Improving Palliative Care: through an advocacy agenda! Jim Cleary, MBBS FAChPM ! ! Associate Professor of Medicine (Medical Oncology) ! University of Wisconsin School of Medicine & Public Health ! Palliative Care Physician ! UW Hospital & Clinics ! Program Director, Non Communicable Diseases ! UW Global Health Institute ! Director, WHO Collaborating Center for Pain Policy and Palliative Care ! UW Carbone Cancer Center ! Madison, Wiscons in ! ! Twitter: @jfclearywisc ! Email: jfcleary@wisc.edu ! Blog: http://painpolicy.wordpress.com ! Website: http://www.painpolicy.wisc.edu !
Palliative Care as a model! • Uganda serves as a brilliant model, like Wisconsin and Catalonia, for the importance of an integrated government and community non-governmental approach. Each one by themselves in isolation, will not achieve much. Oxford Textbook of Palliative Medicine, 3rd Edition • “You can have morphine without palliative care but can’t have palliative care without morphine!”
The First Home for the Dying: Lyon 1842 Lyon ! Paris ! NY ! 2000 ! 1900 ! 1950 ! 1850 ! 1842: ! Jeanne Garnier, a widow ! ! Founder of the Women of Calvary !! ! ! “ I started my hospice with 50 Francs; ! ! …………..providence did the rest. ” ! A house for patients at the end of the lifetime ! An image, too often unhoped-for, which bring comfort, ! a start of happiness in the medium of the suffering. ! A house where one speaks again of the life, ! even if is also there to die . ! 1875: ! Paris ! 1899: ! Calvary Hospice, New York !
Establishes a Framework to: 1. Prevent abuse and diversion, and 2. Ensure the availability of drugs for medical purposes
“ the medical use of narcotic drugs continues to be indispensable for the relief of pain and suffering… adequate provision must be made to ensure the availability of narcotic drugs for such purposes. ” ( Preamble , p. 13) !
Cecily Saunders Lyon ! Paris ! Chicago ! NY ! Saunders ! Nottingham Adelaide ! 1950 ! 2000 ! 1850 ! Sydney ! London ! Nurse Social Worker Physician 1957: St Joseph � s Hospice Documented use of regular morphine at St Luke � s St Christopher’s Hospice
Clinical Training !
Canada: The birth of Palliative Care Lyon ! Paris ! Chicago ! NY ! Saunders ! St Christopher ’ s ! Cork ! 2000 ! Canada ! Adelaide ! 1950 ! Nottingham ! 1850 ! Dublin ! Sydney ! London ! Balfour Mount MD ! Uro-oncologist: visited St Christopher ’ s ! 1975: Palliative Care Service ! ! Royal Victoria Hospital, Montreal ! ! “ Hospice ” in French means “ poor house ” ! ! “ Although these are the sickest people in our health care system, when medical technology doesn't know what to do, the quality and quantity of care falls away. How can we justify that?" !
Evidence? ! Advocacy TOOL! !
Wisconsin Cancer Pain Initiative • Dahl, PhD (Professor of Pharmacology) • Joranson, MSW (WI Controlled Substances Board) – 1970s: Heroin for pain relief • US based: 1986 – WHO Demonstration Project. – Role Model Initiative. – Education • Wisconsin Pain Initiative – Alliance of State Pain Initiatives.
“ Balance ” is the Fundamental Principle ! National policy should establish a drug control system that prevents diversion and ensures adequate availability for medical use Drug control measures should not interfere with medical access to opioid
WHO: Cancer Pain Relief ! 1986 ! 1996 !
Pain and Policy Study Group • 1996: Pain and Policy Study Group – National – International • WHO Collaborating Center for Pain Policy & Palliative Care – Cancer Control – Access to Controlled Medications Program • Close Ties with INCB – Opioid Consumption Data – Model Laws – Estimates Process
Achieving Balance in National Opioids Control Policy: Guidelines for Assessment (2000) ! ! For governments and health professionals ! Explains need, rationale and imperative ! 16 criteria ! Simplified Checklist ! 22 Languages 21 !
WHO Public Health Model __________________________ Educ Education tion Drug ug Availa ilability bility Workshops ! ! SE Asia (Philippines) ! ! ! Africa (Entebbe) ! ! ! Europe (Budapest) ! ! Polic olicy y
Consumption of Morphine 1980 - 2003 East vs. West Europe (mg/capita/yr) 25 mg/capita ! 20 Western Europe Eastern Europe 15 10 5 0 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 8 8 8 8 8 8 8 8 8 8 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 2 2 2 2
Joranson, ! Lancet 2006 ! World Health Organization Collaborating Center " for Pain Policy and ! Palliative Care !
2006 International Pain Policy Fellowship ! Dr. Simbo Daisy " Dr. Henry Ddungu ! Uganda/APCA ! Amanor-Boadu ! Nigeria ! Dr. Jorge Eisenchlas ! Prof. Sne ž ana Bo š njak ! Argentina ! Serbia ! Prof. Rosa Buitrago ! Dr. Marta Ximena León Republic of Panama ! Colombia ! Mrs. Nguyen Thi " Mr. Gabriel Madiye ! Sierra Leone ! Phuong Cham ! Vietnam ! Pain & Policy Studies Group ! Supported by the ! University of Wisconsin ! Open Society Institute ! October 2006 Madison, Wisconsin !
Essential Medicines !" 16th edition (updated) 2010 " WHO Model List ! 2. ANALGESICS, ANTIPYRETICS, NON-STEROIDAL ANTI-INFLAMMATORY MEDICINES (NSAIMs), MEDICINES USED TO TREAT GOUT AND DISEASE MODIFYING AGENTS IN RHEUMATOID DISORDERS (DMARDs) 2.1 Non-opioids and non-steroidal anti-inflammatory medicines (NSAIMs) ! acetylsalicylic acid ! Suppository: 50 mg to 150 mg. Tablet: 100 mg to 500 mg. ! Ibuprofen ! ! Tablet: 200 mg; 400 mg. >3 months. paracetamol* ! Oral liquid: 125 mg/5 ml. Suppository: 100 mg. Tablet: 100 mg to 500 mg. ! ! ! * Not recommended for anti - inflammatory use due to lack of proven benefit to that effect. ! ! ! 2.2 Opioid analgesics ! Codeine ! ! Tablet: 15 mg (phosphate); 30 mg (phosphate). ! ! Morphine ! ! Injection: 10 mg (morphine hydrochloride or morphine sulfate) in 1 - ml ampoule. ! ! ! Oral liquid: 10 mg (morphine hydrochloride or morphine sulfate)/5 ml. ! ! ! Tablet: 10 mg (morphine sulfate). ! ! ! Tablet (prolonged release): 10 mg; 30 mg; 60 mg (morphine sulfate) !
International Association of Hospice and Palliative Care " List of Essential Medicines for Palliative Care ! (http://www.hospicecare.com/resources/pdf-docs/iahpc-list-em.pdf) ! ! ! Codeine ! ! Fentanyl, ! Morphine Manifesto ! ! Methadone, ! ! Morphine (immediate and sustained release), ! ! Oxycodone, ! ! Tramadol ! NOTE: NO GOVERNMENT SHOULD APPROVE MODIFIED RELEASE MORPHINE, FENTANYL OR OXYCODONE ! WITHOUT ALSO GUARANTEEING WIDELY AVAILABLE NORMAL RELEASE ORAL MORPHINE. !
Global Consumption of Morphine High-Income vs. Low - and Middle - Income Countries, 2008 Population Consumption of Morphine Percent total 100 90 80 91% 70 83% 60 50 40 30 20 10 17% 9% 0 High Income (48) Low- and Middle-Income (102) Source: International Narcotics Control Board; United Nations Population Data, 2007; World Bank Income Classification, 2008. By: Pain & Policy Studies Group, University of Wisconsin /WHO Collaborating Center, 2010.
Global Trend 1980 - 2008 ! 10000 9000 Morphine ME Total ME 8000 7000 6000 5000 4000 3000 2000 1000 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Source: International Narcotics Control Board By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2010
Total ME: High Income vs. Low and Middle Income Countries ! 9000 8000 High Income LMICs Global Total 7000 6000 5000 4000 3000 2000 1000 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Source: International Narcotics Control Board By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2010
7 Morphine
Cancer Control ! Prevention ! Early ! Palliation ! 1 / 3 ! Prevention ! Detection ! 1 / 3 ! Treatment ! 1 / 3 ! Palliative Care ! Early ! Treatment !
• Measurement • Sustainable delivery systems • Tobacco, obesity, alcohol • Vaccination (HBV, HPV) • Dispel myths about cancer 2020 Targets • Screening & early detection • Effective pain control • Training opportunities • Reduce health emigration • Improve cancer survival for all.
× Liberia:(( × × × 3(kg( Government(or(wholesaler(places( Competent(authority(submits( INCB(confirms(morphine(quan2ty( order(with(registered(supplier( annual(na2onal(morphine(es2mate((( What does it × × take to get X access to Pa2ent(receives(monitoring(and( followBup( Product(delivered(to(central( medical(stores( pain relief? × × × Clinician(asks(about(pain( Distributed(to(district(medical( Pa2ent(fills(prescrip2on( stores( × ! × × Pa2ent(reports(pain( Clinician(writes( Distributed(to(facility( prescrip2on(
WHO Public Health Model __________________________ Drug ug Educ Education tion Availa ilability bility Polic olicy y
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