Interventions for Pain Relief
The goal of pain control is not to cure disease, but to allow patients to function as effectively as possible and to minimize pain. Interventions for pain relief include drugs, radiotherapy, and anesthetic, neurosurgical, psychological, and behavioral approaches (see table 52.1). However, analgesic drugs are the mainstay of treatment and the focus of this chapter. According to the World Health Organization (WHO), "A palliative care programme cannot exist unless it is based on a rational national drug policy," and this includes "regulations that allow ready access of suffering patients to opioids" (WHO 2002, 87).
[Table .]
WHO Three-Step Analgesic Ladder and Its Effectiveness
WHO has developed a "three-step analgesic ladder" (figure 52.1) for cancer pain and its treatment (WHO 1986), which includes a strong opioid (morphine) (table 52.2). The ladder is equally appropriate for patients with HIV/AIDS (O'Neill, Selwyn, and Schietinger 2003).
[Figure
52.1]
[Table .]
The steps in the ladder represent increasing pain severity and the drugs that should be used in each case:
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Step 1 is limited to nonopioids, including drugs that are widely available (for example, acetaminophen, aspirin, or nonsteroidal anti-inflammatory drugs, or NSAIDs).
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Step 2 describes moderate pain that requires a combination of a nonopioid and opioid for relief.
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Step 3 is for pain requiring a strong opioid. No specific dosages are recommended for opioid drugs because the concept of a standard dose does not apply: effective doses of oral morphine range from as little as 5 mg to more than 1,000 mg every four hours. Adjuvant drugs are also essential to treat side effects of analgesics or to provide additive analgesia (table 52.2).
Controlled field testing and clinical experience has demonstrated that 70 to 90 percent of cancer patients can achieve pain control using the ladder (Goudas, Carr, and Bloch 2001). Although the ladder has not been validated in formal studies for patients with AIDS, recent clinical reports describe its successful application (Anand, Carmosino, and Glatt 1994; Kimball and McCormick 1996; McCormack and others 1993; Newshan and Lefkowitz 2001; Newshan and Wainapel 1993; Schofferman and Brody 1990).
In an ideal world, a trained professional would prescribe pain medication throughout the course of illness, in accordance with the ladder. However, most patients self-medicate pain with analgesics and traditional medicines that they buy over the counter until they have late-stage disease and severe pain that can be treated only with a strong opioid. That is when they are most likely to seek formal medical care, which would start on step 3 of the ladder. Unfortunately, the opioid they need is unlikely to be unavailable in LMICs, even from health professionals.
Adequacy of and Barriers to Pain Control and Palliative Care in Developing Countries
The adequacy of pain control in populations is not easily measured. A useful and available surrogate is the per capita consumption of morphine (Joranson 1993), a figure based on mandatory annual reports by national governments to the International Narcotics Control Board (INCB). Of the 27 million grams of morphine used legally in 2002, 78 percent went to six countries—Australia, Canada, France, Germany, the United Kingdom, and the United States. The rest went to the other 142 countries that reported. Morphine is largely unavailable in Africa, the eastern Mediterranean, and Southeast Asia (figure 52.2).
[Figure
52.2]
The major barriers to palliative care in LMICs are scarce resources, lack of national policies or low priority for pain relief, lack of awareness by health professionals and the public that cancer and AIDS pain can be relieved, concern that medical use of opioids will lead to drug abuse and addiction, and legal restrictions on opioids. Medical, religious, gender, social, and cultural factors also present barriers (see box 52.2). With AIDS, social and self-stigmatization work against adequate care of any kind. In addition, most of the emphasis in poor countries has been on prevention and, more recently, on antiretroviral drugs. In all cases, even less care is in place for children than for adults (Joranson, Rajagopal, and Gilson 2002).
[Box 52.2]
Legal Controls on Opioid Drugs
The Single Convention on Narcotic Drugs of 1961, amended by the 1972 Protocol (United Nations 1961), is an international treaty that aims both to prevent the illicit production of, trafficking in, and use of narcotic drugs and to ensure their availability for medical and scientific needs. The INCB, established in 1968 by the Single Convention, is the independent, quasi-judicial organization that implements the Single Convention.
The Single Convention requires that all countries (even nonsignatories) intending to make opioids available for medical use estimate national opioid needs and report annually on imports, exports, and distribution to the retail level. It also sets out the following principles on which countries can develop their own policies and regulations:
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Individuals must be authorized to dispense opioids by virtue of their professional license or be specially licensed to do so.
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Opioids may be transferred only between authorized parties.
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Opioids may be dispensed only with a medical prescription.
Many governments have imposed even tighter restrictions, such as limiting the number of days for which an opioid prescription can be written.
