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Global Challenges in Cancer Pain. S. Lawrence Librach MD,CCFP,FCFP Professor, Department of Family & Community Medicine Sun Life Financial Chair & Director, Joint Centre for Bioethics, University of Toronto Cancer Pain Physician, Princess Margaret Hospital, Toronto. Objectives.

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Global Challenges in Cancer Pain


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    1. Global Challenges in Cancer Pain S. Lawrence Librach MD,CCFP,FCFP Professor, Department of Family & Community Medicine Sun Life Financial Chair & Director, Joint Centre for Bioethics, University of Toronto Cancer Pain Physician, Princess Margaret Hospital, Toronto

    2. Objectives • Cancer pain management as a human right • Relationship with industry & pain

    3. Pain Management as a Human Right • IASP Montreal Declaration • Declaration that access to pain management is a fundamental human right • Means that there is an ethical & probably legal requirement to act

    4. IASP Montreal Declaration • Pain management is inadequate in most of the world because of: • Inadequate access to treatment • Failure to recognize that chronic pain is a serious chronic health problem

    5. IASP Montreal Declaration • Pain management is inadequate in most of the world because of: • Major deficits in knowledge of health care professionals regarding the mechanisms & management of pain • Chronic pain with or without diagnosis is highly stigmatized

    6. IASP Montreal Declaration • Pain management inadequate in most of the world because: • Most countries have no national policy at all or very inadequate policies regarding the management of pain as a health problem, including an inadequate level of research & education • Pain Medicine is not recognized as a distinct specialty with a unique body of knowledge & defined scope of practice founded on research & comprehensive training programs

    7. IASP Montreal Declaration • Pain management is inadequate in most of the world because: • World Health Organization (WHO) estimates that 5 billion people live in countries with low or no access to controlled medicines and have no or insufficient access to treatment for moderate to severe pain • There are severe restrictions on the availability of opioids & other essential medications, critical to the management of pain

    8. Pain Management as a Human Right • Human Rights Watch www.hrw.org • Global State of Pain Treatment & Access to Palliative Care as a Human Right

    9. Pain Management as a Human Right-HRW • Every year, tens of millions of people around the world with life-threatening illnesses sufferunnecessarily from severe pain and other debilitating symptoms because they lack access topalliative care, an inexpensive health service that aims to improve the quality of life ofpeople with serious health conditions

    10. In Central America and the Caribbean, about half of the countries consume so few opioid medications that even if all were used exclusively to treat patients with terminal cancer and HIV for pain, less than a third of them could receive adequate treatment (Belize, El Salvador, Honduras, Nicaragua, Saint Kitts and Nevis, Trinidad and Tobago, Jamaica, Dominican Republic, and Haiti)

    11. **T&T has 1/20 the population of Canada

    12. INCB Report • Need to achieve a balance between ensuring availability of internationally controlled substances for medical and scientific purposes and preventing their diversion and abuse

    13. INCB Report • The Board considers all levels of consumption of narcotic drugs below 200 S-DDD per million inhabitants per day inadequate. However, this does not imply that levels above 200 S-DDD can be considered adequate as the determination of whether availability of internationally controlled substances required for treatment is sufficient depends on the specific morbidity data

    14. Websites • www.stoptortureinhealthcare.org • Multiple videos & reports • www.treatthepain.com • Video “Life Before Death” • http://www.incb.org/documents/Publications/AnnualReports/AR10_Supp_E.pdf

    15. Pain and industry: ethics

    16. How to dance with porcupines: rules and guidelines ondoctors’ relations with drug companies BMJ 2003 • How to dance with porcupines: rules and guidelines on • doctors’ relations with drug companies

    17. Pharmaceutical Industry & Opioid Availability • Expensive sustained-release opioids seem to be making an appearance on formularies when cheaper alternatives like immediate- release & injectable morphine & hydromorphone are not allowed or in very limited supply in many countries • Sometimes companies abandon markets

    18. Influence of Pharmaceutical Industry on Pain Professionals • Clinical research funding in pain to a great extent funded by industry • Conference support by industry is absolutely necessary for those conferences to take place • Glossy booths for industry • Speakers bureaus & consultant contracts

    19. Influence of Pharmaceutical Industry on Pain Professionals • Articles mostly funded by industry & many ghostwritten • Research often multicentric & may be in jurisdictions where research ethics boards or independent boards have lower standards • Data not made available to researchers

    20. Summary • There is much to do in relieving cancer pain • Pain relief is a human right • Availability of opioids around the globe is an issue • The availability of opioids in T&T is very limited & needed drugs are all generic larry.librach@utoronto.ca