Access to pain reliefT&T 2012

Prepared by: K CapildeoPresenter: J Sabga

Global Consumption of Morphine, 2010

**Austria’s consumption includes use of morphine for substitution therapySources: International Narcotics Control Board; World Health Organization population dataBy: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2012

mg/capita

152 countries

Global Mean5.9912

T&T 1.54

TT’s morphine use per capita:75% below world average!

Grams of morphine per capita versus gross national income.

Nickerson JW, Attaran A (2012) The Inadequate Treatment of Pain: Collateral Damage from the War on Drugs. PLoS Med 9(1): e1001153. doi:10.1371/journal.pmed.1001153http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001153

T&T: rankingsWorld bank: High income, non-OECD– Others include Bahamas, Barbados, Qatar,

SingaporeGDP per capita (IMF 2010-11)– TT is at #42– Taiwan #40, Slovakia #41, Barbados #44

Human development index (UNDP) 2011: TT at #62 (high human development)– Others in group: Mexico #57, Panama #58

Malaysia #61, Kuwait #63, Russia #66

So is cost really the issue?

Can our opioid shortages, causes and and solutions, be equated with situation in poorest countries where absolute lack of funds is the limiting factor?

Numerous drugs on MoH formulary costing >US$1000 per month

Many costly procedures available in MoH service

Drug availability Sept 2012National Radiotherapy Ctr, San Fernando, Sangre Grande

Drug NRC SFGH SGHMorphine liquid Morphine SR 30mg Morphine SR 60mg Morphine suppos. ? ? Pethidine 50mg Methadone liquid Fentanyl patch Oxycodone Codeine Tramadol ±Acetaminophen

Dihydrocodeine

Step 2 analgesics in tT

No access in public service to most step 2 drugs– No codeine, dihydrocodeine,

combinationsOnly one is Tramadol ± AcetaminophenOften out of stock

Step 3 analgesicsFrequent interruptions of supply especially morphine liquid and sometimes 30mg SRMorphine SR 60mg not practical starting doseFrequent use of Pethidine – Not optimal analgesic– BUT, need to conserve precious stocks of

MorphineFew options for patients intolerant to MorphineIf unable to take orally, few outpatient options– No fentanyl patches– No syringe drivers (nor system to monitor same)

Can this distort practice?

Cocktails of Step 1 and Step 2 drugs ± Pethidine, even when Morphine is best option, to conserve Morphine stocksAdmission to acute ward for pain control if unable to take oral analgesicsAggressive use of chemotherapy and radiotherapy in near-futile situations in hope of controlling cancer pain by controlling cancer

Solutions?

Acknowledgements

Dr. S. Chamely, San Fernando General HospitalMrs. A. Lochan, Sangre Grande HospitalMrs. K. Reid, National Radiotherapy CentreMr. K. Stephens, Sangre Grande Hospital