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Opioids for Cancer Pain in the Middle Eastern Countries: A Physician Point of View

Daher, Michel MD, FACS*,†,‡,§

Journal of Pediatric Hematology/Oncology: April 2011 - Volume 33 - Issue - p S23–S28
doi: 10.1097/MPH.0b013e3182121a0f
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Cancer is an increasing problem in the Middle Eastern (ME) countries. It is the fourth leading cause of death in this region. At present, resources for cancer control in the ME countries as a whole are not only inadequate but directed almost exclusively to treatment. In the majority of countries of this region, cancer is generally diagnosed when it is at a relatively advanced stage. Pain is prevalent among people who have cancer, and is one of the most feared and burdensome symptoms. Pain negatively affects the quality of life of patients with cancer. Inadequate and inappropriate pain management of patients who experienced cancer pain has been documented in several studies and this is possibly due to insufficient understanding of pain assessment and management. Middle Eastern countries include a wide range of economically diverse countries, from technically advanced countries with high level cancer care to countries with little or no cancer treatment capabilities. There are large differences in population size, wealth and health expenditure. Palliative care (PC) is an urgent humanitarian need worldwide for people with cancer and other chronic fatal diseases; relieving pain and suffering is an essential part of PC. The need for improved palliative care in ME countries is great. Of 58 million people who die every year, 45 million die in developing countries. An estimated 60% (27 million) of these people in developing countries would benefit from palliative care, and this number is growing as chronic diseases such as cancer rise rapidly. From the situation analysis of palliative care in the ME countries, suggesting that pain relief is insufficient, improvements in palliative care delivery are a high priority.We reviewed the situation of pain management and pain control in Lebanon and the ME countries, the barriers that are present, and we propose the priorities and a reform for an integrated approach to address the problem of under-treated pain at all levels:

  1. Education for health undergraduates and graduates, including adult health professionals
  2. Adoption of universal pain management standards by professional bodies
  3. Promotion of legislative reform
  4. Liberalization of national policies on opioids availability
  5. Provision of affordable opioids
  6. Promotion of pain control programs in all nations, irrespective of resources
  7. Reimbursement issues for professional and facility services for pain care
  8. Continuing collaboration with the foremost international pain relief organizations and the WHO.

*Surgery, University of Balamand

Lebanese Cancer Society

Pain and Palliative Care Working Group

§Medical Ethics and Bioethics Teaching Program, University of Balamand, Saint Georges Hospital, Beirut, Lebanon

Reprints: Michel Daher, MD, FACS Professor of Surgery, University of Balamand President, Lebanese Cancer Society Chairman, Pain and Palliative Care Working Group, Lebanon Director, Medical Ethics and Bioethics Teaching Program, Univ of Balamand Saint Georges Hospital, p.o.box: 166378- Beirut, Lebanon (e-mail: mndaher@inco.com.lb).

Received January 12, 2011

Accepted January 24, 2011

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CANCER IN THE MIDDLE EASTERN COUNTRIES

Cancer is an increasing problem in the Middle Eastern (ME) countries. It is the fourth leading cause of death in this region. It is expected that deaths from cancer in these countries could reach 760.000/year by the year 2020.1,2

Although the incidence of cancer is still well below that in developed countries, the ME countries are expected to experience an increase in cancer in the coming 2 decades, attributed to many factors including population ageing and exposure to risk factors, such as smoking, unhealthy diet and physical inactivity, and environmental pollution.3,4

At present, resources for cancer control in the ME countries as a whole are not only inadequate but directed almost exclusively to treatment. The curability of cancer is directly related to its stage at the time of diagnosis, and in the majority of countries of this region, cancer is generally diagnosed when it is at a relatively advanced stage (Figs. 1,2).5–7

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

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CANCER AND PAIN

Pain is prevalent among people who have cancer, and is one of the most feared and burdensome symptoms. It is a topic of continuing interest as the recent studies on the prevalence of pain in patients with cancer showed figures that ranged from 24% to 60% in patients on active anticancer treatment and 62% to 86% in patients with advanced cancer.8–10

Pain negatively affects the quality of life of patients with cancer.11,12 Therefore, pain management is crucial to reduce the distress of patients and increase productivity and functioning.13,14

Inadequate and inappropriate pain management of patients who experienced cancer pain has been documented in several studies.15 This is possibly due to insufficient understanding of pain assessment and management. The main barriers concerning adequate cancer pain management include the knowledge and attitudes of physicians about opioids, patient reluctance to use opioids for pain relief, and lack of new interventions to improve pain severity of the patient.16–18 Moreover, pain experiences of patient with cancer are often influenced with psychological stress associated with the disease. An effective multidisciplinary approach to pain management is advocated when physicians need to work with other health care professionals.19,20

For these patients who have late stage cancer, the management of pain and other symptoms should be part of their overall treatment and the primary aim of national cancer control programmes.21,22

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DIVERSITY OF THE ME COUNTRIES

This region includes a wide range of economically diverse countries, from technically advanced countries with high-level cancer care to countries with little or no cancer treatment capabilities. There are large differences in population size, wealth, and health expenditure (Fig. 3).

FIGURE 3

FIGURE 3

The availability and quality of treatment is another factor. Cancer is not only often caught sooner, but also usually treated more successfully in some countries compared with less developed ones. The relative survival rate can be 50% or better, but in less developed countries it is only 30%.3,4 Thus, recommendations are tailored, to the extent possible, to different resource levels, both among countries and in different regions or populations within the same country.5–7

Whether we consider incidence, mortality, early detection, or treatment rates, it is clear that there exist significant opportunities to save lives and reduce suffering in the ME countries. Unfortunately, the single most important trend in cancer in these countries today (and in developing countries in general) is the growing gap between what we know and what is actually being done to reduce human suffering and to save lives. Given the impact of the late presentation problem, palliative care (PC) is of paramount importance in the ME countries.

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PALLIATIVE CARE AND OPIOIDS AVAILABILITY IN THE ME COUNTRIES

PC is an urgent humanitarian need worldwide for people with cancer and other chronic fatal diseases; it is particularly needed in places where a high proportion of patients present in advanced stages and there is little chance of cure as it is the case in most ME countries.23

Relieving pain and suffering is an essential part of PC. It reduces suffering and improves the quality of life of patients with cancer and their families through the early identification, assessment, and treatment of pain and other problems, of a physical, psychosocial, or spiritual nature.24,25

Ideally, PC services should be provided from the time of diagnosis of life-threatening illness, adapting to the increasing needs of patients with cancer and their families as the disease progresses into the terminal phase. They should also provide support to families in their bereavement.

The need for improved PC in ME countries is great. Of 58 million people who die every year, 45 million die in developing countries. An estimated 60% (27 million) of these people in developing countries would benefit from PC, and this number is growing as chronic diseases such as cancer rise rapidly.2,3,26

Today at the end of the first decade of the 21st century, the best available evidence indicates a major gap between an increasingly understanding of the pathophysiology of pain (leading to a variety of pain treatment), and widespread inadequacy of its treatment.27,28

From the situation analysis of PC in the ME countries, suggesting that pain relief is insufficient, improvements in PC delivery are a high priority.29 In reality, the ME countries suffer from the same barriers to PC as other developing regions of the world,30,31 which include:

  • (1) Restrictive policies from health care providers towards access to opioids; these are due in great part to an over-concern about drug abuse.
  • (2) Insufficient development of PC: too few PC programmes and of insufficient quality.
  • (3) Lack of awareness of the human right to pain relief and a peaceful death.

Opioids are available in all Middle Eastern countries, but in half of the countries only oncologists can prescribe narcotic analgesics. The duration of the prescription varies from 1 week to 1 month. Opioids consumption, which is a recognized surrogate marker for the quality and quantity of PC is low (between 0.2 and 1.2 mg/capita, except for Israel) compared with most industrialized countries, where it is around 50 mg per capita. These amounts are undoubtedly not meeting the needs of patients. These results suggest that access to opioids is a major issue in the ME countries, very probably because of concern about drug abuse (Fig. 4).

FIGURE 4

FIGURE 4

A situation analysis of PC and opioids consumption in these countries have been made by the International Narcotic Control Board and by the Middle Eastern Cancer Consortium through its program for promotion of PC in some ME countries.32 On the basis of these data, 3 priorities for action emerged:

  1. Ensure full access to affordable inexpensive opioids forall patients in need: This is an internationally recognized principle. Efforts to prevent drug abuse anddiversion must not interfere with ensuring the availability of opioid analgesics for legitimate pain relief. In the presence of necessarily strict regulations regarding narcotics, it is not infrequent to attempt to minimize the amount of morphine available in the country.32–34 The Pain and Policy Studies Group (aWorld Health Organization collaborating center) has developed guidelines that can be used by governments and health professionals to assess the national opioids control policies; the administration of these policies must ensure the availability of opioid analgesics.35 Countries should urgently examine their drug control policies to assess the legal and other barriers to opioid availability.
  2. Develop human resources for palliative care: Studies performed in various ME countries have shown that the most important barriers to efficient PC are the lack of knowledge in correct usage, or concern that patients may become addicted to opioids. It is recommended to incorporate the management of cancer pain into all nursing and medical school curricula in the ME countries, and that continuing education be provided to all who care, directly or indirectly, for patients with cancer. An effective approach to the provision of training in PC is to designate 1 or more institutions as training centers for palliative care, local, regional (for example King Hussein Cancer Centre in Amman or King Faisal Cancer Centre in Riyadh), or international. Health care providers should be educated about morphine use and other PC modalities.
  3. Develop home care programmes: Most patients requiring end-of-life care prefer to receive such care at home. This usually has the advantage that they are surrounded by the family members, who have an important role in care delivery.

Home care is particularly appropriate in ME countries where familial solidarity is still very strong, and has been shown to be feasible and cost-effective as in many other low-income and middle-income countries.36,37 Unfortunately at present, most patients die in hospitals despite their desire to die at home, because actual reimbursement policies currently do not support care at home. Considerable savings for the health care system could be realized if an effective coordinated home care system would be in place.38,39

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POLICY AND PAIN MANAGEMENT IN LEBANON

In Lebanon, national health and political authorities should designate improving pain management as a key objective of public health policy. It is important that individuals experiencing pain receive the best possible care to relieve their suffering. It is imperative that organized efforts on the part of all pain care providers occur at the local and state level to improve our health care policy.40,41

Several barriers to the adequate management of pain have been identified at different level: at the national policy level, in the provision of health care, and among patients themselves.

  • Barriers at the national policy level include restrictive laws and regulations limiting the medical use of narcotics, insufficient support for pain management programs by health authorities, nonrecognition of pain management activities by financing authorities, and insufficient education of health care professionals.30
  • Secondly, barriers in the provision of health services include the underassessment of the pain of the patients by health professionals, divergent perceptions of the needs of the patients among health professionals, and reluctance of the physicians to use potent analgesics and overestimation of the effectiveness of prescribed treatments.28
  • Finally, patients themselves may be reluctant to report pain or to take analgesic medications, particularly morphine. Patients actually expect to experience pain in some medical situations or consider that pain management is not a priority with respect to other components of care.31,42,43

Adoption of policies that make pain management an expectation for all physicians may make adequate relief more accessible to all people with pain. This will occur only when there are no other barriers in the health care system that will obstruct patient access to these important medications, such as the knowledge and attitudes of health care providers or restrictive reimbursement policies.

Positive policy, with no implementation of a professional training, has little chance of affecting health care practice.44,45 Therefore, balanced state policy is insufficient by itself to enhance pain management, but it is a necessary component to achieve this important objective.46

Achieving the appropriate social and medical change that will make pain management a fundamental component of health care is the next great challenge in our country. Education is an important component of our medical system, but there is no systematic approach to teach pain management at any level of training.12,40,41 Unfortunately, we should be aware that these external mandates, too often result in fragmented approaches to pain education, with each specialty offering its own approach without integrating the multidisciplinary complexity of pain and its treatment into a comprehensive curriculum. In contrast, there is a need to update knowledge of medical board members about pain management and public policy.29

Health care professionals need to engage regulators in dialog to eliminate regulatory barriers that govern the prescribing and dispensing of opioids in our country. Theyhave a professional obligation to understand the appropriate role of opioids in pain control and follow accepted guidelines when prescribing, administering, and dispensing these drugs. They also have a professional obligation to assist regulators and law enforcement personnel in identifying persons who may be involved in diverting opioids for nonmedical use.

Finally, reform will require an integrated approach to address the problem of undertreated pain at all levels:

  1. Education for health undergraduates and graduates, including adult health professionals
  2. Adoption of universal pain management standards by professional bodies
  3. Promotion of legislative reform
  4. Liberalization of national policies on opioids availability
  5. Provision of affordable opioids
  6. Promotion of pain control programs in all nations, irrespective of resources
  7. Reimbursement issues for professional and facility services for pain care
  8. Continuing collaboration with the foremost international pain relief organizations and the World Health Organization.
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CONCLUSIONS

Since the time of Hippocrates there have been 2 overall goals of medical care: cure of disease and relief from suffering. These goals are shared by the patient and health care providers.

For too long, pain and its management have been prisoners of myth, irrationality, ignorance, and cultural bias. That is why insufficient pain management is a significant public health concern in ME countries and adequate relief depends on access to a variety of treatment options.10

Pain management is now being addressed across the disciplines of medicine and law. Their respective contributions are coalescing into a coherent position in which unreasonable failure to treat pain is poor medicine and unethical practice. There is a need to promote policies, which create conditions in which human beings can bear even incurable illnesses and death in a dignified manner.47–49

Making real improvements in pain management will require the proactive efforts of many organizations, and we believe that education and discipline should be the cornerstone of efforts to improve pain management.

In ME countries, much of the progress in PC has largely been driven by the nongovernmental sector. This has resulted from an extraordinary collaboration between the state, nongovernmental organizations, health care professionals, and volunteers.

Until we can reliably and easily cure cancer, it is imperative that the principles of PC be incorporated into comprehensive cancer programs. Although much progress has been made, there remains a great deal of suffering in the lives of the patients cared for in the ME countries.29

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Keywords:

opioids; cancer pain; physicians; treatment

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