June 2, 2011

IX. Recommendations

The palliative care and pain treatment gap is an international human rights crisis that needs to be addressed urgently both at the international and national level. Therefore, Human Rights Watch makes the following recommendations:

To Governments around the World

General

  • Establish, where this has not yet been done, a working group on palliative care and pain management. This working group should include all relevant actors, including health officials, drug regulators, health care providers, nongovernmental palliative care providers, and academics, and develop a concrete plan of action for the progressive implementation of pain treatment and palliative care services.
  • Assess both the availability of and the need for pain management and palliative care services.
  • Develop a comprehensive plan of action that addresses the various barriers that impede availability of pain management and palliative care, including government policy, education, and availability of medications.
  • Invite the WHO Access to Controlled Medications Programme to assist in implementing the above recommendations.
  • National human rights commissions or ombudsman offices should, where possible, investigate obstacles to availability of pain management and palliative care services, and request that their governments take urgent measures to address them.

Ensuring an Effective Supply System

  • Submit, in a timely fashion, realistic estimates for the need of controlled medications to the INCB.
  • Ensure an effective distribution system for controlled medications. While procurement, transportation, and stocking regulations should be able to prevent potential abuse, they should not arbitrarily complicate these processes.
  • Countries must ensure that in each region at least a minimum number of pharmacies and hospitals stock morphine.

Developing and Enacting Pain Management and Palliative Care Policies

  • Recognize a human rights obligation to provide effective/adequate palliative care programs.
  • Develop official policies on pain management and palliative care, including as part of cancer and HIV/AIDS control programs.
  • Develop practical guidelines on pain management and palliative care for healthcare workers.
  • Include oral morphine and other essential pain treatment medications in national lists of essential medicines.
  • Ensure that drug control laws and regulations recognize the indispensible nature of opioid and other controlled medicines for the relief of pain and suffering, as well as the obligation to ensure their adequate availability.

Ensuring Instruction for Healthcare Workers

  • Ensure adequate instruction for healthcare workers, including doctors, nurses, and pharmacists, at both undergraduate and postgraduate level.
  • Instruction should also be offered to those already practicing as part of continuing medical education.

Reforming Drug Regulations

  • Review drug control regulations to assess whether they unnecessarily impede accessibility of pain medications. Health care providers should participate in conducting this review.
  • If regulations are found to impede access, they should be amended.
  • Recommendations of WHO and health care providers should be a starting point of revised drug control regulations.
  • Requiring special licenses for health care institutions or providers to handle morphine should be avoided as much as possible. In other cases, transparent and simple procedures should be established for obtaining such special licenses.
  • Special prescription procedures for controlled medications should be avoided as much as possible. Where they are nonetheless in place, they should be minimally burdensome.
  • Limitations on the amount of morphine that can be prescribed per day should be abolished.
  • Unnecessary limitations on the amount of morphine that can be prescribed or dispensed at once should be abolished.

Ensuring Affordability of Medications

  • Countries should seek to ensure the affordability of morphine and other opioid analgesics.

To Global Drug Policy Makers

  • Restore the balance between ensuring availability of controlled medicines and preventing abuse, as provided for by the UN drug control conventions, in global drug policy debates. Access to controlled medicines should be a central and recurring agenda item at the Commission on Narcotic Drugs and other meetings on global drug policy.
  • The Commission on Narcotic Drugs and the INCB should regularly review progress made by countries toward adequate availability of pain treatment medicines, carefully analyzing steps taken to advance this important issue.
  • INCB should significantly increase its efforts to encourage and assist states in improving availability of opioid analgesics.
  • UNODC should amend the model laws and regulations it has developed to include recognition of the indispensible nature of narcotic drugs and psychotropic substances for medical and scientific purposes and the obligation for states to ensure their availability.
  • UNODC and the INCB should develop processes to ensure that human rights, including the right to the highest attainable standard of health, are systematically considered in their work.

To the WHA, WHO, UNAIDS, and the Donor Community

  • The World Health Assembly (WHA) should adopt a resolution calling upon its member states to promote universal access to pain management and palliative care, by taking steps to ensure that their health policies and services address the needs of all patients with life-limiting illness, including by ensuring the availability of pain medicines and training in pain treatment and palliative care for healthcare workers.
  • WHO should continue to treat access to controlled medicines with urgency through its Access to Controlled Medications Programme.
  • Donor countries and agencies, including the Global Fund to fight AIDS, Malaria, and Tuberculosis and the U.S. President’s Emergency Plan for AIDS Relief, should actively encourage countries to undertake comprehensive steps to improve access to pain relief medications and support those that do, including through support for the WHO Access to Controlled Medications Programme.
  • UNAIDS should work with governments to identify and remove obstacles to availability and accessibility of pain management and palliative care services.

To the Global Human Rights Community

  • UN and regional human rights bodies should routinely remind countries of their obligation under human rights law to ensure adequate availability of pain medicines.
  • UN human rights procedures that monitor the right to the highest attainable standard of health and the prohibition on cruel, inhuman and degrading treatment should regularly consider the availability of pain medicines and governments’ efforts to make them available.
  • Human rights groups should include access to pain treatment and palliative care into their work, including by submitting shadow reports to UN treaty bodies, providing information to the UN Special Rapporteurs on the highest attainable level of health and on torture, cruel, inhuman and degrading treatment and punishment to the Human Rights Council.