Multivariate analysis of countries' government and health-care system influences on opioid availability for cancer pain relief and palliative care: More than a function of human development
ABSTRACT Background:Many international governmental and nongovernmental organizations regard unrelieved cancer pain as a significant global public health problem. Although opioids such as morphine are considered essential medicines in the provision of palliative care and for treating cancer pain, especially when the pain is severe, low- and middle-income countries often lack such medications.Aim:The primary aim of this study was to examine countries' government and health-care system influences on opioid availability for cancer pain and palliative care, as a means to identify implications for improving appropriate access to prescription opioids.Design:A multivariate regression of 177 countries' consumption of opioids (in milligrams/death from cancer and AIDS) contained country-level predictor variables related to public health, including Human Development Index, palliative care infrastructure, and health system resources and expenditures.Results:Results were highly explanatory (adjusted R(2) = 82%) and Human Development Index was the most predictive variable when controlling for all other factors in the statistical model (B = 11.875, confidence interval = 10.216, 13.534, p < 0.0001).Conclusions:Study findings demonstrate that a limited number of predictor variables characterizing a country's government and health-care system infrastructure can explain its opioid consumption level, with the greatest influence being very high Human Development Index. However, Human Development Index is not the most policy-relevant factor, and this finding should be reconciled against the reality that many countries with low or medium Human Development Index have succeeded in creating and sustaining a health-care system to strengthen cancer pain care and palliative care, including through the appropriate use of essential prescription opioids.
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ABSTRACT: Globally, cancer incidence and mortality are increasing and the majority of the burden is shifting to low- and middle-income countries (LMICs), where patients often present with late-stage disease and severe pain. Unfortunately, LMICs also face a disproportionate lack of access to pain relieving medicines such as morphine, despite medical and scientific literature that shows morphine to be effective to treat moderate and severe cancer pain. In 2008, an oncologist from Nepal, one of the poorest countries in the world, was selected to participate in the International Pain Policy Fellowship, a program to assist LMICs to improve patient access to pain medicines. Following the World Health Organization public health model for development of pain relief and palliative care, the Fellow, working with colleagues and mentors, has achieved initial successes: three forms of oral morphine (syrup, immediate-release tablets, and sustained-release tablets) are now manufactured in the country, health care practitioners are receiving training in the use of opioids for pain relief, and a new national palliative care association has developed a palliative care training curriculum. However, long-term implementation efforts, funding, and technical assistance by governments, philanthropic organizations, and international partners are necessary to ensure that pain relief and palliative care become accessible by all in need in Nepal and other LMICs.Journal of pain and symptom management 04/2014; 49(1). DOI:10.1016/j.jpainsymman.2014.02.011 · 2.74 Impact Factor
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ABSTRACT: Context Opioids are essential medicines. World Health Organization and Health Action International monitor the price of essential medicines. However, their surveys do not include opioids and there is no information on their affordability. Objectives To provide information on access to pain treatment, as measured by the availability and dispensed price of 5 opioids in 13 formulations, and the affordability of oral immediate release morphine. Methods IAHPC members were distributed by their countries’ Gross National Income (GNI) level: High (HIC), Upper Middle (UMIC), Lower Middle (LMIC), Low (LIC), and randomized. Ten participants were selected from each (n=40). Participants were asked to identify a pharmacy located closest to a public facility which provides diagnosis/treatment for life-threatening conditions and report the lowest dispensed price of the smallest selling unit and strength of each formulation. Availability and Median (Me) price were calculated for each. Affordability and % of international buyer price (IBP) were calculated for morphine oral solid immediate release (IR). Results 30 participants from 26 countries (RR=75%) responded. Significant correlation was found between availability and GNI, [range: 65-8% (HIC and LIC) Rs=0.781; p<0.0001]. Injectable and morphine oral solid sustained release (SR) were the most available (59% and 55%). Methadone (oral) was cheapest (Me= 0.5) followed by fentanyl (transdermal) (Me=2.2). Me price for Morphine oral solid IR and ratios between dispensed and IBP were lower in HIC than in LMIC (price: 0.03 vs. 0.16; ratio: 2.23 vs. 0.03). Affordability for morphine oral solid IR was 5 days (Me=0.1) (range 29-0.25). Conclusion Patients in LMIC and LIC have limited access to opioids and there are subsidies in place for more expensive medications and formulations in all GNI levels, but not for morphine oral solid IR. Additional research is necessary to identify the reasons behind these findings.Journal of pain and symptom management 10/2014; 48(4). DOI:10.1016/j.jpainsymman.2013.12.237 · 2.74 Impact Factor