Pain in Cancer, AIDS, and NCDs, with a Focus on Opioid Analgesics

1. Pain in Cancer, AIDS, and NCDs, with a Focus on Opioid Analgesics James Cleary, MD Pain and Policy Studies Group

2. Uganda as a model! • Uganda serves as a brilliant model, like Wisconsin and Catalonia, for the importance of an integrated government and community non-governmental approach. Each one by themselves in isolation, will not achieve much. Oxford Textbook of Palliative Medicine, 3rd Edition

3. Wisconsin Cancer Pain Initiative • Dahl & Joranson (WI Pharmacy Board) • US based: 1986 • WHO Demonstration Project. • Role Model Initiative. • Education • Wisconsin Pain Initiative • Alliance of State Pain Initiatives.

4. Pain and Policy Study Group • 1996: Pain and Policy Study Group • National • International • WHO Collaborating Center • Cancer Control • Access to Controlled Medications Program • INCB Workshop Estimates; Dec 2009 • Close Ties with INCB • Opioid Consumption Data • Model Laws • Estimates Process

5. Establishes a Framework to: • Prevent abuse and diversion, and • Ensure the availability of drugs for medical purposes

6. Global Trend 1980 - 2008 Source: International Narcotics Control Board By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2010

7. Total ME: High Income vs. Low and Middle Income Countries Source: International Narcotics Control Board By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2010

8. 2006 International Pain Policy Fellowship Dr. Simbo Daisy Amanor-Boadu Nigeria Dr. Henry Ddungu Uganda/APCA Prof. Snežana Bošnjak Serbia Dr. Jorge Eisenchlas Argentina Prof. Rosa Buitrago Republic of Panama Dr. Marta Ximena LeónColombia Mrs. Nguyen Thi Phuong Cham Vietnam Mr. Gabriel Madiye Sierra Leone Pain & Policy Studies Group University of Wisconsin October 2006 Madison, Wisconsin Supported by the Open Society Institute

9. 2008 International Pain Policy Fellowship Dr. Bishnu Dutta Paudel Mr. Radha Raman Prasad Teli Nepal Pain & Policy Studies Group University of Wisconsin October 2006 Madison, Wisconsin Supported by the Open Society Institute

11. WHO Palliative Care Public Health Model DrugAvailability Education Policy

12. “the medical use of narcotic drugs continues to be indispensable for the relief of pain and suffering… adequate provision must be made to ensure the availability of narcotic drugs for such purposes.” (Preamble, p. 13)

13. Measurement Sustainable delivery systems Tobacco, obesity, alcohol Vaccination (HBV, HPV) Dispel myths about cancer Screening & early detection Effective pain control Training opportunities Reduce health emigration Improve cancer survival for all. 2020 Targets

14. 7: Improve Access to Diagnosis, Treatment, Rehabilitation and Palliative Care Access to accurate cancer diagnosis, appropriate cancer treatments, supportive care, rehabilitation services and palliative care will have improved for all patients worldwide. • 8: Effective pain control measures will be available universally to all cancer patients in pain

15. 1274 27.5

16. Deaths from HIV & Cancer

17. Deaths by cause in the world (2005) Noncommunicable diseases: Infectious diseases: HIV/AIDS 4.9% Tuberculosis 2.4% Heart disease 30.2% Malaria 1.5% Total: 58.2M Other Infectious Diseases 20.9% Cancer 15.7% Injuries 9.3% Diabetes 1.9% Other chronic diseases 15.7% (WHO, Chronic Disease Report, 2005)

18. Noncommunicable Diseases (NCDs) Responsible for up to 60% of all deaths, 80% are in low- and middle-income countries Major non-communicable diseases: Cardiovascular disease Cancer Chronic Respiratory disease Diabetes Shared preventable risk factors: Tobacco use Unhealthy diet Physical inactivity Harmful use of alcohol Cancer Chronic Respiratory Diseases Diabetes Cardiovascular Disease Other NCDs Physical inactivity Unhealthy diets Obesity Smoking Harmful use of alcohol

19. Noncommunicable diseases (2006-2015) WHO projects that over the next 10 years, the largest increase in deaths from cardiovascular disease, cancer, respiratory disease and diabetes will occur in low- and middle-income countries. (WHO, Chronic Disease Report, 2005)

20. United Nations general assembly on non-communicable diseases (NCD) • For the first time ever, the United Nations General Assembly held a Non-communicable Disease (NCD) Summit involving Heads of State, in September 2011, to address the threat posed by NCDs to low- & middle-income countries (LMICs). • World Heart Federation • International Diabetes Federation (IDF) • International Union Against Cancer (UICC) • the International Union Against Tuberculosis and Lung Disease • Where was PAIN???

22. World Health Organization

23. Essential Medicines16th edition (updated)2010 WHO Model List 2. ANALGESICS, ANTIPYRETICS, NON-STEROIDAL ANTI-INFLAMMATORY MEDICINES (NSAIMs), MEDICINES USED TO TREAT GOUT AND DISEASE MODIFYING AGENTS IN RHEUMATOID DISORDERS (DMARDs) 2.1 Non-opioids and non-steroidal anti-inflammatory medicines (NSAIMs) acetylsalicylic acid Suppository: 50 mg to 150 mg. Tablet: 100 mg to 500 mg. Ibuprofen Tablet: 200 mg; 400 mg. >3 months. paracetamol* Oral liquid: 125 mg/5 ml. Suppository: 100 mg. Tablet: 100 mg to 500 mg. * Not recommended for anti‐inflammatory use due to lack of proven benefit to that effect. 2.2 Opioid analgesics Codeine Tablet: 15 mg (phosphate); 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)

25. International Association of Hospice and Palliative CareList of Essential Medicines for Palliative Care (http://www.hospicecare.com/resources/pdf-docs/iahpc-list-em.pdf) • Codeine, • Fentanyl, • Methadone, • Morphine (immediate and sustained release), • Oxycodone, • Tramadol NOTE: NO GOVERNMENT SHOULD APPROVE MODIFIED RELEASE MORPHINE, FENTANYL OR OXYCODONE WITHOUT ALSO GUARANTEEING WIDELY AVAILABLE NORMAL RELEASE ORAL MORPHINE.

28. WHO supports global effort to relieve chronic pain • The WHO co-sponsors the first Global Day Against Pain, which seeks to draw global attention to the urgent need for better pain relief for sufferers from diseases such as cancer and AIDS. • The campaign, organised by the International Association on the Study of Pain (IASP) & the European Federation of the IASP Chapters (EFIC), asks for recognition that pain relief is integral to the right to the highest attainable level of physical and mental health…

29. Report on AVAILABILITY “The low levels of consumption of opioid analgesics for the treatment of pain in many countries, in particular in developing countries, continue to be a matter of serious concern to the Board. The Board again urges all Governments concerned to identify the impediments in their countries to adequate use of opioid analgesics for the treatment of pain and to take steps to improve the availability of those narcotic drugs for medical purposes…” (paragraph 97) INCB, 2007 report

32. Opioid availability and cost: West Europe

33. Opioid availability and cost: Eastern Europe

34. Global Consumption of MorphineHigh-Income vs. Low - and Middle - Income Countries, 2008 Percent total 91% 83% 17% 9% Source: International Narcotics Control Board; United Nations Population Data, 2007; World Bank Income Classification, 2008. By: Pain & Policy Studies Group, University of Wisconsin /WHO Collaborating Center, 2010.

35. Global Consumption of Morphine, 2008 Mg/capita Austria (166.9070 mg) Uses morphine for substitution treatment U.S.A (66.5682 mg) Global Mean (6.005 mg) Poland (6.4746 mg) Guatemala Italy (3.4816 mg) Georgia South Africa (10.3011 mg) Serbia Kenya Armenia Nepal Vietnam Jamaica Colombia Panama (158 Countries) The means are calculated by adding the individual mg/capita statistics for all countries and then dividing by the number of countries; data does not Include information for countries from which the INCB did not receive a report Source: International Narcotics Control Board; United Nations population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2010

41. "We must not only stop the harm caused by drugs: let's unleash the capacity of drugs to do good. You think this is a radical idea? Look back to the origins of drug control. The Preamble of the Single Convention recognizes that … the medical use of narcotic drugs continues to be indispensable for the relief of pain… This is hardly the language of a prohibitionist regime. Indeed, this noble goal of UN drug policy, the freedom from physical pain, demonstrates our over-riding commitment to health." Antonio Costa, Exec Director, UN Office on Drugs and Crime (UNODC) March 2010