1
|
Cherny NI, Ziff-Werman B. Ethical considerations in the relief of cancer pain. Support Care Cancer 2023; 31:414. [PMID: 37351702 DOI: 10.1007/s00520-023-07868-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/07/2023] [Indexed: 06/24/2023]
Abstract
The management of pain for patients with cancer and cancer survivors is a critical clinical task that involves a multitude of ethical issues at almost every phase of the cancer experience. This review is divided into three sections: In the first, we address rights and duties in the relief of pain from the perspective of patients, clinicians, health care institutions and organizations, and public policy. This section includes a detailed description of issues and duties in relation to opioid misuse and addiction. In the second section, we discuss the ethical consideration of therapeutic planning. The final section addresses ethical considerations in the management of pain at the end of life including a detailed discussion regarding ethical issues relating to the use of palliative sedation as a clinical intervention of last resort.
Collapse
|
2
|
Pergolizzi J, LeQuang JAK, Coluzzi F, Magnusson P, Lara-Solares A, Varrassi G. Considerations for Pain Assessments in Cancer Patients: A Narrative Review of the Latin American Perspective. Cureus 2023; 15:e40804. [PMID: 37489190 PMCID: PMC10363018 DOI: 10.7759/cureus.40804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/21/2023] [Indexed: 07/26/2023] Open
Abstract
Cancer incidence in Latin America is lower than in Europe or the United States but morbidity and mortality rates are disproportionately high. A barrier to adequate pain control is inadequate pain assessment, which is a relatively easy and inexpensive metric. The objective of this narrative review is to describe pain assessment for cancer patients in Latin America. Cultural factors may influence pain perception, including contextualizing pain as noble or natural suffering and aspects of what is now called "spiritual pain." Unlike other painful conditions, cancer pain may be strongly associated with existential fear, psychosocial distress, anxiety, and spiritual concerns. Pain assessment allows not just quantification of pain intensity but may elucidate pain mechanisms involved or psychosocial aspects that may color the pain. Many current pain assessment instruments capture only pain intensity, which is but one aspect of the pain experience; some have expanded to include functional assessments, mental health status evaluations, and quality of life metrics. A quality-of-life assessment may be appropriate for cancer patients since chronic pain can severely impact function, which can in turn create a vicious cycle by exacerbating pain. The incidence of cancer in Latin America is expected to increase in the ensuing years. Better pain assessment and clinician education are needed to help manage pain in this large and growing patient population.
Collapse
Affiliation(s)
| | | | - Flaminia Coluzzi
- Medical and Surgical Sciences, Sapienza University of Rome, Rome, ITA
| | | | - Argelia Lara-Solares
- Pain and Palliative Care, National Institute of Medical and Nutritional Sciences, Mexico City, MEX
| | | |
Collapse
|
3
|
Paal P, Brandstötter C, Elsner F, Lorenzl S, Osterbrink J, Stähli A. European interprofessional postgraduate curriculum in palliative care: A narrative synthesis of field interviews in the region of Middle, Eastern, and Southeastern Europe and Central and West Asia. Palliat Support Care 2022:1-10. [PMID: 36545761 DOI: 10.1017/s1478951522001651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES In 2018, a study was conducted in the Eastern and South-eastern Europe and Central Asia. National leaders of palliative care were asked to describe developments in postgraduate education in their region. They were asked whether the introduction of a European curriculum would be useful in their country. The aim was to explore the structures of postgraduate education at country level in order to define the barriers and opportunities. METHODS This is an ethnographic study based on semi-structured field interviews. A thematic analysis was chosen for data extraction and a narrative synthesis for the systematic presentation and critical discussion of the results. RESULTS Thirty-two interviews were recorded in 23 countries. The analysis revealed 4 main themes: (1) general barriers to access, (2) necessary to improve palliative care education, (3) palliative care core curriculum - the theoretical framework, and (4) challenges in implementation. These main themes were complemented by 19 subthemes. SIGNIFICANCE OF RESULTS Palliative care is understood as a universal idea, which in practice means accepting social pluralism and learning to respect unique individual needs. This makes teaching palliative care a very special task because there are no golden standards for dealing with each individual as they are. In theory, a European curriculum recommendation is useful to convince governments and other key stakeholders of the importance of postgraduate education. In practice, such a curriculum needs to be adapted to the constraints of health services and human resources. Validated quality assessment criteria for palliative care education are crucial to advance postgraduate education.
Collapse
Affiliation(s)
- Piret Paal
- WHO Collaborating Centre at the Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
- Institute of Palliative Care, Paracelsus Medical University, Salzburg, Austria
| | - Cornelia Brandstötter
- WHO Collaborating Centre at the Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Frank Elsner
- Department of Palliative Medicine, RWTH Aachen University, Aachen, Germany
| | - Stefan Lorenzl
- Institute of Palliative Care, Paracelsus Medical University, Salzburg, Austria
- Department of Neurology, Hospital Agatharied, Hausham, Germany
| | - Jürgen Osterbrink
- WHO Collaborating Centre at the Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | | |
Collapse
|
4
|
Kreye G, Lundeby T, Latino N, Galotti M, Kaasa S. ESMO Designated Centres of Integrated Oncology and Palliative Care (ESMO DCs): education, research and programme development survey. ESMO Open 2022; 7:100622. [PMID: 36356414 PMCID: PMC9808436 DOI: 10.1016/j.esmoop.2022.100622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The European Society for Medical Oncology (ESMO) Designated Centres (DCs) of Integrated Oncology and Palliative Care is an incentive programme established in 2003 aiming to improve the integration of oncology and palliative care services provided by oncologists and oncology centres worldwide. Currently, the ESMO DCs programme has over 250 centres accredited from 54 countries worldwide, in all six world regions. MATERIALS AND METHODS To evaluate how ESMO can support centres to improve programme development, education and research and vice versa what each single centre can do to improve in these areas, we developed a survey which was shared with all active centres. Two hundred and seven ESMO DCs representing 44 countries were invited to participate. We used content analysis to identify response categories using a stepwise approach. After reviewing and coding all responses to each question separately, they were placed into categories, counted and labelled. RESULTS Of the 207 centres that were invited to participate, 146 centres started the survey, representing 43 countries. Five overarching topics were identified. They included (i) joint events and educational activities; (ii) sharing of materials and defining common standards; (iii) sharing of experiences, scientific knowledge and expertise; (iv) research collaboration; and (v) ESMO support. Respondents were willing to support the ESMO DC community group in all topics and were also asking ESMO to support their centres in these issues in the future. CONCLUSION The study showed that the ESMO DCs are willing to provide support to improve education, research and programme development. They are also eager to contribute and collaborate amongst each other, but also request ESMO to offer advice and help to improve these issues in the DCs. In the future, facilitation of joint research projects and development of arenas to share experiences, educational and programme developments, and other resources are to be explored and could be offered to the DCs worldwide.
Collapse
Affiliation(s)
- G. Kreye
- Department of Internal Medicine II, Clinical Division of Palliative Medicine, University Hospital Krems, Krems an der Donau, Austria,Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria,Correspondence to: Dr Gudrun Kreye, Department of Internal Medicine II, Clinical Division of Palliative Medicine, University Hospital Krems, Mitterweg 10, 3500 Krems an der Donau, Austria; Karl Landsteiner University of Health Sciences, Dr. Karl Dorrek str. 30, Krems an der Donau, Austria. Tel: +43-2732-9004-12355; +43-2732-9004-49222; +43-676-858-14-33400
| | - T. Lundeby
- European Palliative Care Research Centre, Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - N. Latino
- European Society for Medical Oncology Head Office, Lugano, Switzerland
| | - M. Galotti
- European Society for Medical Oncology Head Office, Lugano, Switzerland
| | - S. Kaasa
- European Palliative Care Research Centre, Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
5
|
Sullivan DR, Iyer AS, Enguidanos S, Cox CE, Farquhar M, Janssen DJA, Lindell KO, Mularski RA, Smallwood N, Turnbull AE, Wilkinson AM, Courtright KR, Maddocks M, McPherson ML, Thornton JD, Campbell ML, Fasolino TK, Fogelman PM, Gershon L, Gershon T, Hartog C, Luther J, Meier DE, Nelson JE, Rabinowitz E, Rushton CH, Sloan DH, Kross EK, Reinke LF. Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement. Am J Respir Crit Care Med 2022; 206:e44-e69. [PMID: 36112774 PMCID: PMC9799127 DOI: 10.1164/rccm.202207-1262st] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.
Collapse
|
6
|
Lohman D, Cleary J, Connor S, De Lima L, Downing J, Marston J, Morris C, Pardy S, Pettus K. Advancing Global Palliative Care Over Two Decades: Health System Integration, Access to Essential Medicines, and Pediatrics. J Pain Symptom Manage 2022; 64:58-69. [PMID: 35263621 DOI: 10.1016/j.jpainsymman.2022.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/25/2022] [Accepted: 03/02/2022] [Indexed: 10/18/2022]
Abstract
CONTEXT Between 2000 and 2020 Open Society Foundations was one of very few funders that supported global palliative care development and advocacy. OBJECTIVES To describe progress made in three priority areas-the integration of palliative care into public health systems, access to controlled medicines, and pediatric palliative care-during those 20 years. METHODS Activities and developments between 2000 and 2020 on global integration of palliative care into health systems, access to and availability of controlled medicines, and pediatric palliative care are described and analyzed. RESULTS Major progress has been made in each area. Whereas in 2000, integration of palliative care into public healthcare systems was on the agenda in just a few pioneering countries, by 2020 a global consensus had emerged that palliative care should be integral to all health systems including in universal health coverage and countries were increasingly taking steps to integrate it into national health systems. While limited availability of these medicines was barely recognized as a public health or drug control issue in 2000, it had become an important priority in global drug policy debates by 2020 and numerous countries had taken steps to improve access to these medicines. Pediatric palliative care, available mostly in a small number of wealthy countries in the 1990s, has seen rapid growth, especially in low- and middle-income countries, and now has a solid foothold in all world regions. CONCLUSION Despite this progress, significant challenges remain as funding for palliative care advocacy is limited, the overdose crisis in the US has recently had a chilling effect on efforts to improve availability of opioid analgesics, and economic crises related to the COVID-19 pandemic create uncertainty over the future of universal health coverage.
Collapse
Affiliation(s)
- Diederik Lohman
- Open Society Foundations (D.L., S.P.), New York, New York, USA.
| | - James Cleary
- Walther Global Palliative Care and Supportive Oncology, IUSCC, Indianapolis (J.C.), Indiana, USA
| | - Stephen Connor
- Worldwide Hospice Palliative Care Alliance (S.C., C.M.), London, UK
| | - Liliana De Lima
- International Association for Hospice and Palliative Care, Houston (L.D., K.P.), Texas, USA
| | - Julia Downing
- International Children's Palliative Care Network, Makerere University (J.D.), London/ Kampala, UK/ Uganda
| | - Joan Marston
- PatchSA Palliative Treatment for Children South Africa (J.M.), Bloemfontein, South Africa
| | - Claire Morris
- Worldwide Hospice Palliative Care Alliance (S.C., C.M.), London, UK
| | - Sara Pardy
- Open Society Foundations (D.L., S.P.), New York, New York, USA
| | - Katherine Pettus
- International Association for Hospice and Palliative Care, Houston (L.D., K.P.), Texas, USA
| |
Collapse
|
7
|
Razis E, Kassapian M, Andriakopoulou C, Martei YM, Zurn SJ, Hammad N, Romero Y, Dafni U, Ilbawi AM, Trapani D. Essential medicines list in national cancer control plans: a secondary analysis from a global study. Lancet Oncol 2022; 23:e144-154. [PMID: 35240089 DOI: 10.1016/s1470-2045(21)00706-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/26/2021] [Accepted: 12/01/2021] [Indexed: 01/19/2023]
Abstract
With the advent of innovative therapeutics for and the rising costs of cancer management, low-income and middle-income countries face increasing challenges to deliver effective and sustainable health care. Understanding of how countries are selecting and prioritising essential cancer interventions is poor, including in the formulation of policies for essential medicines. We did an in-depth subanalysis from a global dataset of national cancer control plans (NCCPs), aiming to identify possible determinants of inclusion of policies related to essential medicines in the NCCP. The results showed poor global comprehensiveness of NCCPs, and substantial deficits in policies for financial hardships due to cancer care, specifically for access to cancer medicines. Specification of budget allocations, policy of protection from catastrophic health expenditure, and national treatment guidelines in the NCCPs contributed to more consistent policies on essential cancer medicines. The bedrock to deliver effective cancer programmes resides in the assurance of comprehensive, consistent, and coherent policy formulation, to orient resource selection and health investments, ultimately delivering equitable health for all.
Collapse
Affiliation(s)
- Evangelia Razis
- 3rd Department of Medical Oncology, Hygeia Hospital, Athens, Greece.
| | | | | | - Yehoda M Martei
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Shalini Jayasekar Zurn
- Knowledge, Advocacy and Policy, Union for International Cancer Control, Geneva, Switzerland
| | - Nazik Hammad
- Kingston Health Sciences Centre Cancer Centre of Southeastern Ontario at Kingston General Hospital, Kingston, ON, USA
| | - Yannick Romero
- Knowledge, Advocacy and Policy, Union for International Cancer Control, Geneva, Switzerland
| | - Urania Dafni
- Frontier Science Foundation Hellas, Athens, Greece; School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - André M Ilbawi
- Department of Non-communicable Diseases, World Health Organization, Geneva, Switzerland
| | | |
Collapse
|
8
|
Richards GC, Aronson JK, Mahtani KR, Heneghan C. Global, regional, and national consumption of controlled opioids: a cross-sectional study of 214 countries and non-metropolitan territories. Br J Pain 2022; 16:34-40. [PMID: 35111312 PMCID: PMC8801686 DOI: 10.1177/20494637211013052] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The consumption of opioids has increased globally since the 1990s. Previous studies of global opioid consumption have concentrated on morphine alone or a subset of opioids, with a focus on cancer pain and palliative care. In this study, we have determined the global, regional, and national consumption of all controlled opioids, including anaesthetics, analgesics, antidiarrheals, opioid substitution therapies, and cough suppressants. METHODS We conducted a cross-sectional study using data from the International Narcotics Control Board (INCB). We calculated mean opioid consumption (mg/person) globally, regionally, and nationally for 2015-2017, where consumption refers to the total amount of controlled opioids distributed for medical purposes and excludes recreational use. We ranked countries by total consumption and quantified the types of opioids consumed globally. RESULTS Between 2015 and 2017, 90% of the world's population consumed only 11% of controlled opioids. An average of 32 mg/person was consumed annually, but this was not equally distributed across the world. Consumption was the highest in Germany (480 mg/person), followed by Iceland (428 mg/person), the United States (398 mg/person) and Canada (333 mg/person). Oxycodone (35%) was the most heavily consumed controlled opioid globally, followed by morphine (15.9%), methadone (15.8%) and tilidine (14%). CONCLUSION Large disparities persist in most of the world in accessing essential opioid medicines. Consumption patterns should continue to be monitored, and collaborative strategies should be developed to promote access and the appropriate prescribing of opioids in all countries and non-metropolitan territories.
Collapse
Affiliation(s)
- Georgia C Richards
- Global Centre on Healthcare and Urbanisation, Kellogg College, University of Oxford, Oxford, UK
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jeffrey K Aronson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kamal R Mahtani
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Global Centre on Healthcare and Urbanisation, Kellogg College, University of Oxford, Oxford, UK
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
9
|
LeBaron V, Adhikari A, Bennett R, Chapagain Acharya S, Dhakal M, Elmore CE, Fitzgibbon K, Gongal R, Kattel R, Koirala G, Maurer M, Munday D, Neupane B, Sagar Sharma K, Shilpakar R, Shrestha S, Thapa U, Zhang H, Dillingham R, Dutta Paudel B. A survey of cancer care institutions in Nepal to inform design of a pain management mobile application. BMC Palliat Care 2021; 20:171. [PMID: 34740339 PMCID: PMC8570036 DOI: 10.1186/s12904-021-00824-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 07/15/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND One way to improve the delivery of oncology palliative care in low and middle-income countries (LMICs) is to leverage mobile technology to support healthcare providers in implementing pain management guidelines (PMG). However, PMG are often developed in higher-resourced settings and may not be appropriate for the resource and cultural context of LMICs. OBJECTIVES This research represents a collaboration between the University of Virginia and the Nepalese Association of Palliative Care (NAPCare) to design a mobile health application ('app') to scale-up implementation of existing locally developed PMG. METHODS We conducted a cross-sectional survey of clinicians within Nepal to inform design of the app. Questions focused on knowledge, beliefs, and confidence in managing cancer pain; barriers to cancer pain management; awareness and use of the NAPCare PMG; barriers to smart phone use and desired features of a mobile app. FINDINGS Surveys were completed by 97 palliative care and/or oncology healthcare providers from four diverse cancer care institutions in Nepal. 49.5% (n = 48) had training in palliative care/cancer pain management and the majority (63.9%, n = 62) reported high confidence levels (scores of 8 or higher/10) in managing cancer pain. Highest ranked barriers to cancer pain management included those at the country/cultural level, such as nursing and medical school curricula lacking adequate content about palliative care and pain management, and patients who live in rural areas experiencing difficulty accessing healthcare services (overall mean = 6.36/10). Most nurses and physicians use an Android Smart Phone (82%, n = 74), had heard of the NAPCare PMG (96%, n = 88), and reported frequent use of apps to provide clinical care (mean = 6.38/10, n = 92). Key barriers to smart phone use differed by discipline, with nurses reporting greater concerns related to cost of data access (70%, n = 45) and being prohibited from using a mobile phone at work (61%; n = 39). CONCLUSIONS Smart phone apps can help implement PMG and support healthcare providers in managing cancer pain in Nepal and similar settings. However, such tools must be designed to be culturally and contextually congruent and address perceived barriers to pain management and app use.
Collapse
Affiliation(s)
- Virginia LeBaron
- University of Virginia School of Nursing, 225 Jeannette Lancaster Way, Charlottesville, VA 22908 USA
| | | | - Rachel Bennett
- University of Virginia School of Nursing, 225 Jeannette Lancaster Way, Charlottesville, VA 22908 USA
| | | | - Manita Dhakal
- B.P. Koirala Memorial Cancer Hospital, Chitwan, Nepal
| | - Catherine E. Elmore
- University of Virginia School of Nursing, 225 Jeannette Lancaster Way, Charlottesville, VA 22908 USA
| | - Kara Fitzgibbon
- University of Virginia Center for Survey Research, Charlottesville, VA USA
| | | | - Regina Kattel
- Nepal Cancer Hospital & Research Center, Kathmandu, Nepal
| | | | - Martha Maurer
- University of Wisconsin School of Pharmacy, Sonderegger Research Center, Madison, WI USA
| | - Daniel Munday
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Bijay Neupane
- B.P. Koirala Memorial Cancer Hospital, Chitwan, Nepal
| | | | - Ramila Shilpakar
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal
| | - Sudip Shrestha
- Nepal Cancer Hospital & Research Center, Kathmandu, Nepal
| | - Usha Thapa
- B.P. Koirala Memorial Cancer Hospital, Chitwan, Nepal
| | - Hexuan Zhang
- University of Virginia Center for Survey Research, Charlottesville, VA USA
| | - Rebecca Dillingham
- University of Virginia Center for Global Health Equity, Charlottesville, VA USA
| | | |
Collapse
|
10
|
Pastrana T, De Lima L, Pettus K, Ramsey A, Napier G, Wenk R, Radbruch L. Impact of COVID-19 Pandemic on Palliative Care Workers: An International Cross-sectional Study. Indian J Palliat Care 2021; 27:299-305. [PMID: 34511800 PMCID: PMC8428902 DOI: 10.25259/ijpc_6_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 12/01/2022] Open
Abstract
Objectives: The COVID-19 pandemic and the measures taken to mitigate spread have affected countries in different ways. Healthcare workers, in particular, have been impacted by the pandemic and by these measures. This study aims to explore how COVID-19 has impacted on palliative care (PC) workers around the world. Materials and Methods: Online survey to members of the International Association for Hospice and PC during the initial months of the COVID-19 pandemic. Convenience sampling was used. Statistical descriptive and contingency analyses and Chi-square tests with P < 0.05 were conducted. Results: Seventy-nine participants (RR = 16%) from 41 countries responded. Over 93% of those who provide direct patient care reported feeling very or somewhat competent in PC provision for patients with COVID-19. Eighty-four felt unsafe or somewhat safe when caring for patients with COVID-19. Level of safety was associated with competence (P ≤ 0.000). Over 80% reported being highly or somewhat affected in their ability to continue working in their PC job, providing care to non-COVID patients and in staff availability in their workplace. About 37% reported that availability and access to essential medicines for PC were highly or somewhat affected, more so in low-income countries (P = 0.003). Conclusion: The results from this study highlight the impact of COVID-19 on the provision of PC. It is incumbent on government officials, academia, providers and affected populations, to develop and implement strategies to integrate PC in pandemic response, and preparedness for any similar future events, by providing appropriate and comprehensive education, uninterrupted access to essential medicines and personal protective equipment and ensure access to treatment and care, working together with all levels of society that is invested in care of individuals and populations at large. The long-term effects of the pandemic are still unknown and future research is needed to monitor and report on the appropriateness of measures.
Collapse
Affiliation(s)
- Tania Pastrana
- Department of Palliative Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Liliana De Lima
- International Association for Hospice and Palliative Care, Houston, Taxes, United States
| | - Katherine Pettus
- International Association for Hospice and Palliative Care, Houston, Taxes, United States
| | - Alison Ramsey
- International Association for Hospice and Palliative Care, Houston, Taxes, United States
| | - Genevieve Napier
- International Association for Hospice and Palliative Care, Houston, Taxes, United States
| | - Roberto Wenk
- International Association for Hospice and Palliative Care, Houston, Taxes, United States
| | - Lukas Radbruch
- International Association for Hospice and Palliative Care, Houston, Taxes, United States
| |
Collapse
|
11
|
Kuguyo O, Misi FD, Chibonda S, Matimba A, Nhachi C, Tsikai N. Pain management strategies among cervical cancer patients in Zimbabwe. Pain Manag 2021; 11:715-729. [PMID: 34008417 DOI: 10.2217/pmt-2020-0108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To describe pain management regulations, prevalence of pain and pain management practices in a Zimbabwean setting. Materials & methods: A multi-methods approach was used, consisting of: policy and guideline review; review of 410 cervical cancer patient records for pain symptoms and pain management data; and semistructured interviews with oncology healthcare practitioners. Results: We found a lack of policies that are specific for cervical cancer pain management. Although prevalence of pain was 68% (n = 278), only 42% of the patient records indicated pain drugs had been prescribed. Barriers to pain management included inadequate use of pain assessment tools, inaccessibility of key drugs and limited capacity. Conclusion: Cancer pain management in Zimbabwe can be improved by tailoring assessment protocols, improving drug accessibility and strengthening healthcare systems.
Collapse
Affiliation(s)
- Oppah Kuguyo
- Department of Clinical Pharmacology, College of Health Sciences, University of Zimbabwe, Box A178, Avondale, Harare, Zimbabwe
| | - Frances Desales Misi
- Department of Clinical Pharmacology, College of Health Sciences, University of Zimbabwe, Box A178, Avondale, Harare, Zimbabwe
| | - Shirley Chibonda
- Department of Oncology, College of Health Sciences, University of Zimbabwe, Box A178, Avondale, Harare, Zimbabwe
| | - Alice Matimba
- Advanced Courses & Scientific Conferences, Wellcome Genome Campus, Hinxton, CB10 1SA, UK
| | - Charles Nhachi
- Department of Clinical Pharmacology, College of Health Sciences, University of Zimbabwe, Box A178, Avondale, Harare, Zimbabwe
| | - Nomsa Tsikai
- Department of Oncology, College of Health Sciences, University of Zimbabwe, Box A178, Avondale, Harare, Zimbabwe
| |
Collapse
|
12
|
Preferences of quality delivery of palliative care among cancer patients in low- and middle-income countries: A review. Palliat Support Care 2021; 20:275-282. [PMID: 33952378 DOI: 10.1017/s1478951521000456] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND All forms of cancer pose a tremendous and increasing problem globally. The prevalence of cancer across the globe is anticipated to double over the next two decades. About 50% of most cancer cases are expected to occur in low- and middle-income countries (LMICs), where there is a greater disproportionate level in mortality. Access to effective and timely care for cancer patients remains a challenge, especially in LMICs due to late disease diagnosis and detection, coupled with the limited availability of appropriate therapeutic options and delay in proper interventions. METHODOLOGY This study explored several mixed-method researches and randomized trials that addressed the preferences of quality delivery of palliative care among cancer patients in LMICs. A designated set of keywords such as Palliative Care; Preferences; Cancer patients; Psycho-social Support; End-of-life Care; Low and Middle-Income Countries were inserted on electronic databases to retrieve articles. The databases include PubMed, Scinapse, Medline, The Google Scholar, Academic search premier, SAGE, and EBSCO host. RESULTS Findings from this review discussed the socioeconomic and behavioral factors, which address the quality delivery of palliative care among cancer patients. These factors if measured with acceptance level in cancer patients could help to address areas that need improvement from the stage of disease diagnosis to the end-of-life. SIGNIFICANCE OF THE RESULTS Valuable collaborations among international and local health institutions are needed to build and implement a systematic framework for palliative care in LMICs. Policies and programs that are country and culturally specific, encompassing both theoretical and practical models of care in the milieu of existing quandaries should be developed.
Collapse
|
13
|
Maia LO, Daldegan-Bueno D, Fischer B. Opioid use, regulation, and harms in Brazil: a comprehensive narrative overview of available data and indicators. Subst Abuse Treat Prev Policy 2021; 16:12. [PMID: 33499891 PMCID: PMC7836143 DOI: 10.1186/s13011-021-00348-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Global opioid consumption increased multifold post-2000, disproportionately in high-income countries, with severe mortality/morbidity consequences. Latin America features comparatively low opioid availability; Brazil, the region's most populous country, makes an interesting case study concerning opioid use/harms. In this comprehensive overview, we aimed to identify and summarize medical and non-medical data and indicators of opioid availability and use, regulation/control, and harm outcomes in Brazil since 2000. METHODS We searched multiple scientific databases to identify relevant publications and conducted additional 'grey' literature searches to identify other pertinent information. RESULTS Despite some essential indicators, opioid-related data are limited for Brazil. Data indicate that population-level availability of prescription opioids represents only a small fraction of use in comparison to high-income countries. However, within Latin America, Brazil ranks mid-level for opioid consumption, indicating relatively moderate consumption compared to neighboring jurisdictions. Brazil has implemented restrictive regulations to opioid prescribing and is considered 'highly restricted' for opioid access. Codeine remains the major opioid analgesic utilized, but stronger opioids such as oxycodone are becoming more common. Professional knowledge regarding medical opioid use and effects appears limited. National surveys indicate increases in non-medical use of prescription opioids, albeit lower than observed in North America, while illicit opioids (e.g., heroin) are highly uncommon. CONCLUSIONS Overall population-level opioid availability and corresponding levels of opioid-related harms in Brazil remain substantially lower than rates reported for North America. However, the available surveillance and analytical data on opioid use, policy/practice, and harms in Brazil are limited and insufficient. Since existing and acute (e.g., pain-related) needs for improved opioid utilization and practice appear to be substantiated, improved indicators for and understanding of opioid use, practice, and harms in Brazil are required.
Collapse
Affiliation(s)
- Lucas O. Maia
- Centre for Applied Research in Mental Health and Addiction, SFU Faculty of Health Sciences, Simon Fraser University, 515 W. Hastings Street, V6B 5K3 Vancouver, BC Canada
| | - Dimitri Daldegan-Bueno
- Schools of Population Health and Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Rd, 1023 Grafton, Auckland New Zealand
| | - Benedikt Fischer
- Centre for Applied Research in Mental Health and Addiction, SFU Faculty of Health Sciences, Simon Fraser University, 515 W. Hastings Street, V6B 5K3 Vancouver, BC Canada
- Schools of Population Health and Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Rd, 1023 Grafton, Auckland New Zealand
- Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, M5T 1R8 Toronto, ON Canada
- Department of Psychiatry, Federal University of São Paulo, R. Dr. Ovídio Pires de Campos, 785, 05403-903 São Paulo, Brazil
| |
Collapse
|
14
|
Dohlman LE, Kwikiriza A, Ehie O. Benefits and Barriers to Increasing Regional Anesthesia in Resource-Limited Settings. Local Reg Anesth 2020; 13:147-158. [PMID: 33122941 PMCID: PMC7588832 DOI: 10.2147/lra.s236550] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/29/2020] [Indexed: 01/19/2023] Open
Abstract
Safe and accessible surgical and anesthetic care is critically limited for over half of the world's population, particularly in Sub-Saharan African and Southeast Asian countries. Increasing the use of regional anesthesia in these areas has potential benefits regarding access, safety, and cost-effectiveness. Perioperative anesthesia-related mortality is significantly higher in resource-limited countries and every effort should be made to encourage the use of anesthetic techniques in these countries that are safest under the present conditions. Studies from Sub-Saharan Africa, although limited in number, have shown a lower risk of death with regional compared to general anesthesia. Regional anesthesia has the further benefit of decreasing the risk of COVID-19 spread to healthcare providers by avoiding the aerosol-generating procedures that occur during general anesthesia. Neuraxial regional anesthesia is relatively easy to teach and perform and is considered the anesthetic of choice for surgeries below the umbilicus in resource-limited settings due to its safety, efficacy, and low cost. Although regional anesthesia has multiple potential advantages, education and training of anesthetic providers in low-and-middle-income countries (LMIC) are a significant barrier to growth. Anesthesia professionals, especially in Sub-Saharan Africa, are often poorly supported and undervalued, and recruitment and retention of adequate numbers of trained practitioners are a continuing problem. Greater use of regional anesthesia could be one way to safely increase anesthesia access and simultaneously create value and enthusiasm for the field. Deficits in anesthesia infrastructure, equipment, and drugs also limit anesthesia capacity in low-and middle-income countries. Ultrasound-guided regional anesthesia may be helpful in improving access to safe and reliable anesthesia in low-resource countries as it continues to become more user-friendly, durable, and affordable.
Collapse
Affiliation(s)
- Lena Ebba Dohlman
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew Kwikiriza
- Department of Anaesthesia and Critical Care, Mbarara Regional Referral Hospital, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Odinakachukwu Ehie
- Department of Anesthesiology and Perioperative Services, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
15
|
Abu-Odah H, Molassiotis A, Liu J. Challenges on the provision of palliative care for patients with cancer in low- and middle-income countries: a systematic review of reviews. BMC Palliat Care 2020; 19:55. [PMID: 32321487 PMCID: PMC7178566 DOI: 10.1186/s12904-020-00558-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 04/06/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Despite the significant benefits of palliative care (PC) services for cancer patients, multiple challenges hinder the provision of PC services for these patients. Low- and middle-income countries (LMICs) are witnessing a sharp growth in the burden of non-communicable diseases. There is a significant gap between demand and supply of PC in LMICs in current health services. This review aims to synthesise evidence from previous reviews and deliver a more comprehensive mapping of the existing literature about personal, system, policy, and organisational challenges and possible facilitators on the provision of PC services for cancer patients in LMICs. METHODS A systematic review of reviews was performed following PRISMA guidelines. PubMed, EMBASE, SCOPUS, PsycINFO, Web of Sciences, CINAHL, and Cochrane Library databases were searched to identify review papers published between 2000 and 2018 that considered challenges and possible facilitators to PC provision. A modified socioecological model was used as a framework for analysing and summarising findings. RESULTS Fourteen reviews were included. The reviews varied in terms of aim, settings, and detail of the challenges and possible facilitators. The main challenges of personal and health care systems included knowledge deficits and misunderstandings from patients, families, the general public, and health care providers about PC; and inadequate number of trained workforce. Besides, limited physical infrastructure, insufficient drugs for symptom relief and lack of a comprehensive national plan for implementing PC were the core organisational and policy level challenges that were recognised. Furthermore, the main possible facilitators that were identified included provision of adequate training for health care providers and health education for patients, families and the general public to enhance their knowledge, beliefs, and attitudes to PC. Finally, involvement of policymakers and making drugs available for symptom relief should also be in place to improve the health care systems. CONCLUSIONS Understanding challenges to the provision of PC for people with cancer could help in the development of a PC pathway in LMICs. This knowledge could be used as a guide to develop an intervention programme to improve PC. Political influence and support are also required to ensure the sustainability and the provision of high-quality PC.
Collapse
Affiliation(s)
- Hammoda Abu-Odah
- School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Alex Molassiotis
- School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Justina Liu
- School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| |
Collapse
|
16
|
Lohman D, Barrett D. Scheduling medicines as controlled substances: addressing normative and democratic gaps through human rights-based analysis. BMC INTERNATIONAL HEALTH AND HUMAN RIGHTS 2020; 20:10. [PMID: 32316971 PMCID: PMC7171726 DOI: 10.1186/s12914-020-00231-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 04/06/2020] [Indexed: 12/03/2022]
Abstract
Recent years have seen contentious debate about efforts to schedule medicines such as ketamine and tramadol under the international drug control conventions. Proponents argue that misuse poses a significant risk to public health and that scheduling would help address these problems. However, scheduling of medicines can negatively affect their availability, accessibility and affordability for medical purposes, with serious health consequences for patients, especially in low and middle-income countries. The current process for scheduling medicines under the international drug control conventions does not provide sufficient normative standards through which balanced decisions may be reached. It is undemocratic in its structure and opaque in its reasoning. In this article, we argue that such decisions represent de facto limitations on the right to health and may engage the principle of non-retrogression. Using the examples of ketamine and tramadol, we propose that standard legal tests in international human rights law can help to address the normative and democratic deficits in the system and produce more rigorous, fairer and more transparent decisions.
Collapse
Affiliation(s)
- Diederik Lohman
- Dornsife School of Public Health, Drexel University, Nesbitt Hall, 3215 Market Street, Philadelphia, PA 19104 USA
| | - Damon Barrett
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 453, 405 30 Gothenburg, Sweden
| |
Collapse
|
17
|
Al-Masri D, Wilbur K, Elazzazy S, Hassan AA, Wilby KJ. Law, Culture, and Fear: A Qualitative Study of Health Professionals' Perceptions of Narcotic Use Related to Cancer Pain. J Pain Palliat Care Pharmacother 2020; 34:55-62. [PMID: 32091944 DOI: 10.1080/15360288.2019.1704340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Studies have shown barriers to appropriate narcotic use in the Middle East have negatively impacted patient outcomes. This study aimed to explore health professionals' perspectives regarding opioid use for cancer patients in Qatar. Eight focus groups were conducted with physicians, pharmacists, and nurses. An eight-question topic guide framed discussions and targeted contextual barriers and cultural beliefs. Focus groups were audio-recorded and transcribed verbatim. Thematic analysis was used to identify the following themes: narcotic use process, patient-related factors, and healthcare professional-related factors. Laws and regulations were identified as major barriers to appropriate narcotic access, prescribing, and administration. Government-imposed restrictions on permitted dispensed quantities and associated paperwork impeded continuity of patient care and pain relief. The influence of a patient's culture underpinned patient-related barriers, including fear of addiction and family members discouraging opioid use. Fear of prescribing for patient addiction and accusation of inappropriate prescribing by authorities were identified as health professional-related barriers. Facilitators included patient and provider education, as well as the availability of specialized teams to assess and treat cancer-related pain. Findings show narcotic utilization is not simply influenced by a single factor or subset of factors but by a multitude of factors that can be both independent and interrelated.
Collapse
Affiliation(s)
- Dania Al-Masri
- Dania Al-Masri, BSc(Pharm), MSc(Pharm), is with the College of Pharmacy, Qatar University, Doha, Qatar; Kerry Wilbur, BSc(Pharm), ACPR, PharmD, MPH, is with the Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada; Shereen Elazzazy, BSc(Pharm), PharmD, is with the Department of Pharmacy - Clinical Services, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar; Azza A. Hassan, MB BCh, MSc, MD, is with the Supportive & Palliative Care Unit, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar; Kyle J. Wilby, BSP, ACPR, PharmD, PhD, is with the School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Kerry Wilbur
- Dania Al-Masri, BSc(Pharm), MSc(Pharm), is with the College of Pharmacy, Qatar University, Doha, Qatar; Kerry Wilbur, BSc(Pharm), ACPR, PharmD, MPH, is with the Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada; Shereen Elazzazy, BSc(Pharm), PharmD, is with the Department of Pharmacy - Clinical Services, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar; Azza A. Hassan, MB BCh, MSc, MD, is with the Supportive & Palliative Care Unit, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar; Kyle J. Wilby, BSP, ACPR, PharmD, PhD, is with the School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Shereen Elazzazy
- Dania Al-Masri, BSc(Pharm), MSc(Pharm), is with the College of Pharmacy, Qatar University, Doha, Qatar; Kerry Wilbur, BSc(Pharm), ACPR, PharmD, MPH, is with the Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada; Shereen Elazzazy, BSc(Pharm), PharmD, is with the Department of Pharmacy - Clinical Services, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar; Azza A. Hassan, MB BCh, MSc, MD, is with the Supportive & Palliative Care Unit, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar; Kyle J. Wilby, BSP, ACPR, PharmD, PhD, is with the School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Azza A Hassan
- Dania Al-Masri, BSc(Pharm), MSc(Pharm), is with the College of Pharmacy, Qatar University, Doha, Qatar; Kerry Wilbur, BSc(Pharm), ACPR, PharmD, MPH, is with the Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada; Shereen Elazzazy, BSc(Pharm), PharmD, is with the Department of Pharmacy - Clinical Services, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar; Azza A. Hassan, MB BCh, MSc, MD, is with the Supportive & Palliative Care Unit, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar; Kyle J. Wilby, BSP, ACPR, PharmD, PhD, is with the School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Kyle J Wilby
- Dania Al-Masri, BSc(Pharm), MSc(Pharm), is with the College of Pharmacy, Qatar University, Doha, Qatar; Kerry Wilbur, BSc(Pharm), ACPR, PharmD, MPH, is with the Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada; Shereen Elazzazy, BSc(Pharm), PharmD, is with the Department of Pharmacy - Clinical Services, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar; Azza A. Hassan, MB BCh, MSc, MD, is with the Supportive & Palliative Care Unit, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar; Kyle J. Wilby, BSP, ACPR, PharmD, PhD, is with the School of Pharmacy, University of Otago, Dunedin, New Zealand
| |
Collapse
|
18
|
Cox-Seignoret K, Maharaj RG. Unmet needs of patients with cancer in their last year of life as described by caregivers in a developing world setting: a qualitative study. BMC Palliat Care 2020; 19:13. [PMID: 31980019 PMCID: PMC6982385 DOI: 10.1186/s12904-020-0516-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 01/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Palliative care is in its infancy in most of the developing world. We set out to explore the lived experiences of families and caregivers of recently deceased cancer patients in Trinidad and Tobago and to determine the unmet needs of the patients and what recommendations could be derived to improve the current services. METHODS A phenomenological approach with purposeful sampling was used. Participants were referred by key health professionals. Face-to-face interviews were conducted. Interviews were transcribed verbatim, with analysis and data collection occurring concurrently. Thematic content analysis was used to determine common domains, themes and sub-themes. RESULTS Interviews were completed with 15 caregivers. All were spouses or children of the deceased. Ages of the deceased ranged from 43 to 93, the average being 65.5 years. The deceased experienced a variety of cancers including lung, colorectal and oesophageal. Unmet needs were identified under 4 domains of institutions, community, the family unit and the wider society. Institutional unmet needs were delayed diagnosis and treatment and poor inter-institution coordination. Medical and nursing care failed in the areas of health care providers' attitudes, pain management and communication. The family unit lacked physical and psychosocial support for the caregiver and financial aid for the family unit. Societal needs were for public education to address myths and cultural beliefs around cancer. CONCLUSION There is need for systemic interventions to improve the care of those dying from cancer in Trinidad and Tobago. Stakeholders need to commit to palliative care as a public health priority, implementing education, planning services and mobilizing community resources.
Collapse
Affiliation(s)
| | - Rohan G. Maharaj
- The Unit of Public Health and Primary Care, Department of Paraclinical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| |
Collapse
|
19
|
Roydhouse JK, Suzman DL, Menapace LA, Mishra-Kalyani PS, Sridhara R, Blumenthal GM, Beaver JA, Pazdur R, Kluetz PG. Global Variation in Opioid Use in Prostate Cancer Trials. JAMA Oncol 2019; 5:e192971. [PMID: 31513232 DOI: 10.1001/jamaoncol.2019.2971] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance Regional variation in opioid use may be attenuated when pharmaceutical-sponsored trials include care that is often standardized by protocols. Understanding such variation is important for global trials that sometimes include time to opioid use as an end point. Objective To identify whether regional and country-level variation in opioid use exists among prostate cancer clinical trials across the world. Design, Setting, and Participants International phase 3 randomized clinical trials with patients with metastatic prostate cancer and initiation from January 1, 2008, or later were identified through internal databases of the US Food and Drug Administration. Data of patients in the intention-to-treat population from each trial were pooled. Descriptive and regression analyses of the collected data were conducted from September 2018 to February 2019. Exposures Cancer therapy. Main Outcomes and Measures Opioid use data were from concomitant medications reported in the database for each trial. Logistic regression models, descriptive statistics, and χ2 tests were used to compare opioid use across world regions while adjusting for patient age, presence of visceral disease, bony disease, and baseline Eastern Cooperative Oncology Group Performance Status score and pain score. Results In total, 9670 patients (mean [SD] age of 69.2 [8.3] years) from 8 prostate cancer clinical trials in 46 countries were included. Patients in Eastern Europe (adjusted odds ratio [AOR], 0.19; 95% CI, 0.16-0.22) and Asia (AOR, 0.31; 95% CI, 0.25-0.38) were less likely to use opioids compared with patients in North America. These findings held even when the analysis was restricted to patients who reported moderate to high pain levels at baseline (Eastern Europe: AOR, 0.16 [95% CI, 0.12-0.22]; Asia: AOR, 0.47 [95% CI, 0.29-0.79]). Within North America, rates of opioid use were similar between the United States and Canada (AOR, 1.13; 95% CI, 0.93-1.37). Conclusions and Relevance This study found that, despite the clinical trial setting, opioid use appeared to vary by world regions, suggesting that this variability should be considered in international clinical trials.
Collapse
Affiliation(s)
- Jessica K Roydhouse
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Daniel L Suzman
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Laurel A Menapace
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Pallavi S Mishra-Kalyani
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Rajeshwari Sridhara
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Gideon M Blumenthal
- Oncology Center of Excellence, Food and Drug Administration, Silver Spring, Maryland
| | - Julia A Beaver
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Richard Pazdur
- Oncology Center of Excellence, Food and Drug Administration, Silver Spring, Maryland
| | - Paul G Kluetz
- Oncology Center of Excellence, Food and Drug Administration, Silver Spring, Maryland
| |
Collapse
|
20
|
Krishnan A, Rajagopal MR, Karim S, Sullivan R, Booth CM. Palliative Care Program Development in a Low- to Middle-Income Country: Delivery of Care by a Nongovernmental Organization in India. J Glob Oncol 2019; 4:1-8. [PMID: 30241254 PMCID: PMC6223464 DOI: 10.1200/jgo.17.00168] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Limited data describe the delivery of palliative care services in low- and middle-income countries. We describe delivery of care by the Trivandrum Institute of Palliative Sciences (TIPS) in Trivandrum, India. Methods Administrative records were used to describe case volumes, setting of care, and organizational expenditures. An estimate of cost per clinical encounter was derived by dividing 2016 monthly clinical expenditures by the number of patient visits. Costs are reported in US dollars and are corrected for Organization for Economic Co-operation and Development purchasing power parity (PPP). Results A total of 11,620 new patients were seen at TIPS during 2007 to 2016; 59% had cancer. The average annual growth rate in case volumes was 18% (480 new patients in 2007 and 1,882 in 2016). The proportion of patients with cancer increased over time from 56% in 2014 to 66% in 2016 (P < .001). During 2014 to 2016, outpatient visits increased 26% (from 8,524 to 10,732), inpatient days increased 49% (from 1,763 to 2,625), inpatient visits at other hospitals increased 41% (from 248 to 417), and home visits increased 57% (from 3,951 to 6,186). Total clinical expenditures in 2016 were $288,489 (PPP corrected, $5.1 million). Between 2014 and 2016, the cost of delivering care increased by 74%. The mean cost per clinical encounter in 2016 was $15 (PPP corrected, $263). Conclusion Demand for palliative care services has increased substantially, with an increasing proportion related to cancer. The organization of clinical services by TIPS may serve as a model for the development of other palliative care programs in low- and middle-income countries.
Collapse
Affiliation(s)
- Anjali Krishnan
- M.R. Rajagopal and Anjali Krishnan, Trivandrum Institute of Palliative Sciences and Pallium India, Trivandrum, India; Safiya Karim and Christopher M. Booth, Queen's University Cancer Research Institute, Kingston, Ontario, Canada; and Richard Sullivan, King's College London and King's Health Partners Comprehensive Cancer Centre, London, United Kingdom
| | - M R Rajagopal
- M.R. Rajagopal and Anjali Krishnan, Trivandrum Institute of Palliative Sciences and Pallium India, Trivandrum, India; Safiya Karim and Christopher M. Booth, Queen's University Cancer Research Institute, Kingston, Ontario, Canada; and Richard Sullivan, King's College London and King's Health Partners Comprehensive Cancer Centre, London, United Kingdom
| | - Safiya Karim
- M.R. Rajagopal and Anjali Krishnan, Trivandrum Institute of Palliative Sciences and Pallium India, Trivandrum, India; Safiya Karim and Christopher M. Booth, Queen's University Cancer Research Institute, Kingston, Ontario, Canada; and Richard Sullivan, King's College London and King's Health Partners Comprehensive Cancer Centre, London, United Kingdom
| | - Richard Sullivan
- M.R. Rajagopal and Anjali Krishnan, Trivandrum Institute of Palliative Sciences and Pallium India, Trivandrum, India; Safiya Karim and Christopher M. Booth, Queen's University Cancer Research Institute, Kingston, Ontario, Canada; and Richard Sullivan, King's College London and King's Health Partners Comprehensive Cancer Centre, London, United Kingdom
| | - Christopher M Booth
- M.R. Rajagopal and Anjali Krishnan, Trivandrum Institute of Palliative Sciences and Pallium India, Trivandrum, India; Safiya Karim and Christopher M. Booth, Queen's University Cancer Research Institute, Kingston, Ontario, Canada; and Richard Sullivan, King's College London and King's Health Partners Comprehensive Cancer Centre, London, United Kingdom
| |
Collapse
|
21
|
Edwards H, Bennett M. Access to Opioids for Patients with Advanced Disease. Curr Pharm Des 2019; 25:3203-3208. [PMID: 31333089 DOI: 10.2174/1381612825666190716095337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/11/2019] [Indexed: 12/14/2022]
Abstract
Pain at the end of life is common in both malignant and non-malignant disease. It is feared by patients, their families and careers, and professionals. Effective pain control can be achieved for the majority of patients at the end of life using a multimodal approach. Pharmacological management relies predominantly on strong opioids. In spite of this, evidence suggests that under treatment of pain is common resulting in unnecessary suffering. Multiple barriers to use of opioids have been identified. Patient barriers include reluctance to report pain and to take analgesics. Professional barriers include inadequate pain assessment and lack of specialist knowledge and confidence in opioid therapy. Fear of side effects including respiratory depression affects patients and professionals alike. The impact of the "opioid epidemic", with increasing prescribed and illicit opioid use around the world, has also led to increasingly stringent regulation and concern about under prescribing in palliative care. System barriers to use of opioids at the end of life result from limited opioid availability in some countries and also inconsistent and limited access to palliative care. Multiple interventions have been developed to address these barriers, targeted at patients, professionals and systems. There is increasing evidence to suggest that complex interventions combining a number of different approaches are most effective in optimising pain outcomes for patients at the end of life.
Collapse
Affiliation(s)
- Helen Edwards
- Academic Unit of Palliative Care, University of Leeds, Leeds, United Kingdom
| | - Michael Bennett
- Academic Unit of Palliative Care, University of Leeds, Leeds, United Kingdom
| |
Collapse
|
22
|
Arias N, Garralda E, De Lima L, Rhee JY, Centeno C. Global Palliative Care and Cross-National Comparison: How Is Palliative Care Development Assessed? J Palliat Med 2019; 22:580-590. [DOI: 10.1089/jpm.2018.0510] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Natalia Arias
- ATLANTES Research Program, Institute for Culture and Society, University of Navarra, Pamplona, Spain
| | - Eduardo Garralda
- ATLANTES Research Program, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- IdiSNA (Instituto de Investigación Sanitaria de Navarra/Institute of Health Research of Navarra), Pamplona, Spain
| | - Liliana De Lima
- International Association for Hospice and Palliative Care, Houston, Texas
| | - John Y. Rhee
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carlos Centeno
- ATLANTES Research Program, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- IdiSNA (Instituto de Investigación Sanitaria de Navarra/Institute of Health Research of Navarra), Pamplona, Spain
| |
Collapse
|
23
|
Pacurucu‐Castillo SF, Ordóñez‐Mancheno JM, Hernández‐Cruz A, Alarcón RD. World Opioid and Substance Use Epidemic: A Latin American Perspective. PSYCHIATRIC RESEARCH AND CLINICAL PRACTICE 2019; 1:32-38. [PMID: 36101564 PMCID: PMC9175731 DOI: 10.1176/appi.prcp.20180009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/16/2018] [Accepted: 10/31/2018] [Indexed: 12/03/2022] Open
Abstract
The opioid crisis is a growing social and public health phenomenon, particularly in developed countries such as the United States. Since the 1990s, this crisis has shown a variety of causal processes and consequences and has affected quality of life for millions of individuals, families, and communities across the globe. Although abuse of opioid‐based painkillers appears to have triggered the epidemic in the United States, in this article, the problem is examined with a focus on Latin America, where drug‐associated problems constitute threats to the health and quality of life for large segments of the population. After a review of the history of opium consumption and its consequences in the world and in Latin America, the authors present epidemiological data and information about regional market differences, professional involvement, clinical practices, public health realities, and prevention efforts. Recommendations are made for collaborative efforts to promote prevention policies and measures to improve the situation.
Collapse
Affiliation(s)
| | | | | | - Renato D. Alarcón
- Department of PsychiatryMayo Clinic College of MedicineRochesterMN
- Academic AffairsSchool of MedicineUniversidad Peruana Cayetano HerediaLimaPerú
| |
Collapse
|
24
|
Morgan GW, Foster K, Healy B, Opie C, Huynh V. Improving Health and Cancer Services in Low-Resource Countries to Attain the Sustainable Development Goals Target 3.4 for Noncommunicable Diseases. J Glob Oncol 2018; 4:1-11. [PMID: 30582432 PMCID: PMC7010423 DOI: 10.1200/jgo.18.00185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The United Nations Sustainable Development Goals 2015 to 2030 includes a specific goal for health (Sustainable Development Goal [SDG] 3) with 13 targets, including SDG3.4 for the control and treatment of noncommunicable diseases (NCDs), namely, cardiovascular diseases, cancer, diabetes, and chronic lung disease. There is considerable concern that SDG3.4 may not be achieved. The WHO Best Buys for NCDs has emphasized prevention, and although crucial, it alone will not achieve the 30% reduction in NCDs by 2030. Likewise, a strengthened health system is required as all NCDs are likely to require hospital facilities and community services for optimal management. This is a major problem for low-resource countries (LRCs) -that is, low-income countries and lower-middle-income countries-as most currently have a poorly developed health system, including cancer services, in need of upgrading. This is a result of the extreme poverty of LRCs, where 40% to 80% of the population live on less than USD $1.25 per day, with the average health spending by governments in low-income countries at $110 per person per year. In this article, we outline a comprehensive national cancer services plan for LRCs. Surgery, radiotherapy, and chemotherapy for cancer treatment also require input from other specialties, such as anesthesia, pathology, laboratory medicine, a blood bank, and diagnostic radiology. This will provide a focus for adding additional specialties, including cardiology, respiratory medicine, and psychiatry, to support the management of all NCDs and to contribute to the overall strengthening of the health system. The national cancer services plan for LRCs will require significant funding and input from both in-country and overseas experts in health, cancer, and finance working collaboratively. Success will depend on thoughtful strategic planning and providing the right balance of overseas support and guidance, but ensuring that there is in-country ownership and control of the program is essential.
Collapse
Affiliation(s)
- Graeme W Morgan
- Graeme W. Morgan, Kirsty Foster, and Vu Huynh, The University of Sydney; Craig Opie, Royal North Shore Hospital, Sydney, New South Wales; and Brendan Healy, Icon Cancer Group, Brisbane, Queensland, Australia
| | - Kirsty Foster
- Graeme W. Morgan, Kirsty Foster, and Vu Huynh, The University of Sydney; Craig Opie, Royal North Shore Hospital, Sydney, New South Wales; and Brendan Healy, Icon Cancer Group, Brisbane, Queensland, Australia
| | - Brendan Healy
- Graeme W. Morgan, Kirsty Foster, and Vu Huynh, The University of Sydney; Craig Opie, Royal North Shore Hospital, Sydney, New South Wales; and Brendan Healy, Icon Cancer Group, Brisbane, Queensland, Australia
| | - Craig Opie
- Graeme W. Morgan, Kirsty Foster, and Vu Huynh, The University of Sydney; Craig Opie, Royal North Shore Hospital, Sydney, New South Wales; and Brendan Healy, Icon Cancer Group, Brisbane, Queensland, Australia
| | - Vu Huynh
- Graeme W. Morgan, Kirsty Foster, and Vu Huynh, The University of Sydney; Craig Opie, Royal North Shore Hospital, Sydney, New South Wales; and Brendan Healy, Icon Cancer Group, Brisbane, Queensland, Australia
| |
Collapse
|
25
|
Schneider M, Chappuis F, Pautex S. How do expatriate health workers cope with needs to provide palliative care in humanitarian emergency assistance? A qualitative study with in-depth interviews. Palliat Med 2018; 32:1567-1574. [PMID: 30113246 DOI: 10.1177/0269216318794091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Given the worldwide increase of chronic diseases, expatriate health workers on assignment with humanitarian emergency organisations can face more clinical situations that require advanced pain control or palliative care. Multiple reasons can prevent the provision of this care. AIM To better know how health workers react to and cope with this dilemma. DESIGN A qualitative interview study using inductive thematic analysis was performed. SETTING/PARTICIPANTS A total of 15 expatriate health workers took part in individual in-depth interviews after their assignment with the organisation 'Médecins sans Frontières'. RESULTS Clinical situations requiring advanced pain control or palliative care do occur during assignments. Expatriate health workers have different levels of knowledge of pain control and palliative care. Lacking opioids were a main reason for inadequate pain control. The expatriates felt helpless, distressed and frustrated in such situations. Peer support was sometimes helpful. Guidelines for palliative care in emergency settings would have been useful. CONCLUSION Pain control and palliative care needs occur during clinical practice in emergency humanitarian assistance. Training for expatriate health workers should be improved. Humanitarian organisations should strengthen their capacity to provide pain control and palliative care by developing and applying adapted guidelines.
Collapse
Affiliation(s)
- Martin Schneider
- 1 Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - François Chappuis
- 2 Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Sophie Pautex
- 3 Division of Primary Care, Geneva University Hospitals, Geneva, Switzerland
| |
Collapse
|
26
|
|
27
|
Vranken MJ, Mantel-Teeuwisse AK, Schutjens MHD, Scholten WK, Jünger S, Leufkens HG. Access to Strong Opioid Analgesics in the Context of Legal and Regulatory Barriers in Eleven Central and Eastern European Countries. J Palliat Med 2018; 21:963-969. [DOI: 10.1089/jpm.2017.0595] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Marjolein J.M. Vranken
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Aukje K. Mantel-Teeuwisse
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Marie-Hélène D.B. Schutjens
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
- Schutjens de Bruin, Tilburg, The Netherlands
| | | | - Saskia Jünger
- Research Unit Ethics, University Hospital Cologne, Cologne, Germany
- Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health (ceres), University of Cologne, Cologne, Germany
| | - Hubert G.M. Leufkens
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
28
|
Patient and Physician Satisfaction with Analgesic Treatment: Findings from the Analgesic Treatment for Cancer Pain in Southeast Asia (ACE) Study. Pain Res Manag 2018; 2018:2193710. [PMID: 29849841 PMCID: PMC5932441 DOI: 10.1155/2018/2193710] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 02/01/2018] [Accepted: 02/17/2018] [Indexed: 12/05/2022]
Abstract
Aim The aim of this study was to examine patients' and physicians' satisfaction, and concordance of patient-physician satisfaction with patients' pain control status. Methods This cross-sectional observational study involved 465 adults prescribed analgesics for cancer-related pain from 22 sites across Indonesia, Malaysia, Philippines, Singapore, Thailand, and Vietnam. Pain intensity, pain control satisfaction, and adequacy of analgesics for pain control were documented using questionnaires. Results Most patients (84.4%) had stage III or IV cancer. On a scale of 0 (no pain) to 10 (worse pain), patients' mean worst pain intensity over 24 hours was 4.76 (SD 2.47). More physicians (19.0%) than patients (8.0%) reported dissatisfaction with patient's pain control. Concordance of patient-physician satisfaction was low (weighted kappa 0.36; 95% CI 0.03–0.24). Most physicians (71.2%) found analgesics to be adequate for pain control. Patients' and physicians' satisfaction with pain control and physician-assessed analgesic adequacy were significantly different across countries (P < 0.001 for all). Conclusions Despite pain-related problems with sleep and quality of life, patients were generally satisfied with their pain control status. Interestingly, physicians were more likely to be dissatisfied with patients' pain control. Enhanced patient-physician communication, physicians' proactivity in managing opioid-induced adverse effects, and accessibility of analgesics have been identified to be crucial for successful cancer pain management. This study was registered at ClinicalTrials.gov (identifier NCT02664987).
Collapse
|
29
|
Hamdi H, Ba O, Niang S, Ntizimira C, Mbengue M, Coulbary AS, Niang R, Parsons M, Amon JJ, Lohman D. Palliative Care Need and Availability in Four Referral Hospitals in Senegal: Results from a Multicomponent Assessment. J Pain Symptom Manage 2018; 55:1122-1130. [PMID: 29223401 DOI: 10.1016/j.jpainsymman.2017.11.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/27/2017] [Accepted: 11/29/2017] [Indexed: 11/20/2022]
Abstract
CONTEXT With prevalence of noncommunicable diseases and life expectancy rising in Senegal, the need for palliative care is likely growing. No national palliative care needs assessments have been carried out. OBJECTIVES To assess the capacity and need for palliative care in Senegal. METHODS A multicomponent assessment of availability and demand for palliative care was conducted in two tertiary and two regional hospitals in Senegal in 2015 with approval from Senegal's National Ethics Committee for Health Research. The assessment consisted of (1) an inpatient hospital census; (2, 3) surveys of inpatients and outpatients with life-limiting illness; (4) a knowledge, attitudes, and practices survey among health care workers; and (5) a facility survey to assess availability of palliative care medications. RESULTS Nearly half (44.4%) of all inpatients (n = 167) had an active life-limiting illness. Among them, 56.6% reported moderate-to-severe pain in the past three days, 2.3% of whom received morphine, and 76.7% received weak or no pain medication. Inpatients also experienced moderate-to-severe dyspnea (42.1%), fatigue (66.5%), nausea (16.5%), and drowsiness (42.1%). About 39.2% of all outpatients (n = 395) reported moderate-to-severe pain, and 52.8% reported that the treatment they had received relieved their pain only partially or not at all. Two-thirds of all doctors reported feeling comfortable prescribing pain medicines; however, 83.0% rarely or never prescribed morphine. Two of four hospitals reported no use of morphine in 2014. CONCLUSION There is significant need for palliative care in Senegal. Training of health care workers and ensuring availability of relevant medications should be prioritized.
Collapse
Affiliation(s)
- Hana Hamdi
- Columbia University Mailman School of Public Health, New York, New York, USA
| | - Oumar Ba
- Hopital General de Grand Yoff, Dakar, Senegal, Africa
| | - Serigne Niang
- Ministry of Health and Social Action, Dakar, Senegal, Africa
| | | | | | | | | | | | - Joseph J Amon
- Columbia University Mailman School of Public Health, New York, New York, USA
| | | |
Collapse
|
30
|
Affiliation(s)
- Jack E Fincham
- School of Pharmacy, Presbyterian College, Clinton, SC, USA
| |
Collapse
|
31
|
Jennings N, Chambaere K, Macpherson CC, Deliens L, Cohen J. Main themes, barriers, and solutions to palliative and end-of-life care in the English-speaking Caribbean: a scoping review. Rev Panam Salud Publica 2018; 42:e15. [PMID: 31093044 PMCID: PMC6385807 DOI: 10.26633/rpsp.2018.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 08/09/2017] [Indexed: 11/24/2022] Open
Abstract
Objectives To identify common themes documented in the literature on palliative and end-of-life care in English-speaking Caribbean small island developing states (SIDS), and to describe barriers, improvement strategies, and suggested ways forward. Methods In 2015, we conducted a systematic scoping review of relevant literature identified through the MEDLINE and Web of Science databases. We supplemented that with searches of other electronic and hard-copy sources to map key concepts and summarize themes. Results Primary data and other literature from and about English-speaking Caribbean nations are relatively scarce. The available literature offers an overview of the existing situation in the region and explores why palliative and end-of-life care is limited there. This review identified barriers in five main areas recurring across this literature: i) culture and attitudes of health care providers, patients, and those close to them towards terminal illness and death; ii) opioid availability and use; iii) limited development of palliative care services; iv) unmet palliative care needs; and v) limited research on palliative or end-of-life care. Conclusions Our analysis helps to document the need for palliative and end-of-life care in Caribbean SIDS and highlights suggestions for moving forward with related practice, policy, and research.
Collapse
Affiliation(s)
- Nicholas Jennings
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Cheryl C Macpherson
- Bioethics Department, St. George's University School of Medicine and Windward Islands Research and Education Foundation, St. George's, Grenada
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| |
Collapse
|
32
|
Prager GW, Braga S, Bystricky B, Qvortrup C, Criscitiello C, Esin E, Sonke GS, Martínez GA, Frenel JS, Karamouzis M, Strijbos M, Yazici O, Bossi P, Banerjee S, Troiani T, Eniu A, Ciardiello F, Tabernero J, Zielinski CC, Casali PG, Cardoso F, Douillard JY, Jezdic S, McGregor K, Bricalli G, Vyas M, Ilbawi A. Global cancer control: responding to the growing burden, rising costs and inequalities in access. ESMO Open 2018; 3:e000285. [PMID: 29464109 PMCID: PMC5812392 DOI: 10.1136/esmoopen-2017-000285] [Citation(s) in RCA: 150] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 01/05/2018] [Accepted: 01/08/2018] [Indexed: 02/06/2023] Open
Abstract
The cancer burden is rising globally, exerting significant strain on populations and health systems at all income levels. In May 2017, world governments made a commitment to further invest in cancer control as a public health priority, passing the World Health Assembly Resolution 70.12 on cancer prevention and control within an integrated approach. In this manuscript, the 2016 European Society for Medical Oncology Leadership Generation Programme participants propose a strategic framework that is in line with the 2017 WHO Cancer Resolution and consistent with the principle of universal health coverage, which ensures access to optimal cancer care for all people because health is a basic human right. The time for action is now to reduce barriers and provide the highest possible quality cancer care to everyone regardless of circumstance, precondition or geographic location. The national actions and the policy recommendations in this paper set forth the vision of its authors for the future of global cancer control at the national level, where the WHO Cancer Resolution must be implemented if we are to reduce the cancer burden, avoid unnecessary suffering and save as many lives as possible.
Collapse
Affiliation(s)
- Gerald W Prager
- Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Sofia Braga
- Instituto CUF Oncologia, NOVA Medical School, Lisboa, Portugal
| | | | - Camilla Qvortrup
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Carmen Criscitiello
- Division of Early Drug Development for Innovative Therapies, Istituto Europeo di Oncologia, Milano, Lombardia, Italy
| | - Ece Esin
- Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Gabe S Sonke
- Division of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | | | - Michalis Karamouzis
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Ozan Yazici
- Department of Medical Oncology, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Paolo Bossi
- Fondazione IRCCS Istituto Nazionale Tumori Milano, Milano, Italy
| | | | - Teresa Troiani
- Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy
| | | | | | - Josep Tabernero
- Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Christoph C Zielinski
- Comprehensive Cancer Center, Medical University Vienna, General Hospital, and Vienna Cancer Center, Vienna, Austria
| | | | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center, Lisbon, Portugal
| | | | | | - Keith McGregor
- European Society for Medical Oncology, Lugano, Switzerland
| | | | - Malvika Vyas
- European Society for Medical Oncology, Lugano, Switzerland
| | - André Ilbawi
- Cancer Control, Management of Noncommunicable Diseases Unit Department for Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention (NVI), World Health Organization, Geneva, Switzerland
| |
Collapse
|
33
|
Cleary JF, Maurer MA. Pain and Policy Studies Group: Two Decades of Working to Address Regulatory Barriers to Improve Opioid Availability and Accessibility Around the World. J Pain Symptom Manage 2018; 55:S121-S134. [PMID: 28801005 DOI: 10.1016/j.jpainsymman.2017.03.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 03/03/2017] [Indexed: 11/23/2022]
Abstract
For two decades, the Pain & Policy Studies Group (PPSG), a global research program at the University of Wisconsin Carbone Cancer Center, has worked passionately to fulfill its mission of improving pain relief by achieving balanced access to opioids worldwide. PPSG's early work highlighted the conceptual framework of balance leading to the development of the seminal guidelines and criteria for evaluating opioid policy. It has collaborated at the global level with United Nations agencies to promote access to opioids and has developed a unique model of technical assistance to help national governments assess regulatory barriers to essential medicines for pain relief and amend existing or develop new legislation that facilitates appropriate and adequate opioid prescribing according to international standards. This model was initially applied in regional workshops and individual country projects and then adapted for PPSG's International Pain Policy Fellowship, which provides long-term mentoring and support for several countries simultaneously. The PPSG disseminates its work online in several ways, including an extensive Web site, news alerts, and through several social media outlets. PPSG has become the focal point for expertise on policy governing drug control and medicine and pharmacy practice related to opioid availability and pain relief.
Collapse
Affiliation(s)
- James F Cleary
- Pain & Policy Studies Group, University of Wisconsin Carbone Cancer Center, School of Medicine and Public Health, Madison, Wisconsin, USA; World Health Organization Collaborating Center for Pain Policy and Palliative Care, Madison, Wisconsin, USA
| | - Martha A Maurer
- Pain & Policy Studies Group, University of Wisconsin Carbone Cancer Center, School of Medicine and Public Health, Madison, Wisconsin, USA; World Health Organization Collaborating Center for Pain Policy and Palliative Care, Madison, Wisconsin, USA.
| |
Collapse
|
34
|
Cherny N, Sullivan R, Torode J, Saar M, Eniu A. ESMO European Consortium Study on the availability, out-of-pocket costs and accessibility of antineoplastic medicines in Europe. Ann Oncol 2017; 27:1423-43. [PMID: 27457309 DOI: 10.1093/annonc/mdw213] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 05/13/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The management of cancer is predicated on the availability and affordability of anticancer therapies, which may be either curative or noncurative. AIM The primary aims of the study were to evaluate (i) the formulary availability of licensed antineoplastic medicines across Europe; (ii) patient out-of-pocket costs for the medications and (iii) the actual availability of the medication for a patient with a valid prescription. MATERIALS AND METHODS The survey tool was based on the previous ESMO studies that addressed the availability and accessibility of opioids for the management of cancer pain. A total of 185 field reporters from 49 countries were invited to participate. The preliminary set of data was posted on the ESMO website for open peer-review, and amendments have been incorporated into the final report. RESULTS There are substantial differences in the formulary availability, out-of-pocket costs and actual availability for many anticancer medicines. The most profound lack of availability is in countries with lower levels of economic development, particularly in Eastern Europe, and these are largely related to the cost of targeted agents approved in the last 10 years. Discrepancies are less profound among medications on the WHO model essential medicines list (EML) for cancer and in curative settings. However, medicine shortages also affect WHO EML medicines, with relevant therapeutic implications for many patients. CONCLUSIONS The cost and affordability of anticancer treatments with recent market approval is the major factor contributing to inequity of access to anticancer medications. This is especially true with regards to new medications used in the management of EGFR- or ALK-mutated non-small-cell lung cancer, metastatic melanoma, metastatic renal cell cancer, RAS/RAF wild-type metastatic colorectal cancer, HER2 overexpressed breast cancer and castration-resistant metastatic prostate cancer.
Collapse
Affiliation(s)
- N Cherny
- Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - R Sullivan
- Kings Health Partners Integrated Cancer Centre, King's College London, Institute of Cancer Policy, London, UK
| | - J Torode
- Advocacy and Programmes, Union for International Cancer Control (UICC), Geneva, Switzerland
| | - M Saar
- Tartu University Hospital, Tartu, Estonia
| | - A Eniu
- Department of Breast Tumors, Cancer Institute Ion Chiricuta Cluj-Napoca, Cluj-Napoca, Romania
| |
Collapse
|
35
|
Eniu AE, Martei YM, Trimble EL, Shulman LN. Cancer Care and Control as a Human Right: Recognizing Global Oncology as an Academic Field. Am Soc Clin Oncol Educ Book 2017; 37:409-415. [PMID: 28561681 DOI: 10.1200/edbk_175251] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The global burden of cancer incidence and mortality is on the rise. There are major differences in cancer fatality rates due to profound disparities in the burden and resource allocation for cancer care and control in developed compared with developing countries. The right to cancer care and control should be a human right accessible to all patients with cancer, regardless of geographic or economic region, to avoid unnecessary deaths and suffering from cancer. National cancer planning should include an integrated approach that incorporates a continuum of education, prevention, cancer diagnostics, treatment, survivorship, and palliative care. Global oncology as an academic field should offer the knowledge and skills needed to efficiently assess situations and work on solutions, in close partnership. We need medical oncologists, surgical oncologists, pediatric oncologists, gynecologic oncologists, radiologists, and pathologists trained to think about well-tailored resource-stratified solutions to cancer care in the developing world. Moreover, the multidisciplinary fundamental team approach needed to treat most neoplastic diseases requires coordinated investment in several areas. Current innovative approaches have relied on partnerships between academic institutions in developed countries and local governments and ministries of health in developing countries to provide the expertise needed to implement effective cancer control programs. Global oncology is a viable and necessary field that needs to be emphasized because of its critical role in proposing not only solutions in developing countries, but also solutions that can be applied to similar challenges of access to cancer care and control faced by underserved populations in developed countries.
Collapse
Affiliation(s)
- Alexandru E Eniu
- From the Cancer Institute Ion Chiricuta, Cluj-Napoca, Romania; Hematology-Oncology Division, University of Pennsylvania, Philadelphia, PA; National Cancer Institute, Bethesda, MD; Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Yehoda M Martei
- From the Cancer Institute Ion Chiricuta, Cluj-Napoca, Romania; Hematology-Oncology Division, University of Pennsylvania, Philadelphia, PA; National Cancer Institute, Bethesda, MD; Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Edward L Trimble
- From the Cancer Institute Ion Chiricuta, Cluj-Napoca, Romania; Hematology-Oncology Division, University of Pennsylvania, Philadelphia, PA; National Cancer Institute, Bethesda, MD; Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Lawrence N Shulman
- From the Cancer Institute Ion Chiricuta, Cluj-Napoca, Romania; Hematology-Oncology Division, University of Pennsylvania, Philadelphia, PA; National Cancer Institute, Bethesda, MD; Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
36
|
Cherny NI, Sullivan R, Torode J, Saar M, Eniu A. ESMO International Consortium Study on the availability, out-of-pocket costs and accessibility of antineoplastic medicines in countries outside of Europe. Ann Oncol 2017; 28:2633-2647. [PMID: 28950323 PMCID: PMC5834140 DOI: 10.1093/annonc/mdx521] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The availability and affordability of safe, effective, high-quality, affordable anticancer therapies are a core requirement for effective national cancer control plans. METHOD Online survey based on a previously validated approach. The aims of the study were to evaluate (i) the availability on national formulary of licensed antineoplastic medicines across the globe, (ii) patient out-of-pocket costs for the medications, (iii) the actual availability of the medication for a patient with a valid prescription, (iv) information relating to possible factors adversely impacting the availability of antineoplastic agents and (v) the impact of the country's level of economic development on these parameters. A total of 304 field reporters from 97 countries were invited to participate. The preliminary set of data was posted on the ESMO website for open peer review and amendments have been incorporated into the final report. RESULTS Surveys were submitted by 135 reporters from 63 countries and additional peer-review data were submitted by 54 reporters from 19 countries. There are substantial differences in the formulary availability, out-of-pocket costs and actual availability for many anticancer medicines. The most substantial issues are in lower-middle- and low-income countries. Even among medications on the WHO Model List of Essential Medicines (EML) the discrepancies are profound and these relate to high out-of-pocket costs (in low-middle-income countries 32.0% of EML medicines are available only at full cost and 5.2% are not available at all, and for low-income countries, the corresponding figures are even worse at 57.7% and 8.3%, respectively). CONCLUSIONS There is wide global variation in formulary availability, out-of-pocket expenditures and actual availability for most licensed anticancer medicines. Low- and low-middle-income countries have significant lack of availability and high out-of-pocket expenditures for cancer medicines on the WHO EML, with much less availability of new, more expensive targeted agents compared with high-income countries.
Collapse
Affiliation(s)
- N I Cherny
- Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel.
| | - R Sullivan
- Institute of Cancer Policy, Kings Health Partners Comprehensive Cancer Centre, King's College London, London, UK
| | - J Torode
- Union for International Cancer Control (UICC), Geneva, Switzerland
| | - M Saar
- Tartu University Hospital, Tartu, Estonia
| | - A Eniu
- ESMO Global Policy Committee; Department of Breast Tumors, Cancer Institute Ion Chiricuta Cluj-Napoca, Cluj-Napoca, Romania
| |
Collapse
|
37
|
Xia Z. Cancer pain management in China: current status and practice implications based on the ACHEON survey. J Pain Res 2017; 10:1943-1952. [PMID: 28860849 PMCID: PMC5571848 DOI: 10.2147/jpr.s128533] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Purpose Cancer pain can seriously impact the quality of life (QoL) of patients, and optimal management practices are therefore of paramount importance. The ACHEON survey queried physicians and patients from 10 Asian countries/regions to assess current clinical practices in cancer pain management in Asia. This study presents the data obtained for cancer pain management in mainland China, with an emphasis on practices related to opioid drugs. Materials and methods In several tertiary hospitals across China, 250 patients experiencing cancer pain and 100 physicians were surveyed on questions designed to assess current cancer pain management practices and cancer pain impact on QoL. Results The patient survey showed that 88% of patients reported moderate-to-severe cancer pain, with a median duration of 6 months. The physician survey showed that medical school/residency training with regard to cancer pain management was inadequate in ~80% of physicians. A total of 80% of physicians and 67.2% of patients reported that pain scale was used during pain assessment; 84% of physicians expressed that physician-perceived pain severity was not completely consistent with actual pain the patient experienced. Of the 147 patients who recalled the medication received, 83.7% were administered opioid prescriptions. Of the 240 patients who received treatment, 43.8% perceived the inadequacy of controlling pain. The primary barriers from physicians perceived to optimal pain management included patients’ fear of side effects (58%), patients’ fear of addiction (53%), patients’ reluctance to report pain (43%), physicians’ reluctance to prescribe (29%), physicians’ inadequacy of pain assessment (27%) and excessive regulation of opioid analgesics (47%). Conclusion Knowledge of cancer pain management should be strengthened among physicians. Quantitative pain assessment and principle-based pain management should be combined to achieve pain relief. Misconceptions about opioids in patients and physicians and poor report about pain should be overcome through training/education to improve QoL of patients impacted by pain.
Collapse
Affiliation(s)
- Zhongjun Xia
- Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, China
| |
Collapse
|
38
|
Odonkor CA, Kim G, Erdek M. Global cancer pain management: a systematic review comparing trials in Africa, Europe and North America. Pain Manag 2017; 7:299-310. [PMID: 28699421 DOI: 10.2217/pmt-2016-0047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIM Despite the rise in cancer survivorship, few reviews have examined the quality of studies of cancer pain management and practices around the globe. With a void in trials spanning multiple geographical settings, this review evaluates the quality of cancer trials across three continents. MATERIALS & METHODS A literature review and search of established databases was conducted to identify eligible studies. The Cochrane method, the Jadad Score and a cancer pain-specific ad hoc tool were used to evaluate quality of studies. RESULTS Eighteen studies representing a total of 4693 individuals were included in the review. Study quality correlated positively with study sample size and palliative care index. Trials in all three continents were prone to use opioids for pain management, whereas trials in Europe and North America utilized other adjuvant therapies such as antidepressants and steroids. CONCLUSION This review underscores the need for better multidimensional quality assessment tools for cancer pain trials.
Collapse
Affiliation(s)
- Charles A Odonkor
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA
| | - Gabriel Kim
- Department of Internal Medicine, Howard University College of Medicine, Washington, DC 20059, USA
| | - Michael Erdek
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| |
Collapse
|
39
|
Vranken MJM, Mantel-Teeuwisse AK, Jünger S, Radbruch L, Scholten W, Lisman JA, Subataite M, Schutjens MHDB. Barriers to access to opioid medicines for patients with opioid dependence: a review of legislation and regulations in eleven central and eastern European countries. Addiction 2017; 112:1069-1076. [PMID: 28087986 DOI: 10.1111/add.13755] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/25/2016] [Accepted: 01/10/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Barriers linked to drug control systems are considered to contribute to inequitable access to controlled medicines, leaving millions of people in pain and suffering. Most studies focus on access to opioids for the treatment of severe (cancer) pain. This study aims to identify specific access barriers for patients with opioid dependence in legislation and regulations of 11 central and eastern European countries. METHODS This study builds on a previous analysis of legislation and regulations as part of the EU 7th Framework Access To Opioid Medication in Europe (ATOME) project. An in-depth analysis was undertaken to determine specific barriers for patients with opioid dependence in need of opioid analgesics or opioid agonist therapy (OAT). For each country, the number and nature of specific potential barriers for these patients were assessed according to eight categories: prescribing; dispensing; manufacturing; usage; trade and distribution; affordability; penalties; and other. An additional keyword search was conducted to minimize the omission of barriers. Barriers in an additional category, language, were recorded qualitatively. Countries included Bulgaria, Cyprus, Estonia, Greece, Hungary, Latvia, Lithuania, Serbia, Slovakia, Slovenia and Turkey. RESULTS Ten of the 11 countries (all except Estonia) showed specific potential barriers in their legislation and regulations. The total number of barriers varied from two (Slovenia) to 46 (Lithuania); the number of categories varied from one (Slovenia) to five (Lithuania). Most specific potential barriers were shown in the categories 'prescribing', 'usage' and 'other'. The total number in a single category varied from one to 18 (Lithuania, prescribing). Individual differences between countries in the same specific potential barrier were shown; for example, variation in minimum age criteria for admission to OAT ranging from 15 (Lithuania, in special cases) to 20 years (Greece). All countries had stigmatizing language in their legislation. CONCLUSIONS Patients with opioid dependence are likely to experience specific barriers to accessing opioids in addition to those experienced by other non-dependent patients.
Collapse
Affiliation(s)
- Marjolein J M Vranken
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Saskia Jünger
- Institute of General Practice, Hannover Medical School, Hannover, Germany.,Research Unit Ethics, University Hospital Cologne, Cologne, Germany
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital, Bonn, Germany.,Centre for Palliative Care, Malteser Hospital, Bonn, Bonn, Germany
| | - Willem Scholten
- Willem Scholten Consultancy, Medicines and Controlled Substances, Lopik, The Netherlands
| | - John A Lisman
- Lisman Legal Life sciences, Nieuwerbrug, The Netherlands
| | | | - Marie-Hélène D B Schutjens
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands.,Schutjens de Bruin, Tilburg, The Netherlands
| |
Collapse
|
40
|
|
41
|
Abstract
Purpose Access to opioids for pain control is recognized as an urgent issue in low- and middle-income countries. Here we report temporal and regional trends in morphine use in Kerala, India. Methods Oral morphine use data for the State of Kerala (2012 to 2015) was used to describe temporal trends, regional variation, and provider characteristics. Total morphine use was calculated for each district of Kerala to derive an annual per capita use rate (milligrams per capita). Each provider was classified as government, private, nongovernment organization (NGO), or NGO partnership. Results Oral morphine use for Kerala was 1.32 mg/capita and increased over the study period 27% (from 1.23 mg/capita to 1.56 mg/capita). There was substantial variation in morphine use across districts (range, 0.49 mg/capita to 2.97 mg/capita; six-fold difference). This variation increased over time (19-fold difference in 2015). In 2015, 31% of morphine providers (51 of 167) were government institutions; they delivered 48% of total morphine in Kerala. Corresponding data for other providers are private institutions, 23% of centers and 13% of morphine; NGOs, 41% of centers and 34% of morphine; and NGO partnerships, 5% of centers and 4% of morphine. From 2012 to 2015, the total number of centers increased by 35%, from 124 to 167. Conclusion Oral morphine use has increased over time in Kerala but remains substantially lower than estimated need. There is significant geographic variation of use. Efforts are needed to improve palliative care in Kerala and to reduce regional disparities in access to opioids.
Collapse
Affiliation(s)
- M R Rajagopal
- M.R. Rajagopal, Trivandrum Institute of Palliative Sciences and Pallium India, Trivandrum, India; and Safiya Karim and Christopher M. Booth, Queen's University, Kingston, Ontario, Canada
| | - Safiya Karim
- M.R. Rajagopal, Trivandrum Institute of Palliative Sciences and Pallium India, Trivandrum, India; and Safiya Karim and Christopher M. Booth, Queen's University, Kingston, Ontario, Canada
| | - Christopher M Booth
- M.R. Rajagopal, Trivandrum Institute of Palliative Sciences and Pallium India, Trivandrum, India; and Safiya Karim and Christopher M. Booth, Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
42
|
Clark D, Inbadas H, Colburn B, Forrest C, Richards N, Whitelaw S, Zaman S. Interventions at the end of life - a taxonomy for 'overlapping consensus'. Wellcome Open Res 2017; 2:7. [PMID: 28261674 PMCID: PMC5336190 DOI: 10.12688/wellcomeopenres.10722.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Context: Around the world there is increasing interest in end of life issues. An unprecedented number of people dying in future decades will put new strains on families, communities, services and governments. It will also have implications for representations of death and dying within society and for the overall orientation of health and social care. What interventions are emerging in the face of these challenges? Methods: We conceptualize a comprehensive taxonomy of interventions, defined as 'organized responses to end of life issues'. Findings: We classify the range of end of life interventions into 10 substantive categories: policy, advocacy, educational, ethico-legal, service, clinical, research, cultural, intangible, self-determined. We distinguish between two empirical aspects of any end of life intervention: the 'locus' refers to the space or spaces in which it is situated; the 'focus' captures its distinct character and purpose. We also contend that end of life interventions can be seen conceptually in two ways - as 'frames' (organized responses that primarily construct a shared understanding of an end of life issue) or as 'instruments' (organized responses that assume a shared understanding and then move to act in that context). Conclusions: Our taxonomy opens up the debate about end of life interventions in new ways to provide protagonists, activists, policy makers, clinicians, researchers and educators with a comprehensive framework in which to place their endeavours and more effectively to assess their efficacy. Following the inspiration of political philosopher John Rawls, we seek to foster an 'overlapping consensus' on how interventions at the end of life can be construed, understood and assessed.
Collapse
Affiliation(s)
- David Clark
- School of Interdisciplinary Studies, University of Glasgow, Glasgow, UK
| | - Hamilton Inbadas
- School of Interdisciplinary Studies, University of Glasgow, Glasgow, UK
| | - Ben Colburn
- School of Humanities, University of Glasgow, Glasgow, UK
| | - Catriona Forrest
- School of Interdisciplinary Studies, University of Glasgow, Glasgow, UK
| | - Naomi Richards
- School of Interdisciplinary Studies, University of Glasgow, Glasgow, UK
| | - Sandy Whitelaw
- School of Interdisciplinary Studies, University of Glasgow, Glasgow, UK
| | - Shahaduz Zaman
- School of Interdisciplinary Studies, University of Glasgow, Glasgow, UK
| |
Collapse
|
43
|
LeBaron VT, Palat G, Sinha S, Chinta SK, Jamima BJB, Pilla UL, Podduturi N, Shapuram Y, Vennela P, Rapelli V, Lalani Z, Beck SL. Recommendations to Support Nurses and Improve the Delivery of Oncology and Palliative Care in India. Indian J Palliat Care 2017; 23:188-198. [PMID: 28503040 PMCID: PMC5412128 DOI: 10.4103/ijpc.ijpc_153_16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Nurses in India often practice in resource-constrained settings and care for cancer patients with high symptom burden yet receive little oncology or palliative care training. AIM The aim of this study is to explore challenges encountered by nurses in India and offer recommendations to improve the delivery of oncology and palliative care. METHODS Qualitative ethnography. SETTING The study was conducted at a government cancer hospital in urban South India. SAMPLE Thirty-seven oncology/palliative care nurses and 22 others (physicians, social workers, pharmacists, patients/family members) who interact closely with nurses were included in the study. DATA COLLECTION Data were collected over 9 months (September 2011- June 2012). Key data sources included over 400 hours of participant observation and 54 audio-recorded semi-structured interviews. ANALYSIS Systematic qualitative analysis of field notes and interview transcripts identified key themes and patterns. RESULTS Key concerns of nurses included safety related to chemotherapy administration, workload and clerical responsibilities, patients who died on the wards, monitoring family attendants, and lack of supplies. Many participants verbalized distress that they received no formal oncology training. CONCLUSIONS Recommendations to support nurses in India include: prioritize safety, optimize role of the nurse and explore innovative models of care delivery, empower staff nurses, strengthen nurse leadership, offer relevant educational programs, enhance teamwork, improve cancer pain management, and engage in research and quality improvement projects. Strong institutional commitment and leadership are required to implement interventions to support nurses. Successful interventions must account for existing cultural and professional norms and first address safety needs of nurses. Positive aspects from existing models of care delivery can be adapted and integrated into general nursing practice.
Collapse
Affiliation(s)
- Virginia T LeBaron
- Department of Acute and Specialty Care, University of Virginia School of Nursing, Charlottesville, VA, USA
| | - Gayatri Palat
- Palliative Access Programme, Two Worlds Cancer Collaboration-INCTR, Canada.,Department of Pain and Palliative Care, South Indian Cancer Hospital, India
| | - Sudha Sinha
- Department of Medical Oncology, South Indian Cancer Hospital, India.,Department of Pediatrics, South Indian Cancer Hospital, India
| | | | | | | | | | - Yadamma Shapuram
- Department of Pain and Palliative Care, South Indian Cancer Hospital, India
| | - Padma Vennela
- Department of Pain and Palliative Care, South Indian Cancer Hospital, India
| | - Vineela Rapelli
- Department of Pain and Palliative Care, South Indian Cancer Hospital, India
| | - Zahra Lalani
- Palliative Access Programme, Two Worlds Cancer Collaboration-INCTR, Canada.,Vancouver Hospice Society, British Columbia Cancer Agency, Canada
| | - Susan L Beck
- Division of Acute and Chronic Care, University of Utah College of Nursing, Salt Lake City, Utah, USA
| |
Collapse
|
44
|
Karim S, Del Paggio JC, Berry SR, Booth CM. Cancer care in South India: perspectives from visiting Canadian oncologists. ACTA ACUST UNITED AC 2016; 23:e527-e529. [PMID: 28050140 DOI: 10.3747/co.23.3411] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cancer is recognized as an increasing threat to public health in low- and middle-income countries (lMICS).[...]
Collapse
Affiliation(s)
- S Karim
- Department of Oncology, Queen's University, Kingston
| | - J C Del Paggio
- Department of Medicine, University of Toronto, Toronto and
| | - S R Berry
- Department of Medicine, University of Toronto, Toronto and
| | - C M Booth
- Department of Oncology, Queen's University, Kingston;; Department of Public Health Sciences, Queen's University, Kingston, ON
| |
Collapse
|
45
|
The role of opioids in cancer progression: emerging experimental and clinical implications. Ann Oncol 2016; 27:1978-1980. [DOI: 10.1093/annonc/mdw407] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
|
46
|
Sancho Zamora MA. [Opioids availability in the intermediate stay palliative care units in Madrid]. REVISTA DE CALIDAD ASISTENCIAL : ORGANO DE LA SOCIEDAD ESPANOLA DE CALIDAD ASISTENCIAL 2016; 31:380-382. [PMID: 26860784 DOI: 10.1016/j.cali.2015.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 10/09/2015] [Accepted: 11/09/2015] [Indexed: 06/05/2023]
Affiliation(s)
- M A Sancho Zamora
- Equipo de Soporte Hospitalario de Cuidados Paliativos, Hospital Universitario Ramón y Cajal, Madrid, España.
| |
Collapse
|
47
|
Affiliation(s)
- L Radbruch
- Klinik für Palliativmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland. .,Deutsche Gesellschaft für Palliativmedizin, Berlin, Deutschland.
| | - M Schäfer
- Klinik für Anästhesiologie und operative Intensivmedizin, Charité - Universitätsmedizin, Campus Virchow, Berlin, Deutschland.,Deutsche Schmerzgesellschaft, Berlin, Deutschland
| |
Collapse
|
48
|
Connecting the Dots: A Comparative Global Multi-Institutional Study of Prohibitive Factors Affecting Cancer Pain Management. PAIN MEDICINE 2016; 18:363-373. [DOI: 10.1093/pm/pnw143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
|
49
|
De Lima L, Pastrana T. Evaluation of the Effectiveness of Workshops on the Availability and Rational Use of Opioids in Latin America. J Palliat Med 2016; 19:964-71. [DOI: 10.1089/jpm.2016.0091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Liliana De Lima
- International Association for Hospice and Palliative Care (IAHPC), Houston, Texas
| | - Tania Pastrana
- Department for Palliative Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| |
Collapse
|
50
|
Bosnjak SM, Maurer MA, Ryan KM, Popovic I, Husain SA, Cleary JF, Scholten W. A Multifaceted Approach to Improve the Availability and Accessibility of Opioids for the Treatment of Cancer Pain in Serbia: Results From the International Pain Policy Fellowship (2006-2012) and Recommendations for Action. J Pain Symptom Manage 2016; 52:272-83. [PMID: 26988849 DOI: 10.1016/j.jpainsymman.2016.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 01/08/2016] [Accepted: 02/13/2016] [Indexed: 11/19/2022]
Abstract
Cancer is the second leading cause of death in Serbia, and at least 14,000-16,000 patients experience moderate-to-severe cancer pain every year. Cancer pain relief has been impeded by inadequate availability of opioid analgesics and barriers to their accessibility. In 2006, a Serbian oncologist was selected as an International Pain Policy Fellow. The fellow identified barriers to opioid availability in Serbia and implemented an action plan to address the unavailability of oral morphine, attitudinal and knowledge barriers about opioids, and barriers in the national opioid control policy, in collaboration with the government, local partners, and international experts, including those from the World Health Organization. Collaborative efforts resulted in availability of immediate-release oral morphine, registration of controlled-release hydromorphone, and reimbursement of oral methadone for cancer pain; numerous educational activities aimed at changing inadequate knowledge and negative attitudes toward opioids; recognition of opioids as essential medicines for palliative care in a new National Palliative Care Strategy; and recognition of the medical use of opioids as psychoactive-controlled substances for the relief of pain included in a new national law on psychoactive-controlled substances, and the development of recommendations for updating regulations on prescribing and dispensing opioids. An increase in opioid consumption at the institutional and national levels also was observed. This article outlines a multifaceted approach to improving access to strong opioids for cancer pain management and palliative care in a middle-income country and offers a potential road map to success.
Collapse
Affiliation(s)
- Snezana M Bosnjak
- Department of Supportive Oncology, Oncology Intensive Care Unit, Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
| | - Martha A Maurer
- Pain & Policy Studies Group, Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin, USA.
| | - Karen M Ryan
- Research and Sponsored Programs, University of Wisconsin, Madison, Wisconsin, USA
| | - Ivana Popovic
- Hospital Pharmacy, Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
| | - S Asra Husain
- Pain & Policy Studies Group, Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin, USA
| | - James F Cleary
- Pain & Policy Studies Group, Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Willem Scholten
- Willem Scholten Consultancy, Medicines and Controlled Substances, Lopik, The Netherlands
| |
Collapse
|