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The international collaborative project to evaluate the availability and accessibility of opioids for the management of cancer pain in Africa, Asia, Latin America and Middle East
Nathan I ChernyProject coordinatorChair, ESMO Palliative Care Working Group Member, EAPC research steering committeeNorman Levan Chair in Humanistic MedicineDept OncologyUnit Head: Cancer pain and palliative MedicineShaare Zedek Medical Center, Jerusalem, [email protected]
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The opioid regulatory paradox
2 fundamental and conflicting needs
1. to ensure that opioid analgesics are available
to the patients who need them.
2. to prevent these drugs from becoming a source of harm or abuse.
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Rest of the world
US, Australia +NZ:Well documented
The Rest:Sporadic reportingInconsistent methodologiesLack of clear picture
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Aims
1. To evaluate the formal availability and cost to the consumer of the range of opioid drugs used in the management of cancer.
2. To evaluate the barriers to the accessibility of opioid drugs for patients with cancer pain in each participating country.
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Coordinating partner organizations:1. European Society for Medical Oncology (ESMO)
2. European Association for Palliative Care (EAPC)
3. Pain & Policy Studies Group, University of Wisconsin Carbone Cancer Center (PPSG)
4. Union for International Cancer Control (UICC)
5. World Health Organization (WHO)
Roles
1. Survey design
2. Dissemination and data collection
3. Data analysis
4. Authorship
5. Publication
6. Post publication policy initiatives
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Collaborating partners:1. African Organisation for Research and Training in Cancer (AORTIC)2. Latin American and Caribbean Society of Medical Oncology (SLACOM) 3. Latin American Association for Palliative Care (ALCP) 4. African Palliative Care Association (APCA)5. Worldwide Palliative Care Alliance (WPCA)6. Multinational Association of Supportive Care in Cancer (MASCC) 7. Asia Pacific Hospice Palliative Care Network (APHN)8. International Association for Hospice & Palliative Care (IAHPC)9. Middle East Cancer Consortium (MECC) 10. Indian Association of Palliative Care (IAPC)11. Open Society Foundations (OSF)12. Chinese Society of Clinical Oncology (CSCO) 13. Help the Hospices 14. Japanese Society of Medical Oncology (JSMO) 15. Malaysian Society of Clinical Oncology (MSCO) 16. Myanmar Oncology Society 17. Foundation Akbaraly, Madagascar
Roles
1. Identifying potential reporter
2. Authorship
3. Post publication policy initiatives
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Survey development
Based on the survey tool that was previously used in the ESMO/EAPC study
Modifications based on input of participants
English, Spanish, French versions
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Identification of data reporters
Known credible professionals nominated by coordinating and collaborating partners
Minimum of 2 reporters for each country nominated
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Data Collection and Management
Electronic dissemination of surveys and automated data entry coordinated by EAPC
Crosschecking data entry and clarification of discrepancies between reporters
Conflicting data (Individual reporters, multiple reporters)Clarifications soughtPriority given to highly credentialed reportersRepresentative data presented
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Results1. Response rate
2. Formulary and cost 7 essential opioids
3. Actual Availability 7 essential opioids
4. Eligibility Restrictions (Patient permits)
5. Restrictions of prescribing authority
6. Prescription restriction: No. of days supply
7. Prescription restriction: complex prescription forms
8. Pharmacist restrictions
9. Dispensing restrictions
10. Negative laws regarding medical use of opioids
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Response Rate
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Formulary and Cost 7 essential opioids
Codeine
Morphine, Oral Immediate Release (MoIR)
Morphine, Oral Controlled Release (MoCR)
Morphine, injectable (MoINJ)
Oxycodone, Oral Immediate Release (OcIR)
Methadone, Oral (MoPO)
Fentanyl, transdermal patch (FentTD)
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Formulary and Cost: Latin A+ Caribbean
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Formulary and Cost: Africa
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Formulary and Cost: Middle East
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Formulary and Cost: Asia
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Formulary and Cost: Indian States
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Actual Availability7 essential opioids
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Actual Availability: Latin A and Caribbean
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Actual Availability: Africa
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Actual Availability: Middle East
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Actual Availability: Asia
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Actual Availability: Indian States
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Eligibility Restrictions(Patient permits)
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Eligibility Restrictions: Africa + ME
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Eligibility Restrictions : L Am + Caribbean
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Eligibility Restrictions : Asia + Indian States
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Restrictions of prescribing authority
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Prescription Privileges: Africa
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Prescription Privileges: Middle East
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Prescription Privileges: L Am. +Caribbean
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Prescription Privileges: Asia
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Prescription Privileges: Indian States
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Prescription restriction: Number of days supply that can be prescribed
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Days allowed/prescription: Africa + ME
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Days allowed/prescription: L Am + Caribbean
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Days allowed/prescription: Asia + Indian States
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Prescription restriction: Increased bureaucratic burden with multiple copies or special
forms
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Prescription forms: Africa + ME
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Prescription forms: L Am + Caribbean
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Prescription forms: Asia + Indian States
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Pharmacist restrictions
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Pharmacist Restrictions: Africa +ME
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Pharmacist Restrictions: L Am + Caribbean
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Pharmacist Restrictions: Asia + Indian states
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Dispensing restrictions
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Dispensing: Africa
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Dispensing: Middle East
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Dispensing: L Am + Caribbean
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Dispensing: Asia
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Dispensing: Indian States
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Negative laws regarding medical use of opioids
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Laws: Africa + ME
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Laws: Lat. Am +Caribbean
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Laws: Asia + Indian States
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Summary
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Summary Slides: Formulary
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Summary Slides: Formulary
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Restrictive regulations summary: Africa
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Restrictive regulations summary: M.E.
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Restrictive regulations summary: Lat Am +Caribbean
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Restrictive regulations summary: Asia
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Restrictive regulations summary: Indian States
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Restrictive regulations summary
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Disclaimers
Field reports+/- verification of actual regulations
Data not YET subject to open peer reviewConflicting data
Individual reportersMultiple reporters
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Conclusions1. In many places across Africa, Asia , ME and L Am+
Caribbean governments are failing cancer patients in delivery of adequate pain relief.
2. There is a need for increased availability of affordable opioids for the management of cancer pain.
3. In many places opioids on formulary are not routinely available.
4. Field reports suggest that overregulation of opioids is widespread.
4 + barriers of varying severity 79/93 (84%) 6 + barriers of varying severity 36/93 (39%)
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Priority actions
1.Formulary review2.Improving affordability3.Improving availability of opioids on
formulary by better distribution and dispensing
4.Examination of drug control policies 5.Repeal of excessive restrictions which
impede this most fundamental aspect of cancer care.
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Advocacy In action: India
Dr. Nagesh Simha Human Rights Watch ReportDocumentary: Why Millions of Indians
Live in Unbearable Pain? Supreme court Ruling
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Special AcknowledgmentsLogistics
Gracemarie Bricalli Heidi Blumhuber Amelia GiordanoSilvana Gori
Coordinating Partners1. European Society for Medical Oncology (ESMO)
2. European Association Palliative Care (EAPC)
3. Pain and Policies Studies Group, University of Wisconsin Carbone Cancer Center (PPSG)
4. Union for International Cancer Control (UICC)
5. World Health Organization (WHO)
156 individual reporters
Collaborating Partners1. African Organization for Research and Training in Cancer (AORTIC)
2. Latin American and Caribbean Society of Medical Oncology (SLACOM)
3. Latin American Association for Palliative Care (ALCP)
4. African Palliative Care Association (APCA)
5.World Palliative Care Alliance (WPCA)6. Multinational Association for Supportive Care in Cancer (MASCC)
7. International Association of Hospice and Palliative Care (IAHPC)
8. Asia Pacific Hospice Palliative Care Network
9. Middle East Cancer Consortium (MECC)
10.Indian Association of Palliative Care (IAPC)
11.Open Society Foundation (OSF)
12.Chinese Society of Clinical Oncology (CSCO)
13.Help the Hospices
14.Japanese Society of Medical Oncology (JSMO)
15.Malaysian Society of Clinical Oncology (MSCO)
16.Myanmar Oncology Society
17.Foundation Akbaraly, Madagascar