Pain, Palliative Care

Palliative Care Clinical Guidelines: Same guidelines for the whole world?

I have just returned from the European Association of Palliative Care Congress in Lisbon, Portugal. A great meeting!!  The EAPC leadership is doing not only a great job in promoting and improving palliative care in Europe but also globally.  Approximately 3000 people attended from over 80 countries.  I was able to catch up with colleagues from many countries from outside of Europe including Malaysia, Korea, Morroco, Krygystan, India, Panama, Argentina and Australia. I have since heard from many who I did not see at the meeting!

So this globalization of Palliative Care (which I very much appreciate and endorse) creates an interesting dilemma for EAPC.  If it is to take a predominant role in this area along with the International Association for Hospice and Palliative Care and the Worldwide Palliative Care Alliance, it needs to address these global needs.

What is the impact of EAPC’s clinical guidelines process as it moves from predominantly a Western European organization to involve Central and Eastern Europe  and in fact provide leadership for Global Palliative Care. An this is not a small matter, as EAPC is involved in the Access To Opioid Medications in Europe Project which has provide support for WHO projects.  This has included a rewrite of the Achieving Balance document that was originated in Madison to the new WHO Policy Guideline Ensuring Balance in National Policies on Controlled Substances, Guidance for Availability and Accessibility for Controlled Medicines, already available in 13 languages at that site. Congratulations to Willem Scholten and his small team.

EAPC is in the process of rewriting its Use of Opioids in Cancer Pain Guidelines, using an extensive series of evidence based reviews that were presented and discussed at the Bristol Opioid Meeting in Feb, 2010.  Parts of these reviews and the guidelines that were assembled from them, were presented at a session chaired by Geoffrey Hanks.  Geoff asked that we respect that the guidelines are currently under review by a peer reviewed journal, so I am not going a address the content specifically.

My concern, which I expressed in the session, is that many of the randomized controlled trials we have in palliative care (those studies to which give the highest weighting) have in fact been sponsored by the pharmaceutical industry.  This in itself is not a bad thing but may have implications in Low and middle income countries. Let me use some of my own efforts as an example.

I am an author of the original Farrar paper studying the use of oral transmucosal fentanyl citrate in the treatment of breakthrough pain for a small pharmaceutical company.  Nothing wrong with the study, double blind, placebo controlled that was published in JNCI.  Yes the fentanyl products have now been shown over and over again to work for breakthrough pain. But where is the double blind, placebo controlled randomized study showing that immediate release morphine works for breakthrough pain.

Don’t get me wrong. I am not bashing industry studies (Conflict of Interest Statement: I still participate in some industry based studies through contracts with the University of Wisconsin, but do not participate in opioid studies due to a potential conflict that may arise in our WHO work of improving access to these medications).

My concern is the impact of these studies on guidelines that may be used globally. Can low and middle income countries afford “the current” evidence based medicine? We are struggling to improve morphine access in many countries, at the same time as we are assembling evidence that the fentanyl products are the best thing for the treatment of breakthrough pain.   Do we need to notify our readers, for the sake of transparency where guidelines are based on industry funded studies, for the sake of transparency?   Or do we need guidelines that are directed at the different health care environments?

As I often share with my patients, “No easy answers, just lots of very tough questions.”

About Pain policy & palliative care

Improving global pain relief by achieving balanced access to opioids worldwide


One thought on “Palliative Care Clinical Guidelines: Same guidelines for the whole world?

  1. For most of us that provide Paliative Care in middle and low income countries, the named “Guidelines” in some instances as opioid availability, culd become a real puzzle to solve in our clinical settings , where thanks to the Industry, and a lower than basic level of development of Palliative Care we have availability of very expensive opioid presentations, when the cheapest presentations sometimes are not even in our national lists of Essential Medicines. Our best therapeutic efforts must include not only our skills to manage pain but also our sensibility to find out which pain treatment can the patient afford and for how long. How do we use our creativity to treat pain under limited access conditions will determine our patient´s best quality of life. It is a daily challenge! providing Palliative Care following the guidelines when the patient´s resources must be optimized. I´ve been a fellow of the Pain and Policy Studies Fellowship program since 2008, thanks to that wonderful opportunity, my country has just started to leave the under cero level in Palliative Care to move forward to better access to opioid analgesics and national Palliative Care policies. Eva Duarte, Palliative Care Physician, Guatemala.

    Posted by Eva Duarte | June 18, 2011, 12:03 AM

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