangalore, Manipal, Trivandrum, Ahmedabad, and the All-India Institute of Medical Sciences in Delhi. There are also a few voluntary agencies which provide pain and palliative care, such as the Shanti Avedan Ashram in Bombay. The main barriers to pain control are the lack of availability of potent opioids, and inadequate knowledge among doctors and paramedical staff in the use of opioids for pain. Three organizations are promoting education: The Indian Association for the Study of Pain, Indian Society of Oncology, and the Association of Palliative Care. Palliative care units are starting to be formed through the use of teams made up of nurses, doctors, and pharmacists. A tool for the assessment of pain has been developed - the rupee scale. Families are strongly involved in care to assist in pain control in the home.
Japan International Corporation of Welfare Services (JICWELS). The 8th Study Programme for the Overseas Experts on Drug Abuse and Narcotics Control: Administrative Control for Licit Narcotics and Psychotropics. June 21 - July 17, 1993. Tokyo, Japan.

SUMMARY: The textbook includes the following articles: Pharmaceutical Administration in Japan (Mr. Nobuo Uemura), Pharmacological Aspects of Drug Dependence and Abuse (Dr. Tomoji Yanagita), The Roles and Functions of a Regional Narcotic Control Office - Ministry of Health and Welfare (Mr. Toyoya Ikeda), On-the-Spot Inspection (Mr. Fusao Tsutsui), Drug Identification (Mr. Yasumitsu Kondoh), Functions and Roles of the Drug Abuse Prevention Center (Mr. Shunzo Abe), Treatment for Drug Dependence in Medical Model (Dr. Kyohei Konuma), Measures for Narcotics and Psychotropics Control by the Local Government (Mr. Yukio Oikawa), The Manufacture of Narcotic Medicines (Danippon Pharmaceutical Company Limited), Freedom from Cancer Pain and Opioid Availabiliy (Dr. Fumikazu Takeda), The Control of Narcotics in a Japanese Hospital (Mr. Jun-ichi Murakawa).

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Section III. Drug Abuse and Diversion in Asia

Murad, J. E. The role of the pharmacist in drug abuse in developing countries. Pharmacy International 1982;(October):311-313.

SUMMARY: In many developing countries prescriptions are not necessary to obtain medications which are regulated in developed countries. Further, many pharmacies in developing countries are staffed by lay people rather than graduate pharmacists. The author states that drugs like "morphine, meperidine and heroin have not yet caused problems of abuse in the majority of developing countries. In our opinion this occurs because of two factors: the rigorous system of control, and the high price of those drugs in street drug traffic which has limited their use to people with high incomes and people in medical or para-medical professions." The rest of the article discusses the types of drugs which are abused, and the role of the pharmacist in preventing this abuse.
Sharma, K., Shukla, V. Rehabilitation of drug-addicted persons: the experience of the Nav-Chetna Center in India. Bulletin on Narcotics 1988;40(1):43-49.

SUMMARY: "The Nav-Chetna Drug De-Addiction and Rehabilitation Center, Varanasi, India, was established in December 1985. It provides out-patient and residential rehabilitation services, medical treatment, counselling, educational and vocational guidance, yoga therapy and aftercare. Drug-dependent persons under rehabilitation treatment at the Center are encouraged and helped to promote personal development, to build up and strengthen their initiative and confidence and to bring about improvements in their maturation, attitude and behavior to overcome addiction. This is accomplished through a therapeutic-oriented programme, which creates conditions that optimize the natural tendency of the individual to self-actualize and eventually stabilize. Yoga plays a crucial role in this programme at both pre- and post-clinical stages. It offers a new avenue for positive mental and physical health and helps to free individuals from drug dependency and its associated problems." (taken from abstract).
Suwanwela, C., Poshyachinda, V. Drug abuse in Asia. Bulletin on Narcotics. 1986;38 (1&2):41-53.

SUMMARY: "The article focuses on countries and areas in South-East Asia, which are seriously affected by drug abuse and the problems associated with it. Opium has traditionally been used for treating illnesses and alleviating physical and mental stress, as well as for recreational and social purposes. The prohibition of the sale and use of opium in Burma, Hong Kong, Malaysia, Singapore, and Thailand forced many habitual opium users to switch to heroin. Over the past two decades there has been an increasing trend towards drug use, often involving experimentation with more than one substance, among youth in and out of school. [...] During the 1970s the abuse of heroin and other opiates emerged as a serious problem of epidemic nature, predominantly affecting young people in many countries of South-East Asia. While opiates, including heroin, have been abused by inhaling and smoking, there has recently been an increasing trend towards injecting heroin of high purity (80-90 per cent pure heroin). Heroin addiction spread first to the populations of capital cities and then to other cities and towns and even to the hill tribles, as studies in Thailand have revealed. Most recent studies have shown that heroin abuse has spread further in Asia, both socially and geographically, involving such countries as India and Sri Lanka, which had no previous experience with the problem. Studies have also shown that the abuse of manufactured psychotropic substances has been increasing and that heroin addicts resort to these substances when heroin is difficult to find. The article also briefly reviews the history of opium use in China and history of drug abuse in Japan, particularly with regard to the problem of methamphetamine abuse, which has appeared in two epidemic-like waves. The first followed the end of the Second World War and disappeared at the end of the 1950s; the second reappeared in 1975 and since then has gradually been increasing in size." (taken from abstract) A table in the body of the article titled "Drug abuse recorded in various countries and areas in Asia" includes percentage of morphine abuse in its figures. Percentages decrease under morphine from the early 70's to the mid-80's.
Japan International Corporation of Welfare Services (JICWELS). Outline of Drug Abuse and Countermeasures in Japan. Undated. Tokyo, Japan.

SUMMARY: The document reviews the governmental structures for drug abuse control, and summarizes the domestic laws and international conventions which regulate the handling and use of drugs. Although most of the document deals with drug abuse in Japan, there is a section on the Manufacture and Consumption of Narcotics for Medical and Scientific Purposes. Graphs within the document indicate the number of reported morphine addicts which were hospitalized from 1963-1990, number of morphine-related violators from 1985-1991, the amount of solid morphine seized in 1990 and 1991, and the total quantities of opiates seized worldwide, including morphine.

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OPIOID ANALGESICS FOR CANCER PAIN RELIEF: A REVIEW OF CONSUMPTION TRENDS AND THE LITERATURE RELATING TO ASIAN COUNTRIES PURPOSE:

PART A OPIOID ANALGESIC AVAILABILITY