Improving Palliative Care: through an advocacy agenda! Jim Cleary, - - PowerPoint PPT Presentation

▶
improving palliative care
SMART_READER_LITE
LIVE PREVIEW

Improving Palliative Care: through an advocacy agenda! Jim Cleary, - - PowerPoint PPT Presentation

Jan 22, 2023 13 likes •649 views

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 &

slide-1
SLIDE 1

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, Wisconsin!

!

Twitter: @jfclearywisc!

Email: jfcleary@wisc.edu! Blog: http://painpolicy.wordpress.com! Website: http://www.painpolicy.wisc.edu!

slide-2
SLIDE 2

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!”

slide-3
SLIDE 3

The First Home for the Dying: Lyon 1842

1842:!Jeanne Garnier, a widow! !Founder of the Women of Calvary !! ! !“I started my hospice with 50 Francs; ! !…………..providence did the rest.”!

1850! 1950! 2000!

Lyon! NY ! Paris!

1900!

1875: !Paris! 1899: !Calvary Hospice, New York!

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.!

slide-4
SLIDE 4
slide-5
SLIDE 5

Establishes a Framework to:

  • 1. Prevent abuse and

diversion, and

  • 2. Ensure the

availability of drugs for medical purposes

slide-6
SLIDE 6

“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)!
slide-7
SLIDE 7
slide-8
SLIDE 8

Cecily Saunders

1850! 1950! 2000!

Lyon! Saunders! NY ! Paris! London! Adelaide! Nottingham Sydney! Chicago !

Nurse Social Worker Physician 1957: St Josephs Hospice Documented use of regular morphine at St Lukes St Christopher’s Hospice

slide-9
SLIDE 9

Clinical Training!

slide-10
SLIDE 10

Canada: The birth of Palliative Care

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?" !

1850! 1950! 2000!

Lyon! Saunders! NY ! Paris! St Christopher’s! Canada! Dublin! London! Adelaide! Nottingham! Sydney! Chicago ! Cork!

slide-11
SLIDE 11
slide-12
SLIDE 12
slide-13
SLIDE 13

Evidence?! Advocacy TOOL!!

slide-14
SLIDE 14

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.

slide-15
SLIDE 15

“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

slide-16
SLIDE 16
slide-17
SLIDE 17
slide-18
SLIDE 18

WHO: Cancer Pain Relief!

1986! 1996!

slide-19
SLIDE 19

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

slide-20
SLIDE 20
slide-21
SLIDE 21

! For governments and health professionals ! Explains need, rationale and imperative ! 16 criteria ! Simplified Checklist ! 22 Languages

Achieving Balance in National Opioids Control Policy: Guidelines for Assessment (2000)!

21!

slide-22
SLIDE 22
slide-23
SLIDE 23

WHO Public Health Model __________________________

Drug ug Availa ilability bility Educ Education tion Polic

  • licy

y Workshops! !SE Asia (Philippines)! ! !Africa (Entebbe)! ! !Europe (Budapest)! !

slide-24
SLIDE 24

Consumption of Morphine 1980 - 2003 East vs. West Europe (mg/capita/yr)

5 10 15 20 25

8 8 1 8 2 8 3 8 4 8 5 8 6 8 7 8 8 8 9 9 9 1 9 2 9 3 9 4 9 5 9 6 9 7 9 8 9 9 2 2 1 2 2 2 3

Western Europe Eastern Europe

mg/capita!

slide-25
SLIDE 25

Joranson, ! Lancet 2006! World Health Organization Collaborating Center" for Pain Policy and ! Palliative Care!

slide-26
SLIDE 26

2006 International Pain Policy Fellowship!

Pain & Policy Studies Group! University of Wisconsin! October 2006 Madison, Wisconsin! Supported by the ! Open Society Institute!

  • Dr. Simbo Daisy "

Amanor-Boadu!

Nigeria!

  • Prof. Snežana Bošnjak!

Serbia!

  • Prof. Rosa Buitrago!

Republic of Panama!

  • Mrs. Nguyen Thi "

Phuong Cham!

Vietnam!

  • Dr. Henry Ddungu!

Uganda/APCA!

  • Dr. Jorge Eisenchlas !

Argentina!

  • Mr. Gabriel Madiye !

Sierra Leone!

  • Dr. Marta Ximena León

Colombia!

slide-27
SLIDE 27

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)!

slide-28
SLIDE 28
slide-29
SLIDE 29

! Codeine ! ! Fentanyl, ! ! 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.!

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)! !

Morphine Manifesto!

slide-30
SLIDE 30

10 20 30 40 50 60 70 80 90 100

High Income (48) Low- and Middle-Income (102)

Population Consumption of Morphine

Global Consumption of Morphine High-Income vs. Low - and Middle - Income Countries, 2008

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.

Percent total

17% 91% 83% 9%

slide-31
SLIDE 31 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 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 Morphine ME Total ME

Global Trend 1980 - 2008!

Source: International Narcotics Control Board By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2010

slide-32
SLIDE 32 1000 2000 3000 4000 5000 6000 7000 8000 9000 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 High Income LMICs Global Total

Total ME: High Income vs. Low and Middle Income Countries!

Source: International Narcotics Control Board By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2010

slide-33
SLIDE 33

7 Morphine

slide-34
SLIDE 34
slide-35
SLIDE 35
slide-36
SLIDE 36
slide-37
SLIDE 37

Early ! Detection! Prevention! Palliation! Early ! Treatment! Cancer Control!

1/3

!Prevention!

1/3

!Treatment!

1/3

!Palliative Care!

slide-38
SLIDE 38

2020 Targets

  • Measurement
  • Sustainable delivery systems
  • Tobacco, obesity, alcohol
  • Vaccination (HBV, HPV)
  • Dispel myths about cancer
  • Screening & early detection
  • Effective pain control
  • Training opportunities
  • Reduce health emigration
  • Improve cancer survival for all.
slide-39
SLIDE 39
slide-40
SLIDE 40

Competent(authority(submits( annual(na2onal(morphine(es2mate((( INCB(confirms(morphine(quan2ty( Government(or(wholesaler(places(

  • rder(with(registered(supplier(

Product(delivered(to(central( medical(stores( Distributed(to(district(medical( stores( Distributed(to(facility( Clinician(asks(about(pain( Pa2ent(reports(pain( Clinician(writes( prescrip2on( Pa2ent(fills(prescrip2on( Pa2ent(receives(monitoring(and( followBup(

Liberia:(( 3(kg(

What does it take to get access to pain relief?

× × × × × × ×! × × × × ×

X

slide-41
SLIDE 41

WHO Public Health Model __________________________

Drug ug Availa ilability bility Educ Education tion Polic

  • licy

y

slide-42
SLIDE 42
  • Dr. Hrant Karapetyan
  • Dr. Irina Kazaryan

Armenia

  • Dr. Pati Dzotsenidze
  • Mr. Mikheil Pavliashvili

Georgia

  • Dr. Eva Rossina Duarte Juárez
  • Lic. Ana Lucía Espigares

Guatemala

  • Dr. Dingle Spence
  • Mrs. Verna Edwards

Jamaica

  • Dr. Zippy Ali
  • Dr. Jacinta Wasike

Kenya

  • Dr. Adrian Belîi

Republic of Moldova

2008 International Pain Policy Fellowship!

Pain & Policy Studies Group! University of Wisconsin! June 2008, Madison, Wisconsin! Supported by the ! Open Society Institute!

  • Dr. Bishnu Dutta Paudel!
  • Mr. Radha Raman Prasad Teli!

Nepal!

slide-43
SLIDE 43
slide-44
SLIDE 44

Codeine Propox HC/DHC BuprPO BuprTD MoIR MoCR MoInj OcIR OcCR

  • Methad. FentTD

FentTM HmIR HmCR PethInj

Finland France Norway Austria Portugal Italy Denmark Israel Netherlands Cyprus Greece Germany Luxemburg Spain Switzerland UK Belgium Iceland Turkey Free <25% Cost 25-50% Cost 50-75% Cost 100% cost

Opioid availability and cost: West Europe

slide-45
SLIDE 45

Codeine Propox HC/DHC BuprPO BuprTD MoIR MoCR MoInj OcIR OcCR

  • Methad. FentTD FentTM HmIR

HmCR PethInj Czech R. Croatia Latvia Rumania Slovak R. Hungary Estonia Serbia Bulgaria Moldova Poland Russia Monten. Maced. Bosnia-H Lithuania Belarus Albania Georgia Ukraine Free <25% Cost 25-50% Cost 50-75% cost 100% cost

Opioid availability and cost: Eastern Europe!

slide-46
SLIDE 46

Quality of Dying

slide-47
SLIDE 47

Quality of Dying

slide-48
SLIDE 48
slide-49
SLIDE 49
slide-50
SLIDE 50
slide-51
SLIDE 51
slide-52
SLIDE 52

27.5! 1274!

slide-53
SLIDE 53
slide-54
SLIDE 54

The Times of India! Aug 28, 2012!

slide-55
SLIDE 55

2012 PPSG International Pain Policy Fellowship (IPPF)

Supported by – Open Society Institute IPCI: 2006- – US Cancer Pain Relief Committee: 2006- – Livestrong: » 2010-

slide-56
SLIDE 56

The Times of India! Aug 28, 2012!

slide-57
SLIDE 57

"We must not only stop the harm caused by drugs: let's unleash the capacity of drugs to do good. " You think this is a radical idea? Look back to the origins of drug control. The Preamble of the Single Convention recognizes that … the medical use of narcotic drugs continues to be indispensable for the relief of pain… This is hardly the language of a prohibitionist regime. Indeed, this noble goal of UN drug policy, the freedom from physical pain, demonstrates our over-riding commitment to health."

Antonio Costa, Exec Director, " UN Office on Drugs and Crime (UNODC) " March 2010

!

slide-58
SLIDE 58

Noncommunicable diseases: Heart disease 30.2% Cancer 15.7% Diabetes 1.9% Other chronic diseases 15.7% Infectious diseases: HIV/AIDS 4.9% Tuberculosis 2.4% Malaria 1.5% Other Infectious Diseases 20.9% Injuries 9.3%

Total: 58.2M

Deaths by cause in the world (2005)

(WHO, Chronic Disease Report, 2005)

slide-59
SLIDE 59

Noncommunicable Diseases (NCDs)

  • Responsible for up to 60% of all deaths,
  • 80% are in low- and middle-income countries
  • Major non-communicable diseases:

– Cardiovascular disease – Cancer – Chronic Respiratory disease – Diabetes

  • Shared preventable risk factors:

– Tobacco use – Unhealthy diet – Physical inactivity – Harmful use of alcohol

Chronic ! Respiratory! Diseases! Cardiovascular! Disease!

Diabetes! Cancer!

  • Physical

inactivity! Obesity!

Unhealthy! diets !

Smoking!

Harmful use

  • f alcohol!

Other NCDs!

slide-60
SLIDE 60

2005 2006-2015 (cumulative) Geographical regions (WHO classification) Total deaths (millions) NCD deaths (millions) NCD deaths (millions ) Trend: Death from infectious disease Trend: Death from NCD Africa 10.8 2.5 28 +6% +27% Americas 6.2 4.8 53

  • 8%

+17% Eastern Mediterranean 4.3 2.2 25

  • 10%

+25% Europe 9.8 8.5 88 +7% +4% South-East Asia 14.7 8.0 89

  • 16%

+21% Western Pacific 12.4 9.7 105 +1 +20% Total 58.2 35.7 388

  • 3%

+17%

Noncommunicable diseases (2006-2015)

WHO projects that over the next 10 years, the largest increase in deaths from cardiovascular disease, cancer, respiratory disease and diabetes will occur in low- and middle-income countries.

(WHO, Chronic Disease Report, 2005)

slide-61
SLIDE 61

United Nations general assembly on non- communicable diseases (NCD)

  • For the first time ever, the United Nations

General Assembly held a Non-communicable Disease (NCD) Summit involving Heads of State, in September 2011, to address the threat posed by NCDs to low- & middle-income countries (LMICs).

  • World Heart Federation
  • International Diabetes Federation (IDF)
  • International Union Against Cancer (UICC)
  • the International Union Against Tuberculosis

and Lung Disease

slide-62
SLIDE 62

Where has it lead?

  • NCD Strategy/Global Monitoring Framework on NCDs.

– Palliative Care Indicator. – Opioid consumption (minus methadone)/cancer death – Opioid Consumption/capita

  • World Health Assembly 2013

– Inclusion on agenda

slide-63
SLIDE 63

Establishes a Framework to:

  • 1. Prevent abuse and

diversion, and

  • 2. Ensure the

availability of drugs for medical purposes