The Challenges of Ensuring Pain Medication

By Anonymous

On page 18 of this issue of WHO Drug Information, Dr Jack Jagwe describes how action by Hospice Africa Uganda (HAU) has made a dramatic difference to the lives of people in his country suffering from pain.

WHO estimates that annually over 60 million people are adversely affected by lack of access to effective pain medicines controlled within the United Nations Single Convention on Narcotic Drugs (1961) and the United Nations Convention on Psychotropic Substances (1971). These two treaties provide the legal basis for the international prevention of drug abuse, together with the United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances (1988) (1). For almost 50 years, the focus has been on prevention of abuse, but this has led to overly strict rules or inappropriate implementation of the international drug control treaties in many countries. As a result, the medical use of controlled substances has been hampered and in some cases prohibited. Severe undertreatment is reported in more than 150 countries, both developing and industrialized, involving about 80% of the world’s population. A balance therefore needs to be sought between medical need and regulatory requirements.

By not being able to use these substances on a regular basis, physicians became less and less experienced in prescribing pain medication. Pain patients can live for very long periods when using the correct dosage of opioids and there is no proof of undue shortening of life. Conversely, freeing patients of pain prolongs the quality, usefulness and extent of their lives. As proposed in the WHO Guideline on Cancer Pain Relief, (2) pain medication can be effectively evaluated and dosed as part of a Pain Ladder as follows.

Step 1: (mild pain) non-opioid analgesics (e.g. paracetamol, NSAIDS), to which if necessary an adjuvant can be added. When a non- opioid no longer adequately controls the pain, an opioid analgesic should be added.

Step 2: (mild to moderate pain) weak acting opioid analgesics (e.g. codeine), to which non-opioid analgesics and adjuvants can be added if the pain is still persisting or increasing.

Step 3: (moderate to severe pain) strong acting opioids, to which non-opioid analgesics and adjuvants can be added if necessary.

If the pain is increasing, the dosage of the opioid should be increased in steps until the patient is free of pain. The effective analgesic dose of morphine will vary considerably and ranges from as little as 5 mg to more than 1000 mg every four hours. The effective dose varies because of individual variations in systemic bioavailability, so that the correct dose is the dose that works.

The WHO Model List of Essential Medicines includes opioids and analgesics (3) and supports their use within the framework of human rights and health, that is “the Right of everyone to enjoy the highest attainable standards of physical and mental health” (4). In 2005, WHO was urged to develop the Access to Controlled Medications Programme in consultation with the International Narcotics Control Board (INCB). The Programme sets out to improve legitimate medical access to all medications controlled under the drug conventions. Lack of access to controlled medicines does not only affect low- income countries, but many middle- and high-income countries as well. Countries willing to improve access can follow the advice provided in the WHO publication Achieving Balance in National Opioids Control Policies, Guidelines for Assessmem’available on the internet in 22 languages (5).

As proposed by the World Health Assembly, it is the responsibility of governments to make every effort to bring pain medications within the reach of those who need them. Every year 6 million people die from cancer without sufficient analgesia and often without any treatment for their pain. About half of all end stage AIDS patients suffer from severe pain. Then, there are many people with acute severe pain from injuries (e.g. car accidents, victims of war), myocardial infarction and chronic pain patients. Regulations for obtaining pain medicines have become more and more stringent amid concerns for prevention of drug abuse which override the legitimate medical needs of patients. However, evidence shows that the majority of narcotic and psychotropic substances reach drug abusers through illicit trade rather than pharmacy channels.

Additionally, misconceptions have spread based on the unjustified fear that opioid medication may cause dependence or death in patients. The mere presence of physical dependence on opioids prescribed for pain control does not, of itself, constitute drug dependence syndrome or “addiction”. In fact, becoming dependent when using a controlled medicine, after prescription for a legitimate medical purpose, is rare. If it does occur, it can be treated in the same way as any other side-effect.

Ephedrine and ergometrine are essential medicines used in obstetrics and delivery that can be life saving. Although they are not abused as drugs, they can be used to synthesize other drug substances – and for that reason they are controlled under the 1988 Convention. Unfortunately, it is reported that these medicines are often not available when most needed, thus contributing to the 250 000 maternal deaths annually.

Dr Jagwe modestly describes what his organization has achieved. However, the importance of his work cannot be underestimated, either for Ugandans directly, or for the many other countries that may use the work carried out in Uganda as a model. The joint efforts of Hospice Uganda Africa and the Ugandan Ministry of Health to provide regulations and organize pain care and medication in such a way that it reaches many has taken a number of years of enduring effort. The innovation of nurse training to carry out the task of prescribing and administration was an important achievement in finding a solution to overcome the shortage of physicians. A similar innovation has been implemented in the state of Kerala, India, where the shortage of pharmacy assistants was overcome by laymen volunteering to dispense the morphine tablets to the patient at home.

References

1. United Nations Single Convention on Narcotic Drugs (1961), United Nations Convention on Psychotropic Substances (1971). United Nations Convention against the Illicit Traffic in Narcotic Drugs and Psychotropic Substances (1988). http:www.who.int/medicines

2. World Health Organization. Cancer Pain Relief with a Guide to Opioid Availability. 2nd. ed. Geneva, 1996.

3. World Health Organization. Selection and Use of Essential Medicines. Model List of Essential Medicines (Updated March 2005). Technical Report Series, (in press).

4. World Health Organization. Constitution. Geneva, 1948.

5. World Health Organization. Achieving Balance in National Opioids Control Policies, Guidelines for Assessment. Pain and Policy Studies Group. Geneva, 2000.

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