Access to pain reliefT&T 2012

Prepared by: K Capildeo

Presenter: 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 Mean

5.9912

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,

Singapore

GDP 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 SGH

Morphine 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,

combinations

Only one is Tramadol ± Acetaminophen

Often out of stock

Step 3 analgesicsFrequent interruptions of supply especially morphine liquid and sometimes 30mg SR

Morphine SR 60mg not practical starting dose

Frequent use of Pethidine – Not optimal analgesic– BUT, need to conserve precious stocks of

Morphine

Few options for patients intolerant to Morphine

If 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 stocks

Admission to acute ward for pain control if unable to take oral analgesics

Aggressive 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 Hospital

Mrs. A. Lochan, Sangre Grande Hospital

Mrs. K. Reid, National Radiotherapy Centre

Mr. K. Stephens, Sangre Grande Hospital