Pain in Cancer, AIDS, and NCDs, with a Focus on Opioid Analgesics

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Pain in Cancer, AIDS, and NCDs, with a Focus on
Opioid Analgesics

• James Cleary, MD
• Pain and Policy Studies Group

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Uganda as a model!

• Uganda serves as a brilliant model, like
  Wisconsin and Catalonia, for the importance of an
  integrated government and community
  non-governmental approach. Each one by
  themselves in isolation, will not achieve much.
• Oxford Textbook of Palliative Medicine, 3rd
  Edition

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Wisconsin Cancer Pain Initiative

• Dahl Joranson (WI Pharmacy Board)
• US based 1986
• WHO Demonstration Project.
• Role Model Initiative.
• Education
• Wisconsin Pain Initiative
• Alliance of State Pain Initiatives.

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Pain and Policy Study Group

• 1996 Pain and Policy Study Group
• National
• International
• WHO Collaborating Center
• Cancer Control
• Access to Controlled Medications Program
• INCB Workshop Estimates Dec 2009
• Close Ties with INCB
• Opioid Consumption Data
• Model Laws
• Estimates Process

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• Establishes a Framework to
• Prevent abuse and diversion, and
• Ensure the availability of drugs for medical
  purposes

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Global Trend 1980 - 2008
Source International Narcotics Control Board By
Pain Policy Studies Group, University of
Wisconsin/WHO Collaborating Center, 2010
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Total ME High Income vs. Low and Middle Income
Countries
Source International Narcotics Control Board By
Pain Policy Studies Group, University of
Wisconsin/WHO Collaborating Center, 2010
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2006 International Pain Policy Fellowship
Dr. Simbo Daisy Amanor-Boadu Nigeria
Dr. Henry Ddungu Uganda/APCA
Prof. Snežana Bošnjak Serbia
Dr. Jorge Eisenchlas Argentina
Prof. Rosa Buitrago Republic of Panama
Dr. Marta Ximena León Colombia
Mrs. Nguyen Thi Phuong Cham Vietnam
Mr. Gabriel Madiye Sierra Leone
Pain Policy Studies Group University of
Wisconsin October 2006 Madison, Wisconsin
Supported by the Open Society Institute
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2008 International Pain Policy Fellowship
Dr. Hrant Karapetyan Dr. Irina Kazaryan Armenia
Dr. Pati Dzotsenidze Mr. Mikheil Pavliashvili Georgia
Dr. Eva Rossina Duarte Juárez Lic. Ana Lucía Arango Espigares Guatemala
Dr. Dingle Spence Mrs. Verna Walker-Edwards Jamaica
Dr. Zippy Ali Dr. Jacinta Wasike Kenya
Dr. Adrian Belîi Republic of Moldova
Dr. Bishnu Dutta Paudel Mr. Radha Raman Prasad
Teli Nepal
Pain Policy Studies Group University of
Wisconsin October 2006 Madison, Wisconsin
Supported by the Open Society Institute
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WHO Palliative Care Public Health Model
DrugAvailability
Education
Policy
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the medical use of narcotic drugs continues to
be indispensable for the relief of pain and
suffering adequate provision must be made to
ensure the availability of narcotic drugs for
such purposes. (Preamble, p. 13)
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2020 Targets

• Measurement
• Sustainable delivery systems
• Tobacco, obesity, alcohol
• Vaccination (HBV, HPV)
• Dispel myths about cancer
• Screening early detection
• Effective pain control
• Training opportunities
• Reduce health emigration
• Improve cancer survival for all.

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• 7 Improve Access to Diagnosis, Treatment,
  Rehabilitation and Palliative Care Access to
  accurate cancer diagnosis, appropriate cancer
  treatments, supportive care, rehabilitation
  services and palliative care will have improved
  for all patients worldwide.
• 8 Effective pain control measures will be
  available universally to all cancer patients in
  pain

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1274
27.5
16
Deaths from HIV Cancer
17
Deaths by cause in the world (2005)
Noncommunicable diseases
Infectious diseases
HIV/AIDS 4.9
Tuberculosis 2.4
Heart disease 30.2
Malaria 1.5
Total 58.2M
Other Infectious Diseases 20.9
Cancer 15.7
Injuries 9.3
Diabetes 1.9
Other chronic diseases 15.7
(WHO, Chronic Disease Report, 2005)
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Noncommunicable Diseases (NCDs)

• Responsible for up to 60 of all deaths,
• 80 are in low- and middle-income countries
• Major non-communicable diseases
• Cardiovascular disease
• Cancer
• Chronic Respiratory disease
• Diabetes
• Shared preventable risk factors
• Tobacco use
• Unhealthy diet
• Physical inactivity
• Harmful use of alcohol

Cancer
Chronic Respiratory Diseases
Diabetes


Cardiovascular Disease
Other NCDs


Physical inactivity
Unhealthy diets
Obesity
Smoking
Harmful use of alcohol

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Noncommunicable diseases (2006-2015)
2005 2005 2006-2015 (cumulative) 2006-2015 (cumulative) 2006-2015 (cumulative)
Geographical regions (WHO classification) Total deaths (millions) NCD deaths (millions) NCD deaths (millions) Trend Death from infectious disease Trend Death from NCD
Africa 10.8 2.5 28 6 27
Americas 6.2 4.8 53 -8 17
Eastern Mediterranean 4.3 2.2 25 -10 25
Europe 9.8 8.5 88 7 4
South-East Asia 14.7 8.0 89 -16 21
Western Pacific 12.4 9.7 105 1 20
Total 58.2 35.7 388 -3 17
(WHO, Chronic Disease Report, 2005)
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United Nations general assembly on
non-communicable diseases (NCD)

• For the first time ever, the United Nations
  General Assembly held a Non-communicable Disease
  (NCD) Summit involving Heads of State, in
  September 2011, to address the threat posed by
  NCDs to low- middle-income countries (LMICs).
• World Heart Federation
• International Diabetes Federation (IDF)
• International Union Against Cancer (UICC)
• the International Union Against Tuberculosis and
  Lung Disease
• Where was PAIN???

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World Health Organization
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Essential Medicines 16th edition (updated) 2010
WHO Model List
2. ANALGESICS, ANTIPYRETICS, NON-STEROIDAL
ANTI-INFLAMMATORY MEDICINES (NSAIMs), MEDICINES
USED TO TREAT GOUT AND DISEASE MODIFYING AGENTS
IN RHEUMATOID DISORDERS (DMARDs) 2.1 Non-opioids
and non-steroidal anti-inflammatory medicines
(NSAIMs) acetylsalicylic acid Suppository 50 mg
to 150 mg. Tablet 100 mg to 500
mg. Ibuprofen Tablet 200 mg 400 mg. gt3
months. paracetamol Oral liquid 125 mg/5 ml.
Suppository 100 mg. Tablet 100 mg to 500
mg. Not recommended for anti-inflammatory use
due to lack of proven benefit to that
effect. 2.2 Opioid analgesics Codeine Tablet
15 mg (phosphate) 30 mg (phosphate). Morphine I
njection 10 mg (morphine hydrochloride or
morphine sulfate) in 1-ml ampoule. Oral liquid
10 mg (morphine hydrochloride or morphine
sulfate)/5 ml. Tablet 10 mg (morphine
sulfate). Tablet (prolonged release) 10 mg 30
mg 60 mg (morphine sulfate)
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International Association of Hospice and
Palliative CareList of Essential Medicines for
Palliative Care
(http//www.hospicecare.com/resources/pdf-docs/iah
pc-list-em.pdf)

• Codeine,
• Fentanyl,
• Methadone,
• Morphine (immediate and sustained release),
• Oxycodone,
• Tramadol

NOTE NO GOVERNMENT SHOULD APPROVE MODIFIED
RELEASE MORPHINE, FENTANYL OR OXYCODONE WITHOUT
ALSO GUARANTEEING WIDELY AVAILABLE NORMAL RELEASE
ORAL MORPHINE.
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WHO supports global effort to relieve chronic pain

• The WHO co-sponsors the first Global Day Against
  Pain, which seeks to draw global attention to the
  urgent need for better pain relief for sufferers
  from diseases such as cancer and AIDS.
• The campaign, organised by the International
  Association on the Study of Pain (IASP) the
  European Federation of the IASP Chapters (EFIC),
  asks for recognition that pain relief is integral
  to the right to the highest attainable level of
  physical and mental health

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Report on AVAILABILITY
The low levels of consumption of opioid
analgesics for the treatment of pain in many
countries, in particular in developing countries,
continue to be a matter of serious concern to the
Board. The Board again urges all Governments
concerned to identify the impediments in their
countries to adequate use of opioid analgesics
for the treatment of pain and to take steps to
improve the availability of those narcotic drugs
for medical purposes (paragraph 97)

INCB, 2007 report
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Opioid availability and cost West Europe
  Codeine Propox HC/DHC BuprPO BuprTD MoIR MoCR MoInj OcIR OcCR Methad. FentTD FentTM HmIR HmCR PethInj
Finland                                
France                                
Norway                                
Austria                                
Portugal                                
Italy                                
Denmark                                
Israel                                
Netherlands                                
Cyprus                                
Greece                                
Germany                                
Luxemburg                                
Spain                                
Switzerland                                
UK                                
Belgium                                
Iceland                                
Turkey                                
 
         
Free lt25 Cost 25-50 Cost 25-50 Cost 50-75 Cost 50-75 Cost 100 cost 100 cost
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Opioid availability and cost Eastern Europe
  Codeine Propox HC/DHC BuprPO BuprTD MoIR MoCR MoInj OcIR OcCR Methad. FentTD FentTM HmIR HmCR PethInj
Czech R.                                
Croatia                                
Latvia                                
Rumania                                
Slovak R.                                
Hungary                                
Estonia                                
Serbia                                
Bulgaria                                
Moldova                                
Poland                                
Russia                                
Monten.                                
Maced.                                
Bosnia-H                                
Lithuania                                
Belarus                                
Albania                                
Georgia                                
Ukraine                                

         
Free lt25 Cost 25-50 Cost 25-50 Cost 50-75 cost 50-75 cost 100 cost 100 cost
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Global Consumption of Morphine High-Income vs.
Low - and Middle - Income Countries, 2008
Percent total
91
83
17
9
Source International Narcotics Control Board
United Nations Population Data, 2007 World Bank
Income Classification, 2008. By Pain Policy
Studies Group, University of Wisconsin /WHO
Collaborating Center, 2010.
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Global Consumption of Morphine, 2008
Mg/capita
Global mean 5.9847 mg
Armenia 0.6945 mg
Georgia 1.338 mg
Guatemala 0.3561 mg
Jamaica 1. 3652 mg
Kenya 0.1292 mg
Nepal 0.0349 mg
Colombia 1.2390 mg
Panama 0.5170
Sierra Leone N/A
Serbia 0.6659
Vietnam 0.2193
Austria (166.9070 mg) Uses morphine for
substitution treatment
U.S.A (66.5682 mg)
Global Mean (6.005 mg)
Poland (6.4746 mg)
Guatemala
Italy (3.4816 mg)
Georgia
South Africa (10.3011 mg)
Serbia
Kenya
Armenia
Nepal
Vietnam
Jamaica
Colombia
Panama
(158 Countries)
The means are calculated by adding the individual
mg/capita statistics for all countries and then
dividing by the number of countries data does
not Include information for countries from which
the INCB did not receive a report
Source International Narcotics Control Board
United Nations population data By Pain Policy
Studies Group, University of Wisconsin/WHO
Collaborating Center, 2010
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"We must not only stop the harm caused by drugs
let's unleash the capacity of drugs to do good.
You think this is a radical idea? Look back to
the origins of drug control. The Preamble of the
Single Convention recognizes that the medical
use of narcotic drugs continues to be
indispensable for the relief of pain This is
hardly the language of a prohibitionist regime.
Indeed, this noble goal of UN drug policy, the
freedom from physical pain, demonstrates
our over-riding commitment to health." Antonio
Costa, Exec Director, UN Office on Drugs and
Crime (UNODC) March 2010