International Pain Policy Fellowship, Cohort III

1. International Pain Policy Fellowship, Cohort III Country Report : Sri Lanka

2. Country Report For SRI LANKA Dr. N. Jeyakumaran MDConsultant Clinical Oncologist.Teaching Hospital, JaffnaSri Lanka Part I Cancer Pain and Palliative Care

3. Sri Lanka • Total Land area : • 65,610 Sq km • Population : • 20.2 Million Sri Lanka

4. Sri Lanka Nine Provinces. Nine Cancer Units

5. Cancer Pain and Palliative Care Management mainly at Cancer Hospitals. • One Cancer Unit in each province. • Varying pattern of pain management policies. • Pain Management. • Mainly By… • Oncologists. • Anaethetists. • WHO Pain Management. • Radiation treatment. • IV preparations.

7. Cancer Incidence in Sri Lanka No / 100,000

8. Year Sex Number % CR ASR 1985 Male 2 564 51.2 31.7 34.9 Female 2 448 48.8 31.5 39.4 Total 5 012 31.6 37.6 1990 Male 2 979 49.1 34.4 38.6 Female 3 084 50.9 37.0 46.9 Total 6 063 35.7 43.1 1995 Male 3 450 47.1 37.3 43.6 Female 3 875 52.9 43.6 58.6 Total 7 325 40.4 51.2 2000 Male 5 130 47.0 52.0 63.7 Female 5 795 53.0 61.1 84.9 Total 10 925 56.4 74.6 2005 Male 6 058 45.3 62.3 68.1 Female 7 314 54.7 73.4 73.3 Total 13 372 67.9 70.6 Cancer Pattern (1985 – 2005)

9. All Site No CR ASR Breast 1908 9.7 9.7 Lip Oral Cavity & Pharynx 1617 8.2 8.7 Esophagus 1022 5.2 5.6 Cervix Uteri 881 4.5 4.6 Trachea Bronchus & Lungs 832 4.2 4.5 Thyroid 752 3.8 3.6 Colon & Rectum 741 3.8 3.6 Lymphoma 604 3.1 3.3 Ovary 596 3.0 3.0 Leukaemia 570 2.9 3.0  All Sites  13372  67.9  70.6 Leading Cancer sites overall (2005)

11. Rank Male Site No CR ASR 1 Lip Oral Cavity & Pharynx 1240 12.7 14.1 2 Trachea Bronchus & Lung 666 6.9 7.7 3 Esophagus 498 5.1 5.8 4 Colon & Rectum 388 4.0 4.4 5 Lymphoma 360 3.7 3.9 6 Larynx 324 3.3 3.7 7 Leukaemia 313 3.2 3.3 8 Prostate 303 3.1 3.5 9 Unknown Primary Site 257 2.7 2.9 10 Brain 171 1.8 1.8  All Sites  6058  62.3  68.1 Leading Cancer sites in Male (2005)

13. Rank Female Site No CR ASR 1 Breast 1859 18.7 18.3 8.9 2 Uterine Cervix 881 8.9 3 Ovary 496 5.9 5.9 4 Thyroid 3592 5.6 5.6 5 Oesophagus 524 5.5 5.5 6 Lip Oral Cavity & Pharynx 377 3.8 3.8 7 Colon & Rectum 353 3.6 3.6 8 Leukaemia 257 2.8 2,8 9 Lymphoma 243 2.5 2.5 10 Uterus 237 12.4 2.4  All Sites  73.4  73.3 Leading Cancer sites in Female (2005)

16. Source : GLOBOCAN 2008 Estimates

17. Source : GLOBOCAN 2008 Estimates

20. Cancer Mortality Data (1985 – 2003)

21. National Cancer Control Programme. (NCCP) Director - NCCP. Policy - Is being drawn.

22. Role of Govt. in Pain Relief… • Education: • Specialist Training. • Palliative Care included. • Analgesics including Opioids. • Given Free of charge in all Hospitals • Policy towards improved Health Care

23. Pain Management at Cancer Hospitals • Most Cancer Patients present at Late Stages. • Govt. of Sri Lanka provides free Health Care. • Pain Management. • WHO method. • WHO Ladder is followed. • Opioid available in Cancer Hospitals. • Few hospices. • Training Programmes. • Need to be organized.

24. Availability of Pain Relief and Palliative Care Services • Places of Treatment. • At all Cancer Units. • At the Hospices. • Drugs: • Mild Analgesics. • Moderate Analgesics. • Strong Analgesics. • Adjuvant drugs. • For Children. • Oral solutions – Not available.

25. Hospices

28. SathyaSai Suva Sevana

30. Play Therapy

31. Art Therapy

32. Art Therapy

33. Partners in Palliative Care • Training institutions. • Postgraduate Institute of Medicine. • Professional Organizations. • Sri Lanka Medical Association. • Sri Lanka College of Oncologists. • NGO • Sri Lanka Cancer Society. • Cancer Aid for North and East. • International Partners • WHO Palliative Care Centre. • Kerala Palliative Care Centre. • PPSG. • Pallium India & Trivendram Centres • .

34. Part IIHIV/AIDS & Palliative Care Dr. SurajPereraMBBS, MSc, MD Consultant Community Physician National Cancer Control Programme, Ministry of Health , Sri Lanka

35. Number of HIV cases reported up to end of 2011 Sri Lanka Source : National STD/AIDS Control Programme, Ministry of Health, Sri Lanka

36. Trend of reported deaths due to AIDS in Sri Lanka 1987-2009 Source: National STD/AIDS Control Programme, Sri Lanka. (2010).

37. Estimated number of adults and children living with HIV, new infections and AIDS deaths, 1990-2009 Source: Prepared by www.aidsdatahub.org based on UNAIDS (2010). Global Report: UNAIDS Report on the Global AIDS Epidemic.

38. National STD/AIDS Control Programme Ministry of Health Anti Venereal Disease Campaign - established in 1952. With the advent of HIV/AIDS the Anti VD Campaign was restructured as the National STD/AIDS Control Programme (NSACP) in 1985, even before the first case of HIV infection was reported in Sri Lanka. Dr. NimalEdirisinghe, Director National STD/AIDS Control Programme Ministry of Health No. 29, De Saram place, Colombo 10, Sri Lanka (94) 011 26 67163, (94) 011 533 6873 / (94) 011 2682859

39. Objectives for pain relief and palliative care in National STD/AIDS Control Programme • “To maintain the provision of HIV treatment, care and support services for people living with and affected by HIV/AIDS and occupational post exposure prophylaxis (oPEP) for health care workers (HCWs) through the service delivery points of the National STD/AIDS control Programme or other relevant government health facilities in quality assured manner.” • “To coordinate with and support institutions within and outside the Ministry of Health in the expansion of appropriate, high quality HIV treatment, care and support services for people living with and affected by HIV/AIDS and for oPEP in Sri Lanka.”

40. Availability of pain relief and palliative care services in the country for HIV/AIDS patients • Pain relief medications are available for HIV/AIDS patients. • But patients are not experiencing any ‘significant pain’ during their HIV/AIDS journey from diagnosis to death according to the verbal communication of staff of inward facility for AIDS Patients in Sri Lanka .

41. Part III : Opioid Availability

42. Opioid Availability - National Competent Authority (NCA) Medical Supplies Division (MSD), Ministry of Health Director / Medical Supplies Division, Ministry of Health submits annual estimates of medical requirements of narcotic drugs including Morphine

43. Calculating Annual estimates for Opoids • Medical Supplies Division (MSD) of Ministry of Health calculates annual estimates based on estimates send by the Directors of Hospitals in the line Ministry and Provincial Ministries of Health • Additional 10% is added, based on previous year consumption • MSD provides annual statistics to INCB

44. Palliative Care Pain Relief Drugs in Essential Medicines List Morphine & Tramadol is included (National Essential Medicine List Sri Lanka , 2009)

45. Opoid Analgesics available in Sri Lanka

46. Opoid Analgesics available in Sri Lanka

47. Additional Opioids which are needed Oral morphine liquid form Fentanyl dermal patches

48. Availability of Morphine • Sufficiently available most of the times at the Cancer Units. But the instant release Morphine tablets some times are out of stock. • Hospices receive oral morphine stocks from near by Cancer Units. Injectables are bought from Medical Supplies division. • The duration of Morphine prescribed is from one week – one month

49. Prescribing Morphine • Any registered Medical Practitioner at the Sri Lanka Medical Council (SLMC) can prescribe • No special prescription forms required • No special training required. • Nurses are not allowed to prescribe

50. Prescribing Morphine • It is usually started using WHO Pain ladder concept from mild pain medicines to Strong Opioids . • Then doses are increased to achieve a good pain relief. • But when prescribing Morphine to take home the duration varies from 1 – 4 weeks from one cancer unit to other. • As long as the patient is not having much side effects, full course is given depending on the availability of drugs.