Opioid availability in Latin America: the Santo Domingo report progress since the Declaration of Florianopolis

Where Is the Opioid Use Epidemic in Mexico? A Cautionary Tale for Policymakers South of the US-Mexico Border

In North America, opioid use and its harms have increased in the United States and Canada over the past 2 decades. However, Mexico has yet to document patterns suggesting a higher level of opioid use or attendant harms.Historically, Mexico has been a country with low-level use of opioids, although heroin use has been documented. Low-level opioid use is likely attributable to structural, cultural, and individual factors. However, a range of dynamic factors may be converging to increase the use of opioids: legislative changes to opioid prescribing, national health insurance coverage of opioids, pressure from the pharmaceutical industry, changing demographics and disease burden, forced migration and its trauma, and an increase in the production and trafficking of heroin. In addition, harm-reduction services are scarce.Mexico may transition from a country of low opioid use to high opioid use but has the opportunity to respond effectively through a combination of targeted public health surveillance of high-risk groups, preparation of appropriate infrastructure to support evidence-based treatment, and interventions and policies to avoid a widespread opioid use epidemic.

National public health law: a role for WHO in capacity-building and promoting transparency

A robust health infrastructure in every country is the most effective long-term preparedness strategy for global health emergencies. This includes not only health systems and their human resources, but also countries' legal infrastructure for health: the laws and policies that empower, obligate and sometimes limit government and private action. The law is also an important tool in health promotion and protection. Public health professionals play important roles in health law - from the development of policies, through their enforcement, to the scientific evaluation of the health impact of laws. Member States are already mandated to communicate their national health laws and regulations to the World Health Organization (WHO). In this paper we propose that WHO has the authority and credibility to support capacity-building in the area of health law within Member States, and to make national laws easier to access, understand, monitor and evaluate. We believe a strong case can be made to donors for the funding of a public health law centre or unit, that has adequate staffing, is robustly networked with its regional counterparts and is integrated into the main work of WHO. The mission of the unit or centre would be to define and integrate scientific and legal expertise in public health law, both technical and programmatic, across the work of WHO, and to conduct and facilitate global health policy surveillance.

Availability, prices and affordability of essential medicines in Haiti

Background

Haiti is the poorest country in the Western Hemisphere and faces numerous challenges, including inadequate medication access for its residents. The objective of this study was to determine the availability, prices, and affordability of essential medicines in Haiti and compare these findings to other countries.

Methods

We conducted a cross–sectional nationwide survey in 2011 of availability and consumer prices of 60 essential medicines in Haiti using a standardized methodology developed by the World Health Organization and Health Action International. The survey was conducted in 163 medicine outlets in four health care sectors (public, retail, nonprofit and mixed sectors). Medicine prices were expressed as ratios relative to the International Reference Price. Affordability was calculated by comparing the costs of treatment for common conditions with the salary of the lowest paid government worker and was compared to available data from four Latin American countries.

Results

For generic medicines, the availability in public, retail, nonprofit and mixed sectors was 20%, 37%, 24% and 23% of medications, respectively. Most of the available medicines were priced higher than the International Reference Price. The lowest paid government worker would need 2.5 days’ wages to treat an adult respiratory infection with generic medicines from the public sector. For treatment of common conditions with originator brands (OB) purchased from a retail pharmacy, costs were between 1.4 (anaerobic bacterial infection) and 13.7 (hyperlipidemia) days’ wages, respectively. Treatment of pediatric bacterial infections with the OB of ceftriaxone from a retail pharmacy would cost 24.6 days’ wages. Prices in Bolivia, Colombia, Mexico and Nicaragua were frequently lower for comparable medications.

Conclusions

The availability of essential medicines was low and prices varied widely across all four sectors. Over 75% of Haitians live on less than US$ 2.00 /day; therefore, most medication regimens are largely unaffordable. Inclusion of essential medications on the national formulary and working with organizations responsible for importing medications into Haiti, particularly drug donation agencies, are important first steps to increasing medication access.

Hospital versus home death: results from the Mexican Health and Aging Study

CONTEXT

Characterizing where people die is needed to inform palliative care programs in Mexico.

OBJECTIVES

To determine whether access to health care influences the place of death of older Mexicans and examine the modifying effects of demographic and clinical characteristics.

METHODS

We analyzed 2001 baseline and 2003 follow-up data from the Mexican Health and Aging Study. Cases included adults who completed the baseline interview and died before the follow-up interview and for whom a proxy interview was obtained in 2003. The main outcome variable was the place of death (hospital vs. home). The predictors of the place of death were identified using logistic regression analysis.

RESULTS

The study group included 473 deceased patients; 52.9% died at home. Factors associated with hospital death were having spent at least one night in a hospital during the last year of life (odds ratio [OR]: 6.73; 95% confidence interval [CI]: 3.29, 13.78) and dying in a city other than the city of usual residence (OR: 4.68, 95% CI: 2.56, 8.57). Factors associated with home death were not having health care coverage (OR: 2.78, 95% CI: 1.34, 5.88), living in a city of less than 100,000 residents (OR: 2.44, 95% CI: 1.43, 4.17), and older age (OR: 1.03, 95% CI: 1.01, 1.05).

CONCLUSION

Older Mexicans with access to health care services were more likely to die in the hospital even after controlling for important clinical and demographic characteristics. Findings from the study may be used to plan the provision of accessible end-of-life hospital and home-based services.

The medical consumption of opioids in Colombia, 1997-2007

The World Health Organization classifies opioid analgesics as essential medicines in the treatment of severe pain and recommends their increased availability. The combination of availability, training of professionals, and a legal framework granting access to these medicines has led to a sharp increase in the consumption of morphine and other opioids in developed countries. However, in Colombia, consumption of opioid analgesics appears to fail to meet patient needs. To analyze the current trends in medical consumption of opioids in Colombia, the numbers of defined daily doses of opioid analgesics for total inhabitants and the population that died of cancer between 1997 and 2007 were calculated and compared. The import of raw materials and medicines varied greatly every year. However, from 2003, a trend toward the increased consumption of morphine, hydromorphone, and methadone was observed. Availability was inconsistent and opioid consumption showed an increase when calculated for total inhabitants and for cancer deaths. The unreliable availability of opioid analgesics may be responsible for their limited consumption. Chronic underuse and a trend toward increased consumption have been confirmed. Monitoring of consumption to promote rational use is recommended.

Palliative care for Latino patients and their families: whenever we prayed, she wept

Latinos account for 15% of the US population, a proportion projected to grow to 30% by the year 2050. Although there is tremendous diversity within this community, commonalities of language, beliefs, attitudes, and behaviors unite Latinos, making them more similar than different. Differences by national origin, although important, are attenuated when immigrants come to the United States, dominated by an English-language, Anglo-centric culture. For non-Latino and non-Spanish-speaking clinicians, communication barriers and cultural misunderstandings can impede the care of dying Latino patients and their families. We present the case of a young, pregnant, Spanish-speaking woman from Central America diagnosed with a fatal leukemia. As illustrated by this case, Latino immigrants face a number of external challenges to optimal end-of-life care: (1) geographic distance as well as political and economic realities often separate patients from their valued families; (2) undocumented immigrants are frequently uninsured and fear of deportation may create a barrier to accessing health services; (3) language and literacy barriers; and (4) concerns about discrimination. Other Latino issues that may be more pronounced in end-of-life settings include cultural themes and religious and spiritual influences. We recommend that professional interpreters must be used for discussions about goals of care with Spanish-speaking patients and families or when negotiating conflict between the patient, family, and the health care team. Concrete suggestions are provided for clinicians in working with interpreters, eliciting culturally based attitudes and beliefs, and implementing universal strategies for clear health communication.

What predicts the quality of advanced cancer care in Latin America? A look at five countries: Argentina, Brazil, Cuba, Mexico, and Peru

Cancer is now a leading cause of death among adults in most Latin American nations. Yet, until recently, there has been limited research on the quality of, and access to, advanced cancer care in developing regions such as Latin America. This landmark, cross-national study assessed the quality of advanced cancer care in five Latin American countries by surveying a convenience sample of 777 physicians and nurses, and identifying the most salient influences on their quality-of-care assessments based on multiple linear regression analyses. Strategies for disseminating this survey included mass mailings, distribution at professional meetings/conferences, collaboration with Latin American institutions, professional organizations, and the Pan American Health Organization, and online posting. Results indicate that the respondents' assessments of the quality of, access to, and affordability of advanced cancer care varied significantly across nations (P<0.001). The strongest predictor of providers' national-level assessments of the quality of care was their ratings of access to advanced cancer care (Beta=0.647). Other predictors included affordability of care, country (Cuba vs. the other four countries), income-gap quintile, and institutional availability of opioid analgesics. Low prioritization of palliative care in both health care policy formulation and provider education also predicted the quality-of-care ratings. Findings from this study suggest that providers from five different nations hold similar equitable notions of quality care that are dependent on the provision of accessible and affordable care. Measures of social equity, such as the income-gap quintile of nations, and measures of policy barriers, such as the scale developed in this study, should be replicated in future studies to enable policy makers to assess and improve advanced cancer care in their countries.

Side-effects of opioids in chronic pain treatment

The emergence of opioid-induced neurotoxicity has gained increasing recognition in the literature in the past decade. Exciting developments at the receptor and intracellular level have revealed some insights into the potential mechanisms underlying this phenomenon. The hitherto reported clinical benefits of opioid rotation and dose reduction in the treatment of opioid toxicity warrant further clarification in prospective studies, particularly in relation to their relative value.

Methadone Versus Morphine As a First-Line Strong Opioid for Cancer Pain: A Randomized, Double-Blind Study

Purpose

To compare the effectiveness and side effects of methadone and morphine as first-line treatment with opioids for cancer pain.

Patients and Methods

Patients in international palliative care clinics with pain requiring initiation of strong opioids were randomly assigned to receive methadone (7.5 mg orally every 12 hours and 5 mg every 4 hours as needed) or morphine (15 mg sustained release every 12 hours and 5 mg every 4 hours as needed). The study duration was 4 weeks.

Results

A total of 103 patients were randomly assigned to treatment (49 in the methadone group and 54 in the morphine group). The groups had similar baseline scores for pain, sedation, nausea, confusion, and constipation. Patients receiving methadone had more opioid-related drop-outs (11 of 49; 22%) than those receiving morphine (three of 54; 6%; P = .019). The opioid escalation index at days 14 and 28 was similar between the two groups. More than three fourths of patients in each group reported a 20% or more reduction in pain intensity by day 8. The proportion of patients with a 20% or more improvement in pain at 4 weeks in the methadone group was 0.49 (95% CI, 0.34 to 0.64) and was similar in the morphine group (0.56; 95% CI, 0.41 to 0.70). The rates of patient-reported global benefit were nearly identical to the pain response rates and did not differ between the treatment groups.

Conclusion

Methadone did not produce superior analgesic efficiency or overall tolerability at 4 weeks compared with morphine as a first-line strong opioid for the treatment of cancer pain.

Analysis of prescription and dispensation of psychotropic medications in two cities in the State of São Paulo, Brazil

OBJECTIVES: To investigate the prescription and dispensation of psychotropic medications through the analysis of the prescriptions/notices kept at various institutions in two cities in the state of São Paulo. METHODS: The prescriptions kept at drugstores, magistral pharmacies, primary care settings and hospitals were collected and analyzed in collaboration with the Sanitary Vigilance agencies in the year of 1999. The information in the prescriptions/notices were typed and tabulated. RESULTS: A total of 108,215 prescriptions were processed, being 76,954 for benzodiazepines, 26,930 for anorexigenic drugs, 3,540 for opiates and 788 for other drugs. The benzodiazepines most frequently prescribed were: diazepam (31,644), bromazepam (16,911) and clonazepam (7,929). Among the anorexigenic drugs, diethylpropion (14,800) and femproporex (10,942) were the most common. When compared to men, women were given more prescriptions, mainly for anorexigenic drugs: the ratio was 10:1 in the prescriptions for diethylpropion and femproporex. The few magistral pharmacies (n=6) handled even more prescriptions than did the drugstores (n=49). A number of errors and inconsistencies were detected in the prescriptions analyzed. CONCLUSIONS: The results confirm the occurrence of an irrational use of such medications and a series of inadequate practices related to their prescription in Brazil. Therefore, they point out to the need of a comprehensive review of the government's control system of these substances.

Advances in Palliative Care in Latin America and the Caribbean: Ongoing Projects of the Pan American Health Organization (PAHO)

The Pan American Health Organization (PAHO) is engaged in field demonstration projects in Latin America and the Caribbean to expand the availability and effectiveness of palliative care services. Workshops and calls for proposals address the multiple causes of inadequate palliative care services that are typical for countries in the developing world. These include regulatory barriers and drug interdiction policies that interfere with the medical use of opioids, lack of education among health professionals, and insufficient palliative care infrastructure.

Legislation analysis according to WHO and INCB criteria on opioid availability: a comparative study of 5 countries and the state of Texas

Opioids are not always available in many developing countries, including those in Latin America. In this study we analyzed the national laws on opioids and other controlled substances from Argentina, Colombia, Costa Rica, Peru, Mexico, and the state of Texas, according to the principles set by the World Health Organization (WHO) and the International Narcotics Control Board (INCB), as well as to the presence of over-regulations regarding their medical and scientific use. The six main principles outlined by WHO and INCB for opioid availability were analyzed by using a total of 17 criteria as shown in Table 3. The result scores ranged from 17/17 (full compliance with all criteria) to 0/17 (non-compliance). Results showed that with the exception of the state of Texas 16/17 (94%), the countries failed to adequately meet the INCB and WHO criteria: Argentina: 7/17 (41%); Colombia: 9 /17 (53%); Costa Rica: 9/17 (53%); Mexico: 4/17 (24%); and Peru: 7/17 (41%). In all 5 Latin American countries, national laws and regulations imposed limits on the number of days allowed for prescription, the potency of the dosage, and the number of doses allowed per day. In all cases, including Texas, there was confusion on the meaning and utilization of the terms physical dependence, psychological dependence, addiction, tolerance and abuse. In total, combining all cases, only 51% of the criteria were met. Additionally, all laws and regulations, especially in Argentina, include over regulations and statements that may further interfere with patient access to opioids. The prescription criteria were fully met by the state of Texas and all five countries. These results indicate that there is need to revise the existing laws and regulations in countries with opioid availability problems, and identify the potential barriers, which may be playing a significant role in the access to adequate treatment. Such review seeks to carefully consider all possible criteria, since partial resolution of legislative articles will not result in increased opioid availability.

The Pan American Health Organization: its structure and role in the development of a palliative care program for Latin America and the Caribbean

In recent years palliative care has emerged as a major public health care issue, both in developed and developing countries. The rising number of cancer deaths as a result of increased tobacco consumption, control of other diseases, lack of preventive programs, and the difficulties of accessing curative treatments in many countries have made palliative care and pain relief the appropriate, and in many cases, the only option for patients with advanced disease. The World Health Organization (WHO) and its Regional Office for the Americas, the Pan American Health Organization (PAHO), have promoted palliative care as a component of their cancer control program. Some health care workers and policy makers are not adequately informed about the role that intergovernmental agencies such as WHO and PAHO play in the health care field. This has led to confusion and, in some cases, misjudgment of the organization. This paper summarizes the structure and role of PAHO and, specifically, its participation in the development of a palliative care program for Latin America and the Caribbean. Many health care professionals, administrators, and policy makers are unaware of the organization 's objectives in this area and the tools available to assist in the implementation and development of national programs to care for patients with advanced cancer: The information in this paper is based on data found in the PAHO and WHO web sites, as well as other technical publications from different sources, including individuals not formally associated with WHO or PAHO.