Pain and Policy Studies Group: Two Decades of Working to Address Regulatory Barriers to Improve Opioid Availability and Accessibility Around the World

Perceptions of Barriers to Using Opioid Analgesics: A Mixed Methods Study

Background

Availability and accessibility of opioids are a worldwide problem. In low-resource settings, such as Ethiopia, access to opioids is either limited or nonexistent and legally restricted in health care settings. This study aimed to identify barriers for the availability and accessibility of opioids in Ethiopian rural and regional health care settings.

Methods

A mixed-method case study design was used. A total of 220 nurses from primary, secondary, and tertiary health care settings were invited to participate in a survey of knowledge and practice. For the qualitative interview, 38 participants were recruited from educational facilities, health services, and the community across a region.

Results

Barriers in availability and accessibility of opioid analgesics were expressing pain considered as a sign of weakness, lack of knowledge, side effect concerns about prescribing morphine, only doctors being authorized to prescribe morphine, lack of foreign currency to import morphine ingredients, and inequity in accessing morphine in hospitals and none in rural health care settings.

Conclusion

The findings of this study indicate that opioids, particularly morphine, were not consistently available and accessible to all patients in need. Health professionals lacked knowledge about opioids. Strengthening the existing pain-free initiatives and improving the type, dose, and supply of morphine could help reduce needless suffering and enhance access to essential pain medicines for those in need.

Six Key Approaches in Open Society Foundations' Support for Global Palliative Care Development

CONTEXT

Between 1998 and 2021, the Open Society Foundations (OSF) network invested around US$50 million in supporting the emerging field of palliative care worldwide, funding different approaches and interventions to advance its objective of putting palliative care on the global public health agenda.

OBJECTIVE

To describe six approaches that were instrumental to the successes of Open Society Foundations' support in building the global field of palliative care. A robust discussion of lessons learnt is unfortunately not possible because Open Society Foundations did not commission a rigorous evaluation of the impacts of its investments.

METHODS

This article describes these six approaches: Investing in versatile palliative care leaders at national and regional level; investing in palliative care champions within the OSF network; proactively engaging the World Health Organization (WHO) in efforts to promote palliative care; developing tools and skills to improve palliative care financing; using a human rights-based approach; and supporting self-advocacy by people with palliative care needs.

RESULTS

Deep, long-term investments in national and regional champions from the palliative care community and OSF's own network built palliative care leaders with well-rounded skills, knowledge and opportunities to develop their own networks. The active engagement and involvement of the WHO in efforts to advance palliative care enhanced the credibility of palliative care as a discipline as well its champions, whereas the human rights approach resulted in more diverse strategies to overcome barriers to palliative care. The focus on palliative care financing and self-advocacy showed significant promise for impact.

DISCUSSION

The approaches and strategies described helped a nascent palliative care field develop into a health service that is increasingly integrated into public health systems. Other funders and national governments can build on OSF's long term support for the palliative care field and support further integration of palliative care within public health to increase access.

Progress Update: Palliative Care Development Between 2017 and 2020 in Five African Countries

CONTEXT

This article provides a progress update on the development of palliative care in five countries in Africa-Kenya, Rwanda, South Africa, Tanzania, and Uganda-between 2017 and 2021, and explores the role of palliative care advocates and the Open Society Foundations in this process.

OBJECTIVES

To provide a progress update on the development of palliative care in Kenya, Rwanda, South Africa, Tanzania, and Uganda between 2017 and 2021 and to examine the impact of twenty years of Open Society Foundations support for palliative care in the region on the integration of palliative care into publicly funded health systems.

METHODS

In the mid-2000s, palliative care pioneers in these five countries, supported by Open Society Foundations, began to train health care providers and engage policy makers to ensure that people with life-limiting illnesses and their families had access to appropriate services and essential medicines. In the late 2010s, it embraced an approach that mixed strategic communications and advocacy for inclusion of palliative care into universal health coverage with technical assistance.

RESULTS

By the mid-2010s, a vibrant palliative care community existed that worked closely with governments to develop palliative care policies, train providers, and ensure access to morphine. By 2021, Kenya and Rwanda had made significant progress scaling up palliative care services as part of the public health care system, and Uganda's government had instructed public hospitals to start providing these services. In South Africa and Tanzania, governments had yet to commit to publicly funded palliative care services.

CONCLUSION

The experiences in these countries suggest that mixing advocacy, communications, and technical assistance can lead to substantial progress for patient access although full inclusion in universal health coverage remained uncertain in all but Rwanda.

Availability and accessibility of opioids for pain and palliative care in Colombia: a survey study

Introduction: Access to essential medicines, including opioids, is a component of the right to health. Objective: To identify barriers to opioid availability and accessibility for pain and palliative care. Methods: Online survey with Colombian prescribers. Availability barriers were analyzed for each facility (distribution and/or dispensing). Accessibility barriers were analyzed by type. Descriptive analyses were conducted using relative frequencies. Significance within categories and regions was measured using Fisher's exact test. Results: Out of 1,208 prescribers invited, 806 (66.7%) completed the survey. Availability: 76.43% reported barriers. The most cited barrier was “Pharmacies authorized by health insurance companies”, where opioids are frequently unavailable. Accessibility: 74.6% reported barriers. Most frequently cited was “Difficulty securing payment authorization for medication from health insurance companies”. Significant differences were observed in terms of regions and “Cost” (p=0.02). Lack of coordination among procuring and distributing agencies affects availability. Limited awareness and bureaucratic procedures affect accessibility. Conclusions: There are barriers to opioid availability and access in Colombia, related to the existing structure for guaranteeing equitable supply. From the perspective of healthcare providers, problems related to pharmacy availability, prescription and cost of medicines hinder pain treatment.

Historical aspects in pain management in palliative care in an oncological reference unit

OBJECTIVE

Describe the actions implemented for pain management in palliative care oncology and analyze the contribution of Hospital do Câncer IV, as a reference unit at the National Cancer Institute.

METHODS

Study of the history of the present time, whose sources were written documents and interviews with five participants. The collection took place from February to June 2018. The analysis of the written sources took place through internal and external criticism of the documents, considering their chronology and theme.

RESULTS

Professionals contributed with actions for pain management in palliative oncology care: in discussions and final drafting of ordinances, as rapporteurs at national and international events, in the elaboration of humanization conducts and systematization of assistance in addressing pain.

FINAL CONSIDERATIONS

These actions favored assistance in palliative oncology care at various levels of health care for patients and families, with greater technical and scientific recognition for all.

Systematic adaptation of the Thai version of the supportive and palliative care indicators tool for low-income setting (SPICT-LIS)

Background

Identification of patients who might benefit from palliative care among countries with different socioeconomic and medical contexts is challenging. The Supportive and Palliative Care Indicators Tool for a Low-income Setting (SPICT-LIS) was designed to help physicians identify patients in low-income setting who might benefit from palliative care. We aimed to systematically adapt and refine the SPICT-LIS for Thai general palliative care providers.

Methods

We followed the WHO guidelines for translation, cross-cultural adaptation and validation of an instrument for the SPICT-LIS. Three expert panel members did the initial adaptation using forward and backward translations with pretested data. Two iterations of pretesting were conducted to test for applicability and reliability. The case vignettes which were used in the pretesting were modified hospital medical records. The pretesting was done with 30 respondents from various specialties in a community health center and 34 general palliative care providers from a regional referral hospital in the first and second iterations, respectively. To examine instrument reliability, interrater reliability and internal consistency were evaluated. Cognitive interviewing was conducted using semi-structured interviews with general practitioners (GPs) using the “think aloud strategy” and “probing questions”.

Results

The adapted Thai SPICT-LIS had a total of 34 indicators which included 6 general and 28 clinical indicators. The assessment of the adapted Thai SPICT-LIS found that it provided consistent responses with good agreement among the GPs, with a Fleiss kappa coefficient of 0.93 (0.76–1.00). The administration time was 2.3–4.3 min per case. Most respondents were female. The 8 interviewed GPs said they felt that the SPICT-LIS was appropriate for use in a general setting in Thailand.

Conclusion

The study found that the Thai SPICT-LIS could be an applicable, acceptable, and reliable tool for general palliative care providers in Thailand to identify patients who might benefit from palliative care.

The Global Burden of Cancer Pain

OBJECTIVES

To provide an overview of the global disparities in cancer pain management. To discuss cultural, religious, and spiritual considerations in cancer pain assessment and management.

DATA SOURCES

Peer-reviewed articles, book chapters, Internet.

CONCLUSION

Significant disparities in pain management exist globally, especially in developing countries. Cultural and religious differences influence pain care and opioid availability is lacking in many countries. Significant barriers impede good pain management; however, some countries have made positive strides in improving pain management for their population.

IMPLICATIONS FOR NURSING PRACTICE

Globally, nurses have a vital role in recognizing and addressing barriers to good pain management and can be ambassadors to advocate for improved pain assessment and management globally.

Global palliative radiotherapy: a framework to improve access in resource-constrained settings

Radiotherapy is an essential component of cancer therapy. Lack of access to radiotherapy in less-developed countries prevents its use for both cure and symptom relief, resulting in a significant disparity in patient suffering. Several recent initiatives have highlighted the need for expanded access to both palliative medicine and radiotherapy globally. Yet, these efforts have remained largely independent, without attention to overlap and integration. This review provides an update on the progress toward global palliative radiotherapy access and proposes a strategic framework to address further scale-up. Synergies between radiotherapy, palliative medicine, and other global health initiatives will be essential in bringing palliative radiotherapy to patients around the globe.