It is 430 am here in Hong Kong. I am awake. Jet Lag.
I am attending the 3rd Asian Oncology Summit hosted by Lancet Oncology and Elsevier. They are featuring a number of sessions on Palliative Care and Supportive Oncology at this meeting.
Meg O’Brien, Director of UICC’s Global Access to Pain Relief Initiative (GAPRI) gave an excellent address on the Asian cancer pain relief situation. Up to 70 million people/year may be experiencing untreated severe pain at the end of life in Asia alone. She followed Dr Judith Mackay, a Hong Kong physician, who is doing incredible work with the World Lung Foundation on Tobacco control. Judith addressed the broad question of cancer control with some focus on tobacco but she did stress the importance of palliative care in Cancer control programs. Cancer is and will continue to be a growing problem in Asia along with the other Non Communicable Diseases.
Judith and I had met here in Southern China last year at the UICC Cancer Congress. While Judith gave a plenary to the 3000 attendees on Tobacco Control, I had the honor and privilege of sharing a Palliative Care plenary with Kathy Foley. Judith reminded me of that today, when at question time, she recalled a simple question I had asked at the plenary session, that included some 1500 Chinese delegates.
“How many of you, if diagnosed with an advanced cancer, would want access to opioids for the treatment of cancer pain?” I raised my hand from the podium to show I was looking for a response.
3000 hands were raised. OK I didn’t count but I could only see a sea of hands across the cavernous hall.
Judith’s hand was raised in August and she said today that is when cancer pain relief got personal. If she is faced with an advanced cancer diagnosis, she wants access to opioids for pain relief. Pain from cancer is a fear that many people share around the world. Livestrong has found in interviews in numerous countries that consistently people are concerned about two things: the stigma associated with cancer and fear of cancer pain. Doug Ulman CEO of Livestrong, had his hand up, as did John Seffrin and Otis Brawley of the American Cancer Society and David Hill and Carey Adams of the UICC to name just few.
I had first asked this question when working in Romania with Dr Daniela Mosiou and colleagues to address the barriers to opioid availability in Romania. As part of bringing about major changes in their laws (a Lancet publication), we were asked to address a meeting of 100 stakeholders at the Romanian Parliament. Deans of Medical, Nursing and Pharmacy Schools were there as were representatives of the ministry of health, professional medical organizations, continuing medical education and licensing professionals, cancer organizations, hospice, the parliament and even the drug police. Due to a delay in starting and the fact that we did not have simultaneous translation, we had fallen behind schedule. With only 5 minutes before the scheduled coffee break I was asked to delay my talk. I indicated to the chair that would rather not. My Wisconsin colleagues, Dave Joranson and Paul Hutson had in fact covered much of what I wanted to say. I only needed 5 minutes.
After some opening niceties about needing coffee and getting back on schedule, I said I would shorten my comments and simply ask a question.
“How many of you, if diagnosed with an advanced cancer, would want access to opioids for the treatment of cancer pain.”
As I waited for the translation, I kept my hand raised and allowed my eyes to circle the room. All hands went up progressively around the circle until even the drug police to my immediate right had their’s raised.
“Then, why are we denying the people of Romania access to opioids for pain relief?”
Romanians are no longer denied access to opioids for pain relief. That is not to say that everyone who needs them is getting them. This is a long process, bringing about adoption of new practices in medicine. But this concept of access to opioids for pain relief is not a new one. As Meg O’Brien, indicated today, morphine is a 200 year old drug, the use of which still seems novel, despite the he 1961 UN Single Convention on Narcotic drugs that established 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, page 13).
The Pain and Policy Studies group has been about ensuring the availability of narcotic drugs for the relief of pain and suffering. We do not make decisions on what is the appropriate medical purpose. Yes, we participate on guideline panels and committees of organizations such as WHO, ASCO, ACS, the International Association for the Study of Pain, UICC, the International Association of Hospice and Palliative Care, EAPC, the American Pain Society, the American Geriatric Society, to bring the “concept of Balance” to the table. Dave Joranson took this “concept of balance” from PPSG to the WHO and the second edition has just been released by the WHO, under the leadership of Willem Scholten, and endorsed by the International Narcotic Control Board: http://www.who.int/medicines/areas/quality_safety/guide_nocp_sanend/en/index.html
We have to both prevent abuse and diversion while ensuring availability for medical purposes. We need to use evidenced based means to both assess, report and prevent abuse and diversion of opioids and to make decisions as to what are the appropriate medical purposes. Should opioids be only be limited to those with advanced cancer? What about those immediately post surgery, those who are have chronic arthritis, and those with pain from HIV and other life limiting situations. What about my mother, who as a hospice nurse brought the concept of oral morphine back to South Australia from St Christopher’s, who now has significant and debilitating pain from spinal stenosis?
Yes, Judith, this is personal for me, too. Like you , I want ready access to opioids when I am faced with an advanced cancer diagnosis. I want this for me, my wife and my children and I want it for my mother, even though she doesn’t have cancer.
And I am sure it is personal for the millions around the world who are suffering from pain and have no access to pain relief.