World Cancer Congress Montreal 27-30 August 2012 Joan Marston - - PowerPoint PPT Presentation

World Cancer Congress Montreal 27-30 August 2012

Joan Marston

Chief Executive www.icpcn.org.uk

Acknowledgements

WHO Dr Willem Scholten: Team Leader Access to Controlled Medications Programme of the Department of Essential Medicines and Pharmaceutical Policies In collaboration with the Departments of :

!

Chronic Diseases and Health Promotion

!

Mental Health and Substance Abuse

!

HIV

!

Essential Health Technologies

!

Child and Adolescent Health and Development

!

Guidelines Review Committee

! WHO Steering Group on Pain Treatment Guidelines ! WHO Expanded Review Panel ! WHO Expert Advisory Panel on Drug Evaluation ! WHO Guidelines Peer Review Contributors ! WHO consultants ! Expanded Review Panel

Guidelines Development Group

! Pain specialists ! Paediatric palliative care

specialists

! Pharmacists ! Researchers ! Methodologist ! Health systems professionals ! Oncology, neurology;

anaesthesiology; haematology; psychiatry; drug dependence

Huda Abu-Saad Huijer Gouhar Afshan Hendrina Albertyn Rae Bell Mariela Bertolini John Collins Henry Ddungu

• G. Allen Finley

Cleotilde H How

! Henry U. Lu ! Joan Marston ! Rajat Ray ! Carla Ripamonti ! Andrew gray ! Nicola Magrini ! Barbara Milani ! Lulu Muhe ! Willem Scholten

Donors

! Open Society Institute (Zug)

Switzerland

! International Association for

the Study of Pain

! Mayday Fund ! Ministry of Health, Welfare

and Sport (Netherlands)

! Rockefeller Foundation ! The True Colours Trust ! US Cancer Pain Relief

Committee For printing of the Guidelines

! The Diana Princess of Wales

Memorial Fund

! International Children’s

Palliative Care Network

First of three Guidelines

1. Pharmacological Treatment of Persisting Pain in Children 2. Pharmacological Treatment of Acute Pain 3. Pharmacological Treatment of Persisting Pain in Adults

! Overall Objectives of the Guidelines ! Methodology ! Content of the Guidelines Package ! Rationale for a 2- Step approach in children ! Taking the Guidelines forward

Overall Objectives

! To provide evidence-based recommendations on pain

treatment including opioid analgesics, non-opioid analgesics, and adjuvents

! To improve pain management in children – neonates,

infants and children 0-10 years experiencing persisting pain related to medical diseases

Principle regarding Pain Management

Optimal pain management may require a comprehensive approach comprising a combination of non-opioid, opioid analgesics, adjuvents and non-pharmacological strategies. A comprehensive approach is possible even in resource-limited settings

“Pain is a more

terrible lord of all mankind than death itself” Albert Schweitzer

Pharmacological Guidelines

Include Exclude

! Nociceptive pain ! Neuropathic pain ! Conditions considered but

not restricted to

! Cancer ! Major infection (eg HIV/AIDS) ! Sickle-cell disease ! Burns ! Persisting neuropathic pain

related to amputation

! Acute trauma ! Peri-operative pain ! Procedural pain ! Chronic, complex pain not

related to tissue disruption eg fibromyalgia, headache

! Non-pharmacological

interventions

! Disease –specific therapies

Exclude the role of Play

Resources Early Childhood Development in Children’s Palliative Care www.hpca.co.za Textbook of Palliative Care for Children in Africa www.icpcn.org.uk

Targeted audience is Health Care Providers in the broadest sense

! Medical practitioners ! Clinical Officers ! Nurses ! Pharmacists ! Care givers of children ! Policy-makers and Regulatory authorities ! Public Health and Programme Managers

Profiles

Pharmacological profiles of recommended medicines and

Opioid analgesics for safe opioid switching WHO Model Formulary for Children Recommendations for Health –systems issues based on published and unpublished experience in the management of pain in health systems and the guidelines group expert opinion

Content of the Guidelines

1.

Classification of Pain

2.

Evaluation of Persisting Pain in the Paediatric Population

3.

Pharmacological Treatment Strategies

4.

Improving Access to Pain Relief in Health Systems

Also included are

! Recommended Research Agenda ! Opioid Analgesics and International conventions ! Recommendations on the importance of education

Methodology

• 1. Scoping document for review

24 PICOT questions – 21 on medications, 3 on Health Systems

2.

Evidence retrieval and review

2.

Systematic reviews of Randomised Control Trials

3.

Observational studies

3. Values – high value placed on management of pain in children 4. Recommendations

• 5. Research implications

Definition of Quality of Evidence according to GRADE

HIGH – further research is unlikely to change confidence in the estimate of the effect MODERATE – further research is likely to have an important impact on confidence in the estimate of the effect and may change the estimate LOW- further research is likely to have an important impact

• n confidence in the estimate of the effect and is likely to

change the estimate VERY LOW- any estimate of effect is very uncertain

Interpretation of Strong and Weak Recommendations

Related to

" Patients and families ! Clinicians ! Policy makers

" Quality of evidence " Risks/benefits " Values and acceptability " Cost " Feasibility " Policy and Research agenda

Expert Opinion

STRONG RECOMMENDATIONS BUT LOW QUALITY EVIDENCE

Recommendations

! Indications ! Contra-indications ! Precautions ! Skilled Tasks ! Dosage

! Starting dose ! Continuation ! Breakthrough pain ! Discontinuation

! Adverse effects

! Common ! Less common ! Uncommon ! Rare

! Interactions with other medicines ! Notes ! Equianalgesic doses ! References

Principles for the pharmacological management of pain in children

Correct use of analgesic medicines will relieve pain in most children Relies on the following concepts

# Two-Step approach # Dosing at regular intervals # Using the appropriate route of administration # Adapting treatment to the individual child

2 Step Approach

1st Step – Ibuprofen; Paracetamol 2nd Step – Strong Opioid (Morphine recommended) “The risks associated with strong opioids as the second step are acceptable when compared with the uncertainty associated with responses to codeine and tramadol in children”

Recommendations on Opioid-usage

“Start Low and Go Slow” Pain should always be treated when the cause of pain is not addressed, supported by medical evaluation and adequate monitoring

Recommendations

Dosages recommended around 50% of those normally considered Titration based on regular assessment Up-to-date pain education including risk management Opioid analgesics are intended to be used within functioning Health Systems

Questions around Diversion and Addiction

Addendum to address this in process of finalisation Group believes that treating pain effectively is first priority Diversion is a separate issue and very rare in this age group

We have the guidelines

And now ?

Present status of the Guidelines

! Published on the WHO website

http://www.who.int/medicines/areas/ quality_safetyaccess_contr_Med/en/index.html

! For printing in English ! Assessment of evidence on diversion and over-

consumption for an Addendum to the Guidelines

! Research Agenda – ICPCN appointed to co-ordinate the

research

Guideline Package

1.

Guidelines

2.

Brochures for

Physicians and Nurses Pharmacists Policy makers and Regulatory Authorities, Hospital managers and Health Insurers

• 3. Pain Scales for Assessment
• 4. Wall Chart

Research Agenda – 4 groups of priorities

First Priorities

! Assessment of two-step treatment strategy ! Alternative opioids to morphine ! Intermediate potency opioid analgesics (eg Tramadol) ! Long-term safety data concerning 1st step medicines

(ibuprofen, paracetamol)

E-Learning module –www.icpcn.org.uk

Includes Clinical Placement Guidelines

Human Rights Approach and Submissions

! “to leave a person in avoidable pain and suffering should be

regarded as a serious breach of fundamental human rights” Somerville 1995

! “the relief of severe, unrelenting pain would come at the top of

a list of basic human rights.” Cousins 1999

Dissemination , Translation and Advocacy

www.icpcn.org.uk