There were 52 delegates representing policy makers, palliative care services, pain clinics in public hospitals, harm reduction units and non-governmental patient organizations. The ATOME project was represented by experts from the ATOME team and from the Greece country team.
The scene of the symposium was set by the coordinator of the ATOME project, Prof. Lukas Radbruch, and the participants were welcomed by the Greek Secretary of Crime Policy of the Ministry of Justice, Transparency and Human Rights, Mr Marinos Skandamis.
Opioid availability: Greece in international comparison
The representatives of the World Health Organization and the International Observatory of End of Life Care presented the global state of the opioid consumption in 2010. Notably, among 152 countries Greece ranks 100th for morphine consumption and 16th for fentanyl, which is a much more expensive opioid but it is commercially available in Greece.
This is just one of several indicators of the unbalanced and inadequate range of opioid medicines available in Greece.
Dr Pirona from the European Monitoring Center of Drugs and Drug Addiction reported that there has been a considerable increase in opioid substitution treatment in Europe since 1993. However, he noted that large variability exists in the coverage between European Countries. For example, in Greece there is less than 40% coverage of availability of substitution treatment. This means that, in Greece, almost 60% of problem opioid users are in no kind of treatment.
Also, waiting times are rather high in Greece with an average of more than six months waiting time, which is longer than in most other Western European countries.
Historically, cases were even reported where patients had to wait up to seven years. Furthermore, there has recently been a worrisome increase in new HIV infections in Greece.
The President of the Greek Organization Against Drugs (OKANA), Assoc. Prof. Melpomeni Malliori, outlined the recent expansion of the organization’s activities.
During 2011 the number of substitution clinics led by OKANA increased to more than 50 around the country, thus decreasing the waiting lists to two months in Thessaloniki area and three instead of seven years in the Athens Metropolitan area.
She also presented the barriers and the continuing efforts to develop more units, according to the organization’s action plan.
Representatives from the medical community illustrated the paucity of palliative care services for adults, teenagers and children in Greece and presented case studies of successful pain control in a cancer patient and effective substitution therapy in a drug user.
The legal situation in Greece
Dr Spiridon Karanikolas, Legal Advisor at the Ministry of Justice, Transparency and Human Rights, introduced the national strategic action plan that had been worked out during a previous workshop within the ATOME project.
Five key objectives had been identified, among them amendments to the Greek controlled substances legislation, education and harm reduction issues.
Assoc. Prof. E Argyra thoroughly commented on the Greek Code of Narcotics 3459/2006 and outlined the major barriers as follows: “Legislation in Greece is mostly concerned with abuse and fear of opioid dependence, being a criminalization model rather than a public-health model to facilitate care and reduce harm. Our legislation is adding to the stigma of illegality to those in need of opioids.”
She also mentioned the difficulties physicians encounter in pain control due to the limited number of opioids available in the country and the ineffective control system of the availability of licensed drugs.
Marjolein Vranken, lawyer and pharmacist at Utrecht University, confirmed this with the results of the legislation analysis that had been done as part of the ATOME project. Major barriers had been identified in the areas of prescribing, dispensing, and use of stigmatizing language in the Greek legislation.
During the legislation working group in the afternoon there was a lively discussion and delegates agreed to propose changes in the new legislation of controlled substances. In formulating their proposal, they considered the WHO policy guidelines ‘Ensuring balance in national policies on controlled substances’ and the report on legal barriers identified by the team from Utrecht University.
Representatives from patients’ organizations supported the reforms that were suggested by the healthcare professionals.
Commitment, strategy and action
In the afternoon, delegates worked on national strategies and actions to be taken in the near future in order to improve access to opioid medication. Next to legislation, the topics of the working groups were education and harm reduction.
In the education working group, delegates acknowledged barriers such as lack of a palliative care curriculum at undergraduate and postgraduate level in the Schools of Medicine in Greece. Raising awareness and the implementation of treatment guidelines for the correct use of opioids in palliative care emerged as necessary changes. Education of patients and the general public in order to minimize opiophobia were also discussed.
The harm reduction working group delegates were debriefed about opioid substitution therapies and the available programs caring for approximately 8,000 out of 40,000 estimated drug users in Greece.
Next to shortcomings in treatment coverage, risks of diversion, particularly fentanyl diversion, were analyzed and commented due to relevant recent unlucky events in Greece. Lack of systematic controlled destruction of used or intact outdated products were discussed in this context.
The Greek ATOME team has worked systematically in collaboration with the ATOME organizers in order to select, inform and persuade delegates from various fields in palliative care and harm reduction in Greece to participation in the meeting.
Participants accepted the opportunity to communicate and discuss common problems with colleagues with enthusiasm. Dr Willem Scholten from the World Health Organization closed this intensive day by emphasizing the importance of communicating the outcomes of this conference to journals, to the general public, and to have the recommendations adopted by relevant professional associations: “If you keep it a secret what happened here today – nothing will change,” Dr Scholten said.
He further informed the delegates that recommendations will be prepared by the ATOME team at the end of the project in 2014 and communicated to the governments of the 12 countries involved.
The conference delegates agreed to continue collaborating and to form a network of scientific societies, academic institutions and palliative care services. With joint forces, they are determined to promote palliative care in Greece, starting with the legislation reform.