Global Opioid Access: WHO accelerates the pace, but we still need to do more

With the WHO Executive Board recently adopting the resolution ‘Strengthening of palliative care as a component of integrated treatment within the continuum of care’, which is to be referred to the World Health Assembly for ratification in May, Nathan Cherny puts the current global situation in perspective and lays out the next steps needed in this crucial campaign to end suffering to millions.

By Nathan Cherny

In the curious trail that has been my life thus far, some would say that there was a certain inevitability that I would end up working for cancer patients’ right to access medication for adequate relief of their suffering. As a medical student I suffered terrible cancer-related pain from a thoracotomy to remove lung metastases for testicular cancer. As an oncologist and palliative care physician in the Middle East, my current work allows me to look after both Israeli and Palestinian patients. My profession has also taken me to caring for many “medical tourists” from Eastern Europe as well as foreign workers from Thailand, India, Nepal, and the Philippines. Oh, and I was born on Human Rights Day, 10 December 1958!

I hate pain. I am appalled by the global scope of untreated and unrelieved cancer pain. At the initiative of its Palliative Care Working Group, the European Society for Medical Oncology (ESMO) has taken this on board as a global priority issue. ESMO facilitated the first comprehensive study to evaluate the barriers to pain relief in Europe, which highlighted the distressing situation in many Eastern European counties.

In follow-up, a large collaborative group was formed for an even more ambitious study. The Global Opioid Policy Initiative (GOPI) combined the work and talents of ESMO, the European Association for Palliative Care (EAPC), the Union for International Cancer Control (UICC), the Pain and Policies Study Group (PPSG) of the University of Wisconsin, and the World Health Organization (WHO), and 17 other leading oncology and palliative care societies worldwide.

The GOPI studied opioid availability and accessibility for cancer patients in Africa, Asia, the Middle East, Latin America, and the Caribbean. The results were published in a special supplement of the Annals of Oncology in December 2013. The seven manuscripts in the special issue highlighted the global problem of excessively restrictive regulations regarding the prescribing and dispensing of opioids — ‘catastrophe born out of good intentions’.

In order to prevent abuse and diversion, most patients with genuine need to relieve severe cancer pain cannot access the appropriate medication. Millions of people around the world end their lives racked in pain, harming not only the patients but also their families who bear witness to this torturous tragedy.

On 23 January 2014, the WHO Executive Board adopted a stand-alone resolution on palliative care which will be referred to the World Health Assembly for ratification in May 2014. This is great news for all those campaigning to improve access to medication to end suffering to millions. There is still much to be done on this long, winding road, yet we can still be proud. Thanks to our united efforts and the evidence provided by the GOPI data, our voices are being heard.

Overregulation of opioids is not the only problem impeding global relief of cancer pain. In many places around the world there is major need to: educate clinicians in the assessment and management of pain; educate the public regarding the effectiveness and safety of opioid analgesia in the management of cancer pain; and secure supplies of affordable medications.

The next steps: The GOPI Collaborative Group is now writing to Ministers of Health in the many countries where we have identified major over-regulation with a 10 point plan to help redress the problem, covering education, restrictions, limits, professional standards, monitoring, and prescription.

Tell us what actions you can take to incorporate these next steps in your country. Can you contact your Ministry of Health? What could be inspirational for others to know? We make more noise if we all shout together.

Nathan Cherny was the Chair of the ESMO Palliative Care Working Group since 2008 and has been a member of the working group since its inception in 1999. He was the main driving force in the creation of the ESMO Designated Centre of Integrated Oncology and Palliative Care Programme which was launched in 2003 and last year had its 10^th Anniversary.  Nathan also wrote the ESMO 2003 Position Paper: ESMO Policy on Supportive and Palliative Care. Watch the Advocacy in Action 2013 video on: Palliative Care & Quality Of Life Care: Redefining Palliative Care.

Opioid availability and accessibility for the relief of cancer pain in Africa, Asia, India, the Middle East, Latin America and the Caribbean: Final Report of the International Collaborative Project was published as an Annals of Oncology supplement in December 2013.

Annals of Oncology is a multidisciplinary journal that publishes articles addressing medical oncology, surgery, radiotherapy, paediatric oncology, basic research and the comprehensive management of patients with malignant diseases. Follow them on Twitter at @Annals_Oncology.

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Image credits: (1) Photo of Nathan Cherny, via ESMO; (2) GOPI banner, via Global Opioid Policy Initiative/ESMO