Access to opioid analgesics: Essential for quality cancer care

Abstract

Many cancer patients suffer moderate to severe pain, but owing to a focus on the prevention of abuse of and dependence on drugs, medical access to opioid analgesics has been neglected. Today, opioid analgesics are not readily available for medical use in many parts of the world. The World Health Organization (WHO) estimates that 5.5 billion people (83 % of the world’s population) live in countries with low to non-existent access to controlled medicines and have inadequate access to treatment for moderate to severe pain. Although some have been advocating for improved pain management for several decades, only recently has the inadequate access to and availability of opioid analgesics become an internationally recog­nised problem. Measuring opioid analgesic consumption is possible using data from the International Narcotics Control Board. This requires aggregation of the various opioid analgesics expressed in “mg morphine equivalents”. For determining the level of consumption that will be adequate in a country, its per capita consumption can be compared with the consumption level in most developed countries by calculating the Adequacy of Consumption Measure (ACM). A correction of the need for opioid analgesics depending on the morbidity level in a country is possible by using HIV, cancer, and injuries as a proxy, but this has its limitations owing to the unreliability of health statistics in some countries. Independent of the method, all methods show that there is a huge disparity between countries: the difference between the countries with the highest and lowest ACM in 2006 was 40,000 folds. The World Health Organization defined availability, accessibility, and affordability as the key areas of concern around controlled medicines. These three terms relate to the questions: “Is the medicine present in the pharmacy?”, “Is it possible to obtain the medicines from the pharmacy?” and “Has the patient sufficient means to buy it?” If these conditions are not met, the patient’s pain will not be managed. A variety of barriers can be at the root of limited availability, accessibility, and affordability. Four categories of barriers can be distinguished: legislative and policy barriers, knowledge barriers, attitudes barriers, and economic barriers. The World Health Organization established the Access to Controlled Medicines Programme (ACMP), which developed a number of documents to guide policy makers and health-care professionals to improve access to opioid analgesics and other controlled medicines. The ACMP and a number of NGOs also provide support to countries that want to improve access to controlled medicines e.g. by organising workshops and reviewing (draft) legislation. Moreover, international organisations of health-care professionals also called for adequate access to pain medicines and treatment of pain. In order to ensure that “effective pain control measures will be available universally to all cancer patients in pain” by 2020, we will need to record our progress toward and analyse the barriers to adequate pain management. Access to opioid analgesics is essential for quality cancer care because by treating the pain, we improve the patient’s quality of life in one important aspect of his or her disease.