Access to pain control, especially opioid painkillers, remains very difficult in most parts of the world, according to a report issued today by Help the Hospices, despite the fact that an estimated 100 million people could benefit from palliative care.
The World Health Organization (WHO) recommends that pain should be managed with oral opioids if it cannot be controlled adequately by other analgesics such as paracetamol, codeine or non-steroidal anti-inflammatory drugs.
However, a survey carried out by Help the Hospices found that 25% of palliative care providers in Asia, 35% in Latin America, and 39% in Africa cannot always access a strong opioid.
Similarly, for 41% of palliative care providers in Africa and 39% in Latin America oral morphine is not always available and for 21% and 18% respectively oral morphine is never available
Only 55% of healthcare workers providing palliative care in Asia, Africa and Latin America have a weak opioid 'always available'. 22% have access only 'occasionally' or 'never'.
In Asia, Africa and Latin America many were unable to 'always access' any of the adjuvant analgesics useful for neuropathic pain: an anticonvulsant (37%), a tricyclic antidepressant (~30%) and dexamethasone (25%).
Twelve per cent never have access to an anticonvulsant, 7% never have access to paracetamol, and in one major hospital in Malawi, Help the Hospices found that aspirin was the only pain killer always available. But aspirin is not recommended in children therefore there are no suitable pain killers available for children.
The report's author, pharmacist Vanessa Adams, notes that the survey findings are likely to greatly overestimate patient access to analgesics as all respondents were actively involved in providing palliative care. In fact in the areas surveyed most of the populations do not have access to any palliative care.
For example, in Africa 21 out of 47 countries have no identifiable palliative care provision and only four have a reasonable level of provision. In India less than 1% of the people who would benefit from palliative care have access to it, while in Pakistan there is only one palliative care service to serve a population of 158 million.
If healthcare workers wanting to provide palliative care cannot access the required analgesics it is likely that these drugs will be not be available to any other health workers in that country or state.
In South Africa the lack of pain control and palliative care has become a political issue. Gareth Morgan, health spokesman for main opposition party, the Democratic Alliance, said last year that the country’s health department is ignoring the needs of AIDS patients who require pain control.
The DA proposed amending the regulations on prescribing to allow a nurse with sufficient training to dispense morphine. Morphine is a schedule seven drug in South Africa, and under the Medicines and Related Substances Control Act, may only be administered by a doctor.
"The primary need for this drug for palliative care is in clinics, where doctors are seldom available," said Gareth Morgan.
Barriers to pain relief
The report examines the barriers preventing adequate access to essential analgesics and finds that funding is not the main barrier to access. The cost of medicines such as morphine, although comparatively higher in developing countries than in developed countries, is generally relatively inexpensive. The main reasons for lack of availability include:
- lack of knowledge on the part of healthcare workers, policy makers and the public about the use and benefits of opioid analgesics, other analgesics and palliative care
- excessively strict national laws and regulations
- misplaced fear of addiction, abuse, tolerance and / or side effects
- high cost of oral morphine.
- poorly developed healthcare systems and supply chains.
Recommendations
In order to prevent millions suffering pain needlessly the report recommends coordinated international and national programmes to increase awareness, education, supply and access. Palliative care and access to analgesics should be an integral part of all national policies relating to cancer, HIV/AIDS and other chronic diseases.
The report outlines essential steps that need to be taken to improve access to analgesics including improved education and accountability, reviewing laws and policies and strengthening health facilities.
The report is available to download at here