OPIOID ANALGESICS FOR CANCER PAIN RELIEF: A REVIEW OF CONSUMPTION TRENDS AND THE LITERATURE

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 III Congreso Latino-Americano de Cuidados Paliativos E Dor Neoplasica. 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. Although originally prepared in 1994, this monograph has been updated to include statistics from our 1996 monograph. 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. The University of Wisconsin Pain Research Group/WHO Collaborating Center for Symptom Evaluation: Madison, Wisconsin, 1994. (Monograph)

The authors acknowledge with appreciation the encouragement from Professor Charles Cleeland and Dr. Eduardo Bruera. We 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 1: Access to essential drugs
Section 11: 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 Latin America
Section III: Drug Abuse and diversion in Latin America

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 to be accessible to the general population in selected countries (p. 3). Essential drugs are medicines that have been designated by the World Health Organization 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 (p. 4) 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 -and, 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 11 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. The statistic used 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.

Section III contains graphs that describe the morphine and pethidine consumption trends for individual countries (pp. 7-18). On some graphs there is a no data for certain years. Please refer to the tables of data (pp. 19-22) 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-O."

Section III also contains a graph (p. 18) that compares morphine consumption data for the six Latin American 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 (pp. 23-26) that compare national governments' official estimate of medical need for morphine with the amount of morphine that was reported to have been consumed.

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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

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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

Estimated need compared to actual consumption of morphine in Argentina
Estimated need compared to actual consumption of morphine in Chile
Estimated need compared to actual consumption of morphine in Colombia
Estimated need compared to actual consumption of morphine in Cuba
Estimated need compared to actual consumption of morphine in Mexico
Estimated need compared to actual consumption of morphine in Uruguay
Estimated need compared to actual consumption of morphine in Venezuela
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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 Latin America, focusing particularly on the availability of opioids for cancer pain relief. One particular volume of Cancer Pain Release is rich in information about opioid availability issues. It should be noted that these summaries focus primarily on opioid availability issues even though the articles themselves discuss the broader area of palliative care.

Section III summarizes articles that deal with drug abuse and diversion of opioids in Latin America. Although not comprehensive, these articles may help to sensitize palliative care professionals about the prevalence of drug abuse and the importance of preventing diversion of opioid analgesics..

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Section I: International Opioid Policy

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.
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.
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.
Junta Internacional de Fiscalizaci�n de Estupefacientes. Demanda y oferta de opi ceos para las necesidades m‚dicas y cientificas. Nueva York: Naciones Unidas, 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.
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.

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Section II: Cancer Pain Relief and Opioid Availability in Latin America

Bruera, E. Palliative care in Latin America. Journal of Pain and Symptom Management 1993;8(6):365-368.

SUMMARY: This article discusses problems in the delivery of palliative care in Latin America. The author describes models for provision of services and highlights issues relevant to future development. Primary concerns related to palliative care include poverty, insufficient knowledge by physicians and nurses, patients and families receiving inadequate information about their diagnosis or prognosis, drug availability and lack of models for the delivery of palliative care in the region. Barriers to drug availability include the high cost of drugs and highly restrictive controlled substances regulations. These regulations, which often require triplicate prescriptions or prescriptions which are limited to 5 days of treatment, decrease physician prescribing or increase physician non-compliance with the law. The price of morphine hydrochloride has increased significantly between 1991-1992, and has doubled in Argentina during this time. Palliative care programs are slowly developing throughout Latin America, but they are operated by individuals with widely different backgrounds, and the administration of these programs vary. Funding of programs is difficult, and communication between programs is just beginning. Communication is facilitated by regional conferences at which international experts also provide their knowledge. Future development issues involve an increase in knowledge-sharing between programs, continued involvement from the seven WHO collaborating centers and major teaching groups in Latin America, and government support--both financially and through policies--which will further the availability of opioids for pain control.
Colleau, S. and Bruera, E. Cancer pain relief in Central and South America: a progress report. Cancer Pain Release 1993;6(2-3):1-6. (Contains reports on Argentina, Brazil, Colombia, Costa Rica, the Dominican Republic, Mexico, Uruguay and Ecuador, and is also available in Spanish.)

SUMMARY: The introduction to this issue of Cancer Pain Release states that the purpose of presenting the developments in palliative care in Latin America is to encourage communication between health care professionals treating cancer pain in different countries. Despite the lack of financial resources provided to palliative care from governments, progress can continue through the sharing of solutions among individuals and institutions who care about cancer pain relief. Numerous effective small programs can make more impact on the status of palliative care throughout the region than large-scale government-run programs which lack the resources and commitment to be adequately implemented. The following articles in this issue of Cancer Pain Release address the subject of opioid availability.
2. Colleau, S. and Wenk, R. Argentina. Cancer Pain Release 1993;6(2-3):2.
  
  SUMMARY: Argentina has a nationwide hotline which disseminates information to patients and their families regarding medical professionals who provide palliative care, and the availability of opioid analgesics in their area.
3. Colleau, S. and Bruera, E. Brazil. Cancer Pain Release 1993;6(2-3):3.
  
  SUMMARY: Morphine tablets have been commercially available in Brazil since 1990, but they are expensive. The cost is 24 US cents for a 10 mg. tablet. Neither the government nor health insurance covers the costs of home care for terminal cancer patients, and thus the patient is responsible for payment of their medications and other home care costs.
4. Colleau, S., Coyle, N. and De Lima, L. Colombia. Cancer Pain Release 1993;6(2-3):4.
  
  SUMMARY: There is a lack of knowledge regarding pain control among most health professionals in Colombia. As stated in the article, "The prescription of narcotics for pain control is regulated by a decree of January 17,1977, amended on August 16, 1985, which requires the use of an official prescription form available in only one location per city. This applies to the prescription of morphine, pethidine and dehydromorphine. Opioid analgesics are very heavily restricted by the government which allocates distribution to different institutions. As a result, there are periods when morphine is not available, forcing clinicians to prescribe tramadol and/or dipirone for pain control." Since 1990, a Colombian narcotics control officer has participated in annual WHO conferences which focuses on licit opioid availability for cancer pain management. The conferences also deal with decreasing the diversion of opioids into illicit uses.
5. Colleau, S., Quesada Tristan, L. and Herrera, I. S. Costa Rica. Cancer Pain Release 1993;6(2-3):5.
  
  SUMMARY: According to this article, in Costa Rica "only the Health Ministry is allowed to import opioids for distribution to public and private pharmacies. Morphine is available, but exclusively in ampules, as is pethidine. Legislation limits the prescription of morphine and pethidine to 6 ampules every three days, up to a maximum of 6 ampules a day if necessary and the use of special prescription pads is required. The number of prescriptions per day is to be determined by the physician." The need for proper pain control has been given a great deal of press coverage due to a Constitutional Court Case in which a woman with terminal cancer was denied morphine. The Court ruled in July of 1992 that "every citizen has the right to die with dignity and without pain." It is hoped that this publicity will increase public demand for proper pain control.
6. Colleau, S., Patt, R. and Bruera, E. Dominican Republic. Cancer Pain Release 1993;6(2-3):6.
  
  SUMMARY: In the Dominican Republic availability of analgesics is limited due to cost. The mild analgesics which are available are acetaminophen, aspirin, propoxyphene, codeine and oxycodone. According to this article, "Most patients receive nonsteroidal antiinflammatory agents orally for pain. Adjuvant drugs, such as antidepressants and anticonvulsants are available but rarely used. Since August 1990, oral morphine is available but only at the cancer institute in Santo Domingo, and only by special prescription. Very limited supplies of immediate release morphine tablets (15 mg) and elixir (5 mg/Ml) and more recently, controlled release morphine (30 mg tablets) are prescribed for severe pain."
7. Colleau, S., Plancarte, R. and Bruera, E. Mexico. Cancer Pain Release 1993;6(2-3):7.
  
  SUMMARY: Although Mexico has a national cancer pain relief policy, there is still difficulty in obtaining adequate distribution of morphine throughout the country. Due to the strict security measures the Mexican government has taken to prevent diversion, physician and patient access to narcotics for pain has been severely limited. The analgesics which are available are dextropropoxiphene, nalbuphine, buprenorphine, pethidine, and butorphanol. There is a group in Guadalajara which is collaborating with Programa Argentino to develop a system which will facilitate the transportation of opioids within the country. The National Cancer Institute in Mexico City is responsible for overseeing the national policy on cancer pain relief. It establishes regulations on the prescription and administration of opioids and supervises their use and distribution.
8. Colleau, S. Uruguay. Cancer Pain Release 1993;6(2-3):8.
  
  SUMMARY: Uruguay, with a population of 3 million people, has an adequate supply of opioid analgesics, including oral morphine tablets and ampoules. Importation of morphine for commercial distribution in the country is allowed by the government.
9. Colleau, S. Ecuador. Cancer Pain Release 1993;6(2-3):8.
  
  SUMMARY: In Ecuador physicians cannot prescribe opioids for cancer pain due to the strict controlled substances regulation. The article indicates that "there is no difference in Ecuador between the legal and illegal use of opioids so that physicians, cancer patients, or drug addicts are all subject to the same fines and prison terms." Dr. Federico Santos Oehlert is attempting to affect policy change in the country to enable the use of narcotic analgesics for the treatment of pain. He has started a pain unit at Carlos Andrade Marin Hospital in Quito, and is developing a training program utilizing the WHO three step analgesic ladder. He hopes to introduce the use of oral morphine for the relief of cancer pain.
De Lima, L. Colombia: status of cancer pain and palliative care. Journal of Pain and Symptom Management 1993;8(6):404-406.

SUMMARY: The article provides an overview of cancer pain control and palliative care in Colombia. The article reviews several current palliative care programs: La Viga in Cali, National Cancer Institute and Pain Clinic in Bogota, the Pain Clinics in San Vicente de Paul Hospital in Medellin, Hospital Universitario del Valle in Cali, San Ignacio Hospital in Bogota and finally the Palliative Care Unit in Valle del Lili Foundation in Cali. The author also briefly describes the salient problems in providing palliative care in Colombia. There is a lack of commitment from the national government to provide an "adequate and permanent supply of opioids," due to both fear of diversion and lack of knowledge on the part of the authorities. Controlled substances regulations make it difficult to obtain opioids for medical needs. There are not enough opioids available in the country to adequately address patient needs, and a lack of financial resources to provide care to the poor. Communication between different groups is difficult, and there is a lack of recognition and support of palliative care from other medical disciplines.
Quesada, L. Costa Rica: status of cancer pain and palliative care. Journal of Pain and Symptom Management 1993;8(6):407-408.

SUMMARY: The article provides an overview of cancer pain control and palliative care in Costa Rica. Palliative care programs were unknown in Costa Rica prior to 1990. They are now in the earliest stages of development, but a dramatic accomplishment has already been made. The Costa Rican Supreme Court has established that every citizen has the right to die with dignity and without pain. This ruling was as a result of a case of an attorney who had metastatic cervical cancer and was denied morphine because the dosage she needed to control her pain was "unusually high" and considered nonscientific. The patient's husband was a journalist who publicized the case from beginning to end, creating a significant awareness among the public. Despite this, however, opioid availability in Costa Rica remains low. Morphine is only available in parenteral formulation, and 10 mg pills are rarely available. There is also no short-acting morphine alternatives, such as hydromorphone, oxymorphone or oxycodone. Meperidine is available in parenteral formulation and is the most widely used opioid in the country. Opioids can only be imported by the Health Ministry. They must be prescribed on special forms, and only a limited dosage can be prescribed on each form. The doctors understand this to mean that the maximum dosage per prescription is the maximum daily limit that could be prescribed to a patient. Legally this is not true, and the Supreme Court ruling has clarified that a doctor must prescribe enough medication to control a patient's pain. The article only mentions two cancer pain relief programs in the entire country, and both are severely lacking in funds and staff to support it. There was a palliative care conference in January of 1992, which was attended by 200 professionals, most of whom were nurses. Only 6 physicians attended, reflecting the lack of priority placed on palliative care by most of the medical profession in the country.
Wenk, R. Argentina: status of cancer pain and palliative care. Journal of Pain and Symptom Management 1993;8(6):385-387.

SUMMARY: The article provides an overview of cancer pain control and palliative care in Argentina, where significant progress has been made in this area during the past 8 years. Prior to 1984, palliative care did not exist as a medical discipline in this country. Since that time, palliative care has been established, and strides have been made to provide pain relief; This movement has been primarily due to the motivation of practitioners. Morphine consumption has increased from less than 20 daily doses (dd) per million during 1983-87 to 20-99 dd per million during 1985-89. Currently there are more than 20 palliative care teams assisting patients in 14 cities, as well as 8 professional organizations focusing on palliative care. However, problems revolve around an inability to develop a vertical structure of change in the country. Although official programs for palliative care delivery and teaching have been created, they are ineffective due to bureaucracy and passivity of the leaders in the upper and intermediate levels of the program. Further, the pharmaceutical industry "has no variety of commercial morphine preparations, nor does it provide low cost oral preparations." There also needs to be a much greater in-depth emphasis on education, especially of nurses and physicians. All of these shortcomings reflect the lack of an effective nationwide policy for cancer pain control and palliative care. Fortunately, the process of change "from down upward" has been effective in Argentina. It has accomplished a great deal, especially considering the social and economic constraints which are typical of most developing countries.
Colleau, S. Mexico adopts national cancer pain policy. Cancer Pain Release 1990;4(2-3):1.

SUMMARY: On July 6, 1990, the Mexican Declaration of Cancer Pain Relief was signed into law. Through this policy, the Mexican government "recognizes the importance of cancer pain relief as a public health issue; it commits itself to make necessary drugs (especially oral morphine) available and to train relevant health professionals in the diagnosis and treatment of cancer pain." The Mexican National Cancer Institute will be responsible for coordinating the Cancer Pain Relief Program. It will "develop programs to evaluate and monitor the consumption and distribution of analgesics; it will also develop information and education programs so that appropriate treatment options become better known to the public."
Colleau, S. Dedication, volunteers: key ingredients to initiate cancer pain relief program in Argentina. Cancer Pain Release 1989;3(2):1.

SUMMARY: This article summarizes the efforts of "Programa Argentino," a small group of medical providers and volunteers who are actively working to alleviate cancer pain in Argentina through the guidelines of the World Health Organization. The group is lead by Dr. Roberto Wenk, who assists hospitals and clinics in providing pain control, gives public presentations and has organized the translation of the WHO monograph Cancer Pain Relief into Spanish. Dr. Wenk states that "Argentine legislation on alcaloids favors the use of the WHO method of cancer pain management. Pharmacies are allowed to sell up to 0.8 grams of morphine upon presentation of a triplicate prescription form. Patients need to have been hospitalized to be prescribed larger quantities of morphine. In general, it is possible to buy opioids in most public pharmacies in Argentine cities of more than 200,000 people."
Colleau, S. Dominican Cancer Institute starts pain relief program in Santo Domingo. Cancer Pain Release 1989;3(2):1.

SUMMARY: A cancer pain control program has been started in the Dominican Republic with the assistance of Dr. Charles Cleeland and the Madison Collaborating Center. On March 20,1989 the Institute received its first shipment of 5000 15 mg tablets of oral morphine. It is receiving training and disseminating information on the use of narcotics for treating pain. The institute is gathering data on the severity of pain experienced by cancer patients, the impact of their teaching program and on morphine availability for pain control and treatment.
Colleau, S. Mexican NCI receives morphine sulfate, starts training program in cancer pain relief. Cancer Pain Release 1989;3(1):1.

SUMMARY: On September 30, 1988 oral morphine was used for the first time in Mexico. The oral morphine was part of a shipment of 72,000 tablets which will be used to start up the WHO demonstration project for cancer pain relief. This occurred after two years of planning between the WHO Collaborating Center for Symptom Evaluation in Wisconsin and Mexican government officials and medical professionals to create a national cancer pain relief program in Mexico. Another part of the program was a seminar organized by the Mexico NCI and the Wisconsin Collaborating Center to train Mexican specialists in the use of analgesics, including morphine for cancer pain management.
Wenk, R. Availability of opioid analgesics in Argentina. Journal of Pain and Symptom Management 1987;2(4):191-192.

SUMMARY: Undertreatment of pain is the norm for cancer patients in Argentina. The pharmaceutical companies have not concentrated on producing oral opioids. Morphine or codeine solutions are generally used for treating pain. "Only 10% to 20% of the public pharmacies make them, with the maximum amount of morphine HCl ranging from 0.5 g to 2 g for each triplicate prescription." Only pre-prepared products are paid for patients under Argentina's social security system. Since the pharmacist needs to prepare the solutions, the patients must pay for the drugs themselves; a cost which may be prohibitive for some.

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Section III. Drug Abuse and Diversion in Latin America

Galduroz, J. C. F. and Masur, J. The unofficial history of drug use: a study in a Brazilian sample. British Journal of Addiction 1990;85:1577-81

SUMMARY: The article reviews a research study which attempted to determine why illicit drug users stop using drugs. An interesting result of this study is that of the 59 respondents who quit use, only 11.8% reported having been through a drug treatment program. Other respondents described reasons such as "physical-mental problems/disliked side effects," "interpersonal reasons," "job or school/performance lowering," "religious/spiritual involvement" and the like. The article briefly mentions the phenomena of natural recovery from addiction as reported by Waldorf and Biernacki in their 1981 article.
Ortiz, A., Romano, M., Soriano, A. Development of an information reporting system on illicit drug use in Mexico. Bulletin on Narcotics 1989;41(1-2):41-52.

SUMMARY: In 1986 Mexico instituted a drug reporting system in order to assess trends in illicit drug use in the country over time. After a review of the international literature, it was determined that the most frequently used systems involved either "case-reporting" or "event-reporting." Event-reporting is less expensive and specialized than case-reporting, and thus this was the system chosen. 42 institutions in the country, either public health or criminal justice institutions, participate in the reporting system. This approach biases the reporting towards lower socioeconomic individuals who cannot afford to use the private health system. All individuals who are in the participating institutions and who have a history of illicit drug use are surveyed in June and November of each year. The indicators are based on previous Mexican research, and information from other countries and from the World Health Organization. Of the data obtained in 1986 and 1987, opiates were the least illicitly used drug. Within this category, "other opiates" were used less than heroin. Nonetheless, less than 1% of the respondents cited abusing opiates, and the percentages were decreasing during the survey periods.
Agreda, R. F. Basic elements for a national comprehensive plan for drug abuse control in Peru. Bulletin on Narcotics 1987;39(2):37-49.

SUMMARY: This article describes the prevention of drug abuse and diversion in Peru as well as problems related to drug abuse, illicit trafficking and illicit coca bush cultivation. It addresses the need for a national policy which would focus on the following issues: prevention, suppression of illicit trafficking, control and monitoring of legal drugs, and crop eradication and substitution. A national policy has been developed which encompasses these issues and is being directed by the Executive Office of Drug Control under the Ministry of Interior. It is important to note that this policy recognizes the legitimate medical need for narcotics. Regarding this aspect of the policy, the article states that "the objectives are to prevent both the illegal use of substances intended for medical and scientific purposes and the diversion of such substances into illegal channels. For this purpose, a special service will monitor these substances in accordance with the requirements of the system of international drug control. The plan is also intended to make timely and accurate assessments of the requirements for narcotic drugs and psychotropic substances and to ensure the availability and lawful distribution of the amounts required." The article discusses the strategies which will be required to meet the objectives of a policy which promotes medical availability while preventing diversion.
Cagliotti, C.N. Co-operation between South American countries in the struggle against drug abuse and illicit drug trafficking. Bulletin on Narcotics 1987; 39(1):61-67.

SUMMARY: This article describes efforts to prevent drug abuse and diversion in South American countries. "The South American Agreement on Narcotic Drugs and Psychotropic Substances (ASEP), which entered into force on 26 March 1976, has enhanced co-operation between South American countries in the struggle against drug problems. This co-operation has promoted the regional responsibility and the use of regional resources in coping with the drug problem in South America and has helped to increase the regional support for international drug control initiatives. The established machinery and instruments within ASEP, which are designed to suit best the circumstances in South America, include the annual conference of States parties, the Permanent Secretariat, the regional centres, the technical advisory committees, and other co-coordinated programs and activities intended to reduce drug problems. Each of the five regional centres that have been or are being established focuses on one of the following subject areas: treatment and rehabilitation, preventative education, suppression of illicit drug trafficking, documentation, and customs techniques. With regard to the eradication of narcotic crops, ASEP considers the idea of integrated community development to be an appropriate approach to eradicating coca plantations in those areas where the growing of coca bush is part of the cultural tradition." (taken from abstract)
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.
Tragen, I. G. Co-operation of countries within the Organization of American States to combat drug problems. Bulletin on Narcotics 1987;39(1):57-60.

SUMMARY: The Organization of American States has given high priority to the promotion of working agreements among member states to combat drug problems, in particular drug trafficking. The General Assembly of the Organization of American States, at its Fourteenth Regular Meeting in 1984, adopted Resolution 699 which recognizes drug trafficking as a crime affecting all of mankind. As a result of this resolution, the Inter-American Specialized Conference on Traffic in Narcotic Drugs took place in 1986. The Conference adopted further measures which focused on reducing the illegal cultivation of narcotic crops, eliminating clandestine drug laboratories, interrupting the flow and distribution of illicit drugs and finding methods of eliminating the profitability of drug trafficking operations. Both meetings were action-oriented and determined concrete strategies on which countries can work to combat illegal drug operations. Bilateral agreements have been developed as a result of this work.

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

PART A OPIOID ANALGESIC AVAILABILITY