November 16 and 17, 2009
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The World Health Organization (WHO) estimates that millions of people around the world are in immediate need of pain management, including those suffering from end-stage HIV/AIDS, terminal cancer, and injuries caused by accidents and violence; as well as surgery patients and children in pain. The National Institute on Drug Abuse (NIDA) and the Clinton Foundation HIV/AIDS Initiative share a common interest in ensuring adequate access to pain relief medications for those who suffer. On November 16 and 17, 2009, these two organizations and the National Institutes of Health Office of AIDS Research brought together participants from several countries and international organizations working with a variety of diseases to discuss how to increase access to pain treatment and palliative care while minimizing the risk of drug diversion.
The meeting, held in Bethesda, Maryland, focused on resource-limited settings in developing countries where the challenges are particularly difficult. Participants made clear the scope of the problem: Fully 5 billion people live in countries with low or no access to controlled medicines such as morphine and other opioid analgesics, and have no or insufficient access to treatment for moderate to severe pain.
Participants discussed common problems of access to pain medication and control of medication abuse, identified the barriers to progress in pain control and palliative care, and explored ways to overcome these hurdles. The unique situations of three resource challenged countries—Zambia, Kenya, and Ethiopia—were presented, as well as a general review of the situation in Africa. A representative of the African Palliative Care Association described how that group has tried to foster appropriate drug policies to ensure adequate drug availability, to increase health care workers’ education in pain treatment, and to help implement palliative care programs. In addition, representatives of international organizations (such as WHO) and donor groups, nongovernmental agencies, and government agencies of developed countries described their programs to both stem the flow of medications for illicit use and to help developing countries increase access to pain medications.
Speakers noted that barriers to an adequate drug supply include inadequate policies and infrastructure in national health care programs, laws that restrict drug availability, lack of funding, lack of an adequate supply of drugs, and a shortage of trained health care providers. To overcome these barriers, they said, pain treatment and palliative care must be integrated into the treatment and care of disease at all levels of the community—from patients to palliative care experts. Doctors and nurses need to be trained in how to administer drugs in the correct and safe dosages, especially in pediatric care. And standards for the assessment of pain need to be developed.
Furthermore, the participants stressed that governments need to be prompted to develop policies and laws that strike a balance between the availability of opioids for pain treatment and control of these substances. Laws that restrict drug availability and are overly focused on the diversion of drugs for illicit uses should be changed so they do not restrict drugs for legitimate uses. At the same time, there is a need to develop safeguards for the distribution of opioid medications from the manufacturer to the patient, incorporating appropriate handling and storage procedures. Speakers also acknowledged the needs of suppliers of drugs, pointing out that they need incentives to make needed drugs widely available and keep prices affordable.
Participants also remarked on the importance of developing standards for the quality and formulations of medicines, particularly pediatric-specific drug formulations. In a related vein, they acknowledged that counterfeiting of medicines must be prevented.
The importance of initiating and supporting change from within a country and not attempting to impose approaches or methods from outside that do not fit the local situation was emphasized. Participants also stressed the importance of evaluating drug policies and laws country by country and developing national strategies to increase access to pain medications. As one speaker pointed out, policy change will require identifying key players and stakeholders such as health ministries, tax and immigration officials, treasury departments, and so forth, and then working with them to review national health policies and related regulations.
Advocacy efforts were described and suggested. Speakers noted that effective advocacy can help change opinions, behaviors, and policy. They also suggested that international reform efforts must be better coordinated to increase the profile of the problem. They recommended that countries’ action plans be presented to the media to spread the message and increase awareness of the problem. In all these efforts, “it is important to put a human face on the issue.”
Participants spoke of the need for more assistance from international agencies, and the need to increase funding for proven strategies and their advocates. They agreed that with the assistance of donors and partner governments, there must be coordination of country-driven national responses to these problems. All groups involved must share information and knowledge to prevent an overlap of efforts.
While sustained donor investment and involvement have been catalysts for change, there was agreement that the base of donors needs to be increased. But as one speaker remarked, more donors are needed not simply as providers of money but also as voices spreading the message that pain management and palliative care are important parts of adequate public health care.
Finally, there was a consensus on the need to develop methods of evaluating program effectiveness so that governments and agencies will understand how their funding and efforts are leading to results.
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