Breaking Out of the Vicious Cycle of Under-Treatment

Comprehensive steps to address all barriers simultaneously are needed in countries where a vicious cycle of under-treatment exists. Governments have the responsibility to lead this process. They need to develop plans for the implementation of palliative care and pain treatment, adopt relevant policies, introduce instruction for healthcare workers, and ensure adequate availability of morphine and other opioid medications. The WHO, INCB, and donor community must assist in these efforts.

A number of countries have begun such efforts, with some success. Uganda and Vietnam with the support of the international community, have made important progress in improving pain treatment and palliative care services for the population.[162] But both still have a long way to go. Morphine consumption in both continues to be low, certain regulatory barriers remain, and large numbers of people suffering from moderate to severe pain still do not have access to adequate treatment. But the steps these countries have taken are laying the foundation for replacing the vicious cycle of under-treatment of pain with a positive cycle in which simpler drug control regulations and better knowledge among healthcare providers leads to increased demand for morphine, reinforcing the importance of pain management and palliative care and leading to greater awareness among healthcare workers and the public.

Uganda

Uganda, an East African country of about 31 million, has made considerable progress in tearing down barriers that have traditionally impeded the ability of people to access pain treatment medications. In 1998, Ugandan government officials, representatives of non-governmental organizations, and WHO sat down together at a conference entitled "Freedom from Cancer and AIDS Pain" to discuss ways in which pain treatment could be made available to the population. At the meeting, participants agreed to take a series of simultaneous steps to deal with key barriers:

• The Ministry of Health and WHO were to develop a national palliative care policy, and cancer and AIDS pain relief policies.
• Although Hospice Africa Uganda had taught palliative medicine in the medical, nursing and pharmacy schools and to practicing post graduate health professionals since 1993, the Government initiated meetings which resulted in the endorsement of a 9-month full time course training at Hospice Africa Uganda, to increase the number of prescribers.
• The drug control authority was to develop new drug regulations, update the essential drug list, conduct estimates of the medical need for morphine, and request an increased national allowance from INCB.

In addition, a commitment was made to ensure coordination of palliative care activities for AIDS and cancer, to set up multidisciplinary clinics for cancer patients, to increase awareness of palliative care among the population, and to identify a demonstration project in Uganda's Hoima District where Little Hospice Hoima, a branch of Hospice Africa Uganda was already active.[163]

In its five-year Strategic Health Plan for 2000-2005, the governmentstated that palliative care was an essential clinical service for all Ugandans, becoming the first nation in Africa to do so. It also added liquid morphine to its essential drug list, adopted a new set of Guidelines for Handling of Class A Drugs for healthcare practitioners-also a first in Africa-and, in 2003, authorized prescribing of morphine by nurses who have been trained in palliative care.

By early 2009, 79 nurses and clinical officers had received training on pain management and been authorized to prescribe oral morphine; several thousand healthcare workers had attended a short course on pain and symptom management; and 34 out of 56 districts in Uganda had oral morphine available and in use. Despite this impressive progress, many challenges remain, including ensuring availability of oral morphine throughout Uganda; keeping it affordable; preventing stock-outs; and training all relevant healthcare workers.[164]

Vietnam

Since 2005, Vietnam, a country of 84 million people, has made considerable progress in expanding access to palliative and pain treatment services. This progress started with the creation of a working group on palliative care. This working group, which consisted of ministry of health officials, cancer and infectious disease physicians, and experts from NGOs supported by the US President's Emergency Plan for AIDS Relief, decided to conduct a rapid situation analysis to assess the availability of and the need for palliative care in Vietnam, and to subsequently develop a national palliative care program based on its findings.

The rapid situation analysis found, among others, that:

·Severe chronic pain was common among cancer and HIV/AIDS patients;

·Availability of opioid analgesics and other key medications was severely limited;

·Palliative care services were not readily available to the population; and

·Clinicians lacked adequate training.[165]

Based on these finding, the working group recommended that national palliative care guidelines be developed, a balanced national opioid control policy be developed, training for healthcare workers be expanded, and that availability and quality of palliative care services be improved at all levels.

In September 2006, the ministry of health issued detailed Guidelines on Palliative Care for Cancer and AIDS Patients, which provide guidance to practitioners on palliative care and pain management. In February 2008, it issued new guidelines on opioid prescription which have eased a number of key regulatory barriers. For example, the maximum daily dose has been abolished; prescriptions can now be issued for 30 days, rather than 7;[166] and district hospitals and commune health posts are now authorized to prescribe and dispense. The ministry has also approved a package of training courses for practicing physicians and two medical colleges now offer instruction on palliative care to undergraduate medical and nursing students.

Yet, numerous challenges remain as only a few hundred healthcare workers have received training so far, understanding of palliative care among healthcare officials continues to be limited, various regulatory barriers persist,[167] and few pharmacies and hospitals stock oral morphine.