Last month, the World Health Assembly passed the resolution: WHA67.19 ‘Strengthening of palliative care as a component of comprehensive care throughout the life course’.
One of the items in the resolution addresses access to essential pain medicines and “urges member states to review and, where appropriate, revise national and local legislation and policies for controlled medicines, using WHO policy guidance to improve access and rational use of pain management medicines, in line with the United Nations international drug control conventions.”
Liz Gwyther and Zodwa Sithole met with Dr Naidoo, President of the INCB, to discuss issues of access to opioid medication and how the UN treaties promote availability of opioids. Dr Naidoo is an internationally recognised addiction medicine professional who is a Founder member of the International Society of Addiction Medicine. He founded the Jullo centre for addiction treatment and recently established the Jullo Foundation.
In the meeting this week, Dr Naidoo explained that INCB are planning a high level review and an update of the report on opioid availability for the United Nations general Assembly UNGASS meeting in 2016. The INCB report on the Availability of Internationally Controlled Drugs published in 2010 reported that “Africa has continued to be the region with the lowest levels of consumption for opioid analgesics. South Africa currently has the highest consumption level for opioid analgesics in the region, averaging 600 S-DDD per million inhabitants per day. (S-DDD are defined daily doses for statistical purposes). In six countries in the region (Cameroon, Chad, Mali, Nigeria, Rwanda and United Republic of Tanzania), average consumption of opioid analgesics amounted to less than 1 S-DDD per million inhabitants per day. No consumption of opioid analgesics was reported by the Central African Republic, the Congo, Djibouti, Equatorial Guinea, the Gambia, Guinea, Guinea-Bissau, Liberia, Somalia or Swaziland.” We look forward to the update in 2016 to see an improvement in access to pain medication in Africa.
When asked if INCB could set up technical assistance programmes for countries with low or no access to morphine or other opioid medications, Dr Naidoo explained that INCB is not a technical assistance body but a quasi-legal body so does not have the mandate to set up technical assistance programmes. The INCB secretariat can provide assistance/cooperation in the areas of regulatory control, estimates, etc. The main problem with regard to technical assistance is shortage of human and financial resources for that purpose. However, INCB does distribute information and draw countries’ attention to low usage through missions to countries. INCB promote availability of opioid medicines as WHO Essential Medicine but there is sometimes misunderstanding by governments of the role of INCB. INCB conducts regular missions to countries and highlights ensuring availability and accessibility in countries with low S-DDDs in addition to training professionals on rational prescribing of pain medication for palliative care. INCB reports do recommend attention to issues of availability for medical & scientific use.
INCB wishes to draw the attention of state parties to the various tools and methodologies made available by the INCB to estimate consumption of opioids and other substances, such as the Guide on Estimating Requirements for Substances under International Control. Dr Naidoo comments that countries need to become familiar with guidelines regarding accessibility; that countries need to pay attention to appropriate medical education for pain control, oncology care and also addiction treatment. He is concerned that universities curricula no not provide adequate training for prescribers so that doctors are over-cautious in prescribing thus in effect denying treatment.
Dr Naidoo has specifically taken note of our request to ensure access to essential pain medication for children. The International Children’s Palliative Care Network are conducting a Survey on improving pain management in children around the world. Please take time to complete this survey.
Dr Rajagopal from India had asked Dr Gwyther and Ms Sithole to bring focus on the availability of low cost opioids and formulations in developing countries, because the cost factor is indeed the barrier once we have taken care of regulatory issues and educated the professionals. Dr Naidoo noted that immediate release morphine, in particular morphine liquid is low cost and the need to ensure access to low cost opioids in developing countries. Dr Raj also reminded us of the palliumindia.org/manifesto signed by 60 launch partners – including HPCA – across the world.
Dr Naidoo spoke about his concerns regarding neglect of addiction medicine, that he will be speaking to Margaret Chan the Director-General of the World Health Organization about including addiction as a NCD requiring attention, recognizing addiction as a primary disease with its own body of knowledge i.e.: Addiction Medicine; and a systematized approach to treating addiction, including training in medical and social work curricula. He will be plenary speaker at the International Society of Addiction Medicine (ISAM) conference in Japan this October and will speak about access to medicines, treatment for addiction and bringing policy into the work on the ground.
We were very appreciative of Dr Naidoo’s time and explanations and the support for implementing the WHA resolution from INCB.