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Pain in Cancer, AIDS, and NCDs, with a Focus on Opioid Analgesics. James Cleary, MD Pain and Policy Studies Group. Uganda as a model!.

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Pain in cancer aids and ncds with a focus on opioid analgesics

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

James Cleary, MD

Pain and Policy Studies Group


Uganda as a model
Uganda as a model!

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

    Oxford Textbook of Palliative Medicine, 3rd Edition


Wisconsin cancer pain initiative
Wisconsin Cancer Pain Initiative

  • Dahl & Joranson (WI Pharmacy Board)

  • US based: 1986

    • WHO Demonstration Project.

    • Role Model Initiative.

    • Education

  • Wisconsin Pain Initiative

    • Alliance of State Pain Initiatives.


Pain and policy study group
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



Global Trend 1980 - 2008

Source: International Narcotics Control Board

By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2010


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


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 LeónColombia

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


2008 International Pain Policy Fellowship

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


Who palliative care public health model
WHO Palliative Care Public Health Model

DrugAvailability

Education

Policy


the medical use of narcotic drugs continues to be indispensable for the relief of pain and suffering… adequate provision must be made to ensure the availability of narcotic drugs for such purposes.” (Preamble, p. 13)


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.

2020 Targets


  • 7: Improve Access to Diagnosis, Treatment, Rehabilitation and Palliative Care Access to accurate cancer diagnosis, appropriate cancer treatments, supportive care, rehabilitation services and palliative care will have improved for all patients worldwide.

  • 8: Effective pain control measures will be available universally to all cancer patients in pain


1274 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.

27.5


Deaths from hiv cancer
Deaths from HIV & Cancer 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.


Deaths by cause in the world 2005
Deaths by cause in the world (2005) 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.

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)


Noncommunicable diseases ncds
Noncommunicable Diseases (NCDs) 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.

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


Noncommunicable diseases 2006 2015
Noncommunicable diseases (2006-2015) 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.

WHO projects that over the next 10 years, the largest increase in deaths from cardiovascular disease, cancer, respiratory disease and diabetes will occur in low- and middle-income countries.

(WHO, Chronic Disease Report, 2005)


United nations general assembly on non communicable diseases ncd
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???



Essential medicines 16th edition updated 2010 who model list
Essential Medicines (NCD)16th edition (updated)2010 WHO Model List

2. ANALGESICS, ANTIPYRETICS, NON-STEROIDAL ANTI-INFLAMMATORY MEDICINES (NSAIMs),

MEDICINES USED TO TREAT GOUT AND DISEASE MODIFYING AGENTS IN RHEUMATOID DISORDERS (DMARDs)

2.1 Non-opioids and non-steroidal anti-inflammatory medicines (NSAIMs)

acetylsalicylic acid Suppository: 50 mg to 150 mg. Tablet: 100 mg to 500 mg.

Ibuprofen Tablet: 200 mg; 400 mg. >3 months.

paracetamol* Oral liquid: 125 mg/5 ml. Suppository: 100 mg. Tablet: 100 mg to 500 mg.

* Not recommended for anti‐inflammatory use due to lack of proven benefit to that effect.

2.2 Opioid analgesics

Codeine Tablet: 15 mg (phosphate); 30 mg (phosphate).

Morphine Injection: 10 mg (morphine hydrochloride or morphine sulfate) in 1‐ml ampoule.

Oral liquid: 10 mg (morphine hydrochloride or morphine sulfate)/5 ml.

Tablet: 10 mg (morphine sulfate).

Tablet (prolonged release): 10 mg; 30 mg; 60 mg (morphine sulfate)


International Association of Hospice and Palliative Care (NCD)List of Essential Medicines for Palliative Care

(http://www.hospicecare.com/resources/pdf-docs/iahpc-list-em.pdf)

  • Codeine,

  • Fentanyl,

  • Methadone,

  • Morphine (immediate and sustained release),

  • Oxycodone,

  • Tramadol

NOTE: NO GOVERNMENT SHOULD APPROVE MODIFIED RELEASE MORPHINE, FENTANYL OR OXYCODONE WITHOUT ALSO GUARANTEEING WIDELY AVAILABLE NORMAL RELEASE ORAL MORPHINE.


Who supports global effort to relieve chronic pain
WHO supports global effort to relieve chronic pain (NCD)

  • The WHO co-sponsors the first Global Day Against Pain, which seeks to draw global attention to the urgent need for better pain relief for sufferers from diseases such as cancer and AIDS.

  • The campaign, organised by the International Association on the Study of Pain (IASP) & the European Federation of the IASP Chapters (EFIC), asks for recognition that pain relief is integral to the right to the highest attainable level of physical and mental health…


Report on availability
Report on AVAILABILITY (NCD)

“The low levels of consumption of opioid analgesics for the treatment of pain in many countries, in particular in developing countries, continue to be a matter of serious concern to the Board.

The Board again urges all Governments concerned to identify the impediments in their countries to adequate use of opioid analgesics for the treatment of pain and to take steps to improve the availability of those narcotic drugs for medical purposes…” (paragraph 97)

INCB, 2007 report



Opioid (NCD)availability and cost: Eastern Europe


Global consumption of morphine high income vs low and middle income countries 2008
Global Consumption of Morphine (NCD)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.


Global consumption of morphine 2008
Global Consumption of Morphine, 2008 (NCD)

Mg/capita

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


"We must not only stop the harm caused by drugs: (NCD)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


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