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May 1, 2013 Volume 77, Number 5
Committee News: Pain Management in Developing Countries: An Update Andres Missair, M.D., EDRA Committee on Global Humanitarian Outreach

Carlos Bollini, M.D.



According to the 1948 Universal Declaration of Human Rights, the right to health includes relief from pain.1 Under this premise, 5.5 billion people are at risk of human rights violations on a daily basis.2 This staggering statistic is the result of inequitable distribution and access to treatment for moderate and severe pain across international borders. In 2008, low- and middle-income countries, comprising 83 percent of the global population, accounted for only 9 percent of the global consumption of morphine,3 a drug classified as an essential medicine by the World Health Organization (WHO). In contrast, high-income countries, representing 17 percent of the world’s population, accounted for 91 percent of morphine consumption (Figure 1). The factors that have led to this “pharmacologic disparity” are highlighted in a 2006 survey of hospice and palliative care providers from Asia, Africa and Latin America. In all three continents, similar trends were identified as barriers to morphine access: excessively strict national laws and regulation; fear of addiction, tolerance and side effects by patients and practitioners; poorly developed health care systems and supply; and lack of education by health care professionals, the public and policymakers.3 Subsequent surveys by the WHO, International Narcotics Control Board and other non-governmental agencies have confirmed this pattern throughout the world, including within Eastern Europe.4 According to Meg O’Brien, director of the Global Access to Pain Relief Initiative, morphine procurement in the developing world, on a national level, has more to do with overcoming bureaucratic factors and physician misconception than cost.5

Despite the statistics and seemingly insurmountable obstacles, progress is being achieved in certain countries. Greater international recognition of the issue in recent years has promoted several key initiatives with promising results. The WHO Access to Controlled Medicines Program (ACMP) was developed in 2005, accepted by the United Nations Commission on Narcotic Drugs and World Health Assembly in 2007, and finally ratified in 2010. The ACMP has focused on lifting barriers to opioid access and other controlled medicines through policy analysis and normative guidance to national governments, training and practical assistance of health care professionals, and research support.2 Armed with a $55 million budget, the ACMP has partnered with national pain societies, other NGOs, and the WHO regional offices in developing countries to promote the necessary changes in attitude, education, policy, and administrative systems that are fundamental for sustainable availability and accessibility of opioids.3

In recent years, the Pain & Policy Studies Group, a WHO Collaborating Center at the University of Wisconsin, implemented the International Pain Policy Fellowship (IPPF) program. This initiative has led to significant progress in the availability of and access to opioids in countries such as Sierra Leone, Colombia and Serbia. In 2006, for example, there was no oral morphine available to the 6 million people of Sierra Leone.3 By February 2009, and after three years of efforts by the IPPF Fellow, the only hospice in the country began treating patients with oral morphine. The success of the program resulted in a duplication of imported morphine powder during subsequent years. The IPPF Fellow is now working on expanding the availability of oral morphine throughout the Sierra Leone public health system. In Colombia, the IPPF program has also achieved substantial progress. In early 2009, only four states (13 percent) had opioid analgesics available 24 hours a day, seven days a week.3 Even in the capital city, Bogota, morphine was not consistently available to all patients. Despite adequate national supplies, patient access was limited by an inefficient pharmaceutical distribution chain and administrative barriers on opioid prescriptions. Today, thanks to the IPPF program, 32 Columbian states have at least one pharmacy location with 24/7 access to hydromorphone, methadone, morphine and pethidine.3 Throughout the world, thanks to the leadership of the WHO and organizations such as the PPSG, opioid availability is slowly improving (Figure 2, page 53).

In an effort to reduce the reliance on opioids for acute pain management, several programs have been developed to introduce and teach regional anesthesia techniques in developing countries. One such program started by physician volunteers at the University of Miami combines free regional anesthesia workshops with equipment donations to help establish sustainable regional anesthesia services in developing countries. Due to its relative simplicity and low cost, nerve stimulation is the primary guidance modality taught in these courses. Thus far, regional anesthesia services have been established in Nicaragua and Colombia. While peripheral nerve blocks are not a comprehensive solution to the chronic and palliative care requirements of a population, they can reduce the overall opioid consumption of patients in acute pain and, thereby, increase availability for those in chronic need. For example, in a recent survey by Carlos Bollini, M.D., et al., of practicing anesthesiologists in Argentina, up to 91 percent of respondents felt they required additional training in regional anesthesia techniques. This sentiment is present throughout many middle- and low-income countries and is, perhaps, one of the greatest obstacles to establishing regional anesthesia services in developing countries. Ironically, it is also one of the cheapest to overcome. In response, many academic anesthesiologists in Brazil, Uruguay, Chile, Colombia and Argentina have donated their time to conduct yearly workshops in regional anesthesia, explains Dr. Bollini. Unfortunately, the progress achieved in pain education has been overshadowed by a lack of equipment at many health care centers in these countries.

For years, anesthesiologists have been considered the ultimate advocates for patient safety. Following the realization that intraoperative patient outcome is impacted by preoperative medical conditions, we have also become subspecialists in perioperative medicine. Our expertise in analgesia and opioid pharmacology now leads us down a new path: that of human rights activists.


May 2013 ASA Newsletter



Andres Missair, M.D., EDRA, is Associate Director, Fellowship Program, and Assistant Professor, Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of Miami.

Carlos Bollini, M.D. is Associated Anesthesiologyst, Instituto Argentino de Diagnóstico y Tratamiento, University of Buenos Aires, Buenos Aires, Argentina.


References:
1. Brennan F, Cousins MJ. Pain relief as a human right. Pain: Clin Updates. September, 2004;12(5):1-4.
2. World Health Organization Department of Essential Medicines and Pharmaceutical Policies. Access to Controlled Medications Programme: improving access to medications controlled under international drug conventions. http://www.who.int/medicines/areas/quality_safety/ACMP_BrNote_Genrl_EN_Apr2012.pdf. Published April, 2012. Accessed March 18, 2013.
3. Bosnjak S, Maurer MA, Ryan KM, Leon MX, Madiye G. Improving the availability and accessibility of opioids for the treatment of pain: The International Pain Policy Fellowship. Support Care Cancer. 2011;19(8):1239-1247.
4. Cherny NI, Baselga J, De Conno F, Radbuch L. Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Europe: a report from the ESMO/EAPC Opioid Policy Initiative. Ann Oncol. 2010:21(3):615-626.
5. Pain in the developing world: how poorer nations are losing out on palliative care. The 2 x 2 project website. http://www.the2x2project.org/developing-palliative-care/. Accessed March 18, 2013.
6. Global state of pain treatment: access to medicines and palliative care. Human Rights Watch website. http://www.hrw.org/reports/2011/06/02/global-state-pain-treatment-0. Published June 3, 2011. Accessed March18, 2013.
7. Global Access to Pain Relief Initiative (GAPRI). Union for International Cancer Control website. http://www.uicc.org/programmes/gapri. Accessed March 18, 2013.