May 12, 2011

I. Overview: Palliative Care and Pain Treatment

Palliative care seeks to improve the quality of life of patients facing life-limiting or terminal illness. Its purpose is not to cure a patient or extend his or her life. Palliative care prevents and relieves pain and other physical and psychosocial problems, “adding life to the days, not days to the life,” in the much-quoted words of Dame Cicely Saunders, founder of the first modern hospice. The World Health Organization recognizes palliative care as an integral part of healthcare that should be available to those who need it.[30] While palliative care is often associated with cancer, a much wider circle of patients with health conditions can benefit from it, including patients in advanced stages of neurological disorders, cardiac, liver, or renal disease or chronic and debilitating injuries.

One key objective of palliative care is to offer patients treatment for their pain. Chronic pain is a common symptom of cancer and HIV/AIDS, as well as other health conditions.[31]Research consistently finds that 60 to 90 percent of patients with advanced cancer experience moderate to severe pain.[32] Prevalence and severity of pain usually increase with disease progression: several researchers have reported that up to 80 percent of patients in advanced stages of cancer experience significant pain.[33] Pain symptoms are a problem for a significant proportion of people living with HIV as well, even as the increasing availability of antiretroviral drugs in middle and low-income countries prolongs lives.[34] With the advent of antiretroviral therapy (ART), the international AIDS community has understandably focused on treatment for people living with HIV. Unfortunately, this has led to a widespread but incorrect perception that these people no longer needed palliative care. In fact, various studies have shown that a considerable percentage of people on ART continue to experience pain and other symptoms that improve with simultaneous delivery of palliative care and ART.[35]

Moderate to severe pain profoundly impacts quality of life. Persistent pain has a series of physical, psychological, and social consequences. It can lead to reduced mobility and consequent loss of strength; compromise the immune system; and interfere with a person’s ability to eat, concentrate, sleep, or interact with others. [36] A WHO study found that people who live with chronic pain are four times more likely to suffer from depression or anxiety. [37] The physical effect of chronic pain and the psychological strain it causes can even influence the course of disease, as the WHO notes in its cancer control guidelines, “Pain can kill.” [38] Social consequences include the inability to work, care for oneself, children, or other family members, participate in social activities, and find emotional and spiritual closure at the end of life. [39]

According to the WHO, “Most, if not all, pain due to cancer could be relieved if we implemented existing medical knowledge and treatments” (original emphasis).[40] The mainstay medication for treating moderate to severe pain is morphine, an inexpensive opioid made of poppy plant extract. Morphine can be injected, taken orally, delivered through an IV, or into the spinal cord. It is mostly injected to treat acute pain, generally in hospital settings. Oral morphine is the drug of choice for chronic cancer pain and can be taken both in institutional settings and at home. Morphine is a controlled medication, meaning that its manufacture, distribution, and dispensing is strictly regulated at both international and national levels.

Medical experts have recognized the importance of opioid pain relievers for decades. The 1961 Single Convention on Narcotic Drugs, the international treaty governing use of narcotic drugs, explicitly states that “the medical use of narcotic drugs continues to be indispensable for the relief of pain and suffering” and that “adequate provision must be made to ensure the availability of narcotic drugs for such purposes.”[41] The WHO includes both morphine and codeine (a weak opioid) in its Model List of Essential Medicines, a roster of the minimum essential medications that should be available to all persons who need them.[42]

Yet, approximately 80 percent of the world’s population has either no, or insufficient, access to treatment for moderate to severe pain and tens of millions of people around the world— including around 5.5 million cancer patients and 1 million end-stage HIV/AIDS patients—suffer from moderate to severe pain each year without treatment.[43]

But palliative care is broader than just relief of physical pain. Other key objectives may include provision of care for other physical symptoms and psychosocial and spiritual care for patients and family members who face life-threatening or incurable and often debilitating illness. Anxiety and depression are common symptoms.[44] Palliative care interventions like psychosocial counseling have been shown to considerably diminish incidence and severity of such symptoms and to improve the quality of life of patients and their families.[45]

Palliative care also seeks to alleviate other physical symptoms, such as nausea and shortness of breath, which are frequently associated with life-limiting illness and significantly impact a patient’s quality of life.

The WHO has urged countries, including those with limited resources, to make palliative care services available. It recommends that countries prioritize implementing palliative care services in the community—providing care in medical institutions that deal with large numbers of patients requiring palliative care services and in people’s homes rather than at healthcare institutions—where it can be provided at low cost and where people with limited access to medical facilities can be reached.[46]

[30] WHO, “National Cancer Control Programmes: Policies and Managerial Guidelines, second edition,” pp. 86-87.

[31]  Pain is also a symptom in various other diseases and chronic conditions and acute pain is often a side-effect of medical procedures. This paper, however, focuses on pain and other symptoms due to life-limiting illnesses.

[32] C.S. Cleeland, J.L. Ladinsky, R.C. Serlin, and N.C. Thuy, “Multidimensional Measurement of Cancer Pain: Comparisons of U.S. and Vietnamese Patients,” Journal of Pain and Symptom Management , vol. 3, no. 1 (1988), pp. 23-27; C.S. Cleeland, Y. Nakamura, T.R. Mendoza, K.R. Edwards, J. Douglas, and R.C. Serlin, “Dimensions of the Impact of Cancer Pain in a Four Country Sample: New Information from Multidimensional Scaling,” Pain , vol. 67 (1996), pp. 2-3 and 267-273; R.L. Daut and C.S. Cleeland, “The prevalence and severity of pain in cancer,” Cancer, vol. 50 (1982), 1913-8; K.M. Foley, “Pain Syndromes in Patients with Cancer,” in K.M. Foley, J.J. Bonica, and V. Ventafridda, eds., Advances in Pain Research and Therapy (New York: Raven Press, 1979), pp. 59-75; K.M. Foley, “Pain Assessment and Cancer Pain Syndromes,” in D. Doyle, G.W.C Hanks, and N. MacDonald, eds., Oxford Textbook of Palliative Medicine, 2nd edition (New York: Oxford University Press, 1979), pp. 310-331; J. Stjernsward and D. Clark, “Palliative Medicine: A Global Perspective,” in D. Doyle, G.W.C. Hanks, N. Cherny, and K. Calman, eds., Oxford Textbook of Palliative Medicine, 3rd edition (New York: Oxford University Press, 2003), pp. 1199-1222.

[33] K.M. Foley, J.L. Wagner, D.E. Joranson, and H. Gelband, “Pain Control for People with Cancer and AIDS,” Disease Control Priorities in Developing Countries, 2nd edition(New York: Oxford University Press, 2006), pp. 981-994; Francois Larue et al., “Underestimation and under-treatment of pain in HIV disease: a multicentre study,” British Medical Journal, vol. 314, no. 13, 1997, http://www.bmj.com/cgi/content/full/314/7073/23 (accessed April, 2007); J. Schofferman and R. Brody, “Pain in Far Advanced AIDS,” in K.M. Foley, J.J. Bonica, and V. Ventafridda, eds., Advances in Pain Research and Therapy (New York: Raven Press, 1990), pp. 379-386; E.J. Singer, C. Zorilla, B. Fahy-Chandon, S. Chi, K. Syndulko, and W.W. Tourtellotte, “Painful Symptoms Reported by Ambulatory HIV-Infected Men in a Longitudinal Study,” Pain, vol. 54 (1993), pp. 1 and 15-19.

[34]P. Selwyn and M. Forstein, “Overcoming the false dichotomy of curative vs. palliative care for late-stage HIV/AIDS,” JAMA, vol.290 (2003), pp.806-814.

[35] See K. Green, “Evaluating the delivery of HIV palliative care services in out-patient clinics in Viet Nam, upgrading document,” London School of Hygiene and Tropical Medicine, 2008.

[36] F. Brennan, D.B. Carr, and M.J. Cousins, “Pain Management: A Fundamental Human Right,” Anesthesia & Analgesia, vol. 105, no. 1, July 2007, pp. 205-221.

[37] O. Gureje, M. Von Korff, G.E. Simon, R. Gater, “Persistent pain and well-being: a World Health Organization study in primary care,” JAMA, vol. 280 (1998), pp. 147-151. See also B. Rosenfeld et al., “Pain in Ambulatory AIDS Patients. II: Impact of Pain on Psychological Functioning and Quality of Life,” Pain, vol. 68, no. 2-3 (1996), pp.323-328.

[38] WHO, “National Cancer Control Programme: Policies and Managerial Guidelines, second edition,” p. 83.

[39] R.L. Daut, C.S. Cleeland, and R.C. Flanery, “Development of the Wisconsin Brief Pain Questionnaire to Assess Pain in Cancer and Other Diseases,” Pain, vol. 17, no. 2 (1993), pp. 197-210.

[40] WHO, “Achieving Balance in Opioid Control Policy: Guidelines for Assessment,” 2000, p. 1.

[41] United Nations Economic and Social Council (ECOSOC), "Single Convention on Narcotic Drugs of 1961, as amended by the 1972 Protocol amending the Single Convention on Narcotic Drugs, 1961," preamble, http://www.incb.org/incb/convention_1961.html (accessed January 15, 2009).

[42] The 16th edition of WHO Model List of Essential Medicines, approved in 2010, includes the following opioid analgesics (available at: http://www.who.int/medicines/publications/essentialmedicines/Updated_sixteenth_adult_list_en.pdf, accessed February 22, 2011)

CODEINE

Tablet: 15 mg (phosphate) [c]; 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).

[43]  WHO Briefing Note, “Access to Controlled Medications Programme,” February 2009, http://www.who.int/medicines/areas/quality_safety/ACMP_BrNoteGenrl_EN_Feb09.pdf (accessed July 17, 2009).

[44] A 2006 literature review that compared prevalence of eleven common symptoms among patients with five advanced stage life-limiting illnesses found that studies reported depression prevalence of 3 to 77 percent in patients with advanced cancer, 10 to 82 percent in AIDS patients, 9 to 36 percent in patients with heart disease, 37 to 71 in patients with chronic obstructive pulmonary disease, and 5 to 60 in renal patients. For anxiety, reviewed studies reported prevalence of 13 to 79 percent in patients with advanced cancer, 8 to 34 percent in AIDS patients, 49 percent in patients with heart disease, 51 to 75 in patients with chronic obstructive pulmonary disease, and 39 to 70 percent in patients with renal disease. J.P. Solano, B. Gomes, I.J. Higginson, “A Comparison of Symptom Prevalence in Far Advanced Cancer, AIDS, Heart Disease, Chronic Obstructive Pulmonary Disease and Renal Disease,” Journal of Pain and Symptom Management, Vol 31 No 1 (2006).

[45]See, for example,  WHO, “National Cancer Control Programme: Policies and Managerial Guidelines, second edition,” p. 83-91.

[46]  Ibid., pp. 91-92.