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In September 2007, the report "Access to Pain Relief: An Essential Human Right" was published by the UK national hospice charity Help the Hospices. With an introduction by the World Health Organization (WHO), the report investigated the widespread lack of access to pain relief available to terminally ill people in many parts of the world, highlighting the fact that cost is not usually the main barrier. Currently, half of the world's 234 countries have no palliative care services available to their populations, and one third have yet to take the first steps in planning to build service capacity. In countries in which hospice and palliative care services are present, provision is mostly localized, with only 15% of countries having achieved a measure of integration with mainstream healthcare service providers.

 

There are currently 6 million cancer deaths and more than 10 million new cases of cancer every year, and the number is expected to rise to 15 million by 2020. It is estimated that 100 million people could benefit from basic palliative care every year. This number is made up of 33 million people dying (60% of the total number dying in the world each year) and their 66 million family members, companions, or carers (based on a conservative estimate of 2 people giving care and support for every person who dies). The actual number of people who receive palliative care is far lower. Although Sub-Saharan Africa has twice as many deaths per 1000 head of population annually as North America, it has only 1.5% of global palliative care resources compared to 55% in North America.

 

"Access to Pain Relief: An Essential Human Right" was published to mark World Hospice and Palliative Care Day in October 2007 (http://www.worldday.org). It revealed that approximately 80% of the world's cancer sufferers have no access to analgesics and that although most pains can be controlled, an estimated 7% of all people in the world suffer cancer pain that could be relieved but is not. It also looked at incidences of pain and the availability of analgesics with reference to other advanced and terminal diseases, including AIDS, heart disease, chronic obstructive pulmonary disease, and renal disease. It pointed out that most people denied access to pain relief are in developing countries, and at the same time, pain incidence is often higher in developing countries. The report showcased the findings of a new survey conducted among 69 hospice and palliative care services in Asia, Africa, and Latin America and drew together disparate sources of information about the state of access to pain relief globally.

 

The survey asked healthcare workers to score their patients' access to analgesics on the WHO Essential Medicines List or the International Association of Hospice and Palliative Care (IAHPC) list of essential medicines for palliative care (using a Likert-type scale) and detail reasons why they thought patients were not able to access oral morphine. Survey findings included the following information:

 

* Twenty-five percent of palliative care providers in Asia, 35% in Latin America, and 39% in Africa cannot always access a strong opioid.

 

* For 41% of palliative care providers in Africa and 39% in Latin America, oral morphine is not always available, and for 21% and 18%, respectively, oral morphine is never available.

 

* Only 55% of healthcare workers providing palliative care in Asia, Africa, and Latin America have a weak opioid "always available"; 22% have access only "occasionally" or "never."

 

* In Asia, Africa, and Latin America many were unable to "always access" any of the adjuvant analgesics useful for neuropathic pain: an anticonvulsant (37%), a tricyclic antidepressant (approximately 30%), and dexamethasone (25%).

 

* Twelve percent never have access to an anticonvulsant.

 

* Seven percent never have access to acetaminophen.

 

* In one main hospital in Malawi, aspirin is the only pain killer that is "always available," and because aspirin is not recommended for children, no suitable pain killers are available for children in pain.

 

* Professional training for 71% of the palliative care workers in Asia and 82% in Latin America did not include either pain relief or opioid use.

 

 

The report's author, pharmacist Vanessa Adams, noted that the survey findings are likely to greatly overestimate patient access to analgesics, because all respondents were actively involved in providing palliative care. In the areas surveyed, most of the populations do not have access to any palliative care. For example, in Africa, 21 out of 47 countries have no identifiable palliative care provision and only 4 have a reasonable level of provision. In India, less than 1% of the people who would benefit from palliative care have access to it, and in Pakistan there is only 1 palliative care service to serve a population of 158 million. If healthcare workers who want to provide palliative care cannot access the required analgesics, it is likely that these drugs will be not be available to any other healthcare workers in that country or state.

 

The report also examined the barriers that prevent adequate access to essential analgesics and found that funding is not the main barrier to access. The cost of medicines such as morphine, although comparatively higher in developing countries than in developed countries, is generally relatively inexpensive. The main reasons for lack of availability include

 

* lack of knowledge on the part of healthcare workers, policymakers, and the public about the use and benefits of opioid analgesics, other analgesics, and palliative care;

 

* excessively strict national laws and regulations;

 

* misplaced fear of addiction, abuse, tolerance, or side effects; and

 

* poorly developed healthcare systems and supply chains.

 

 

In order to prevent millions of people from suffering pain needlessly, the report recommended coordinated international and national programs to increase awareness, education, supply, and access. Palliative care and access to analgesics should be an integral part of all national policies relating to cancer, HIV/AIDS, and other chronic diseases. The report outlined essential steps that need to be taken to improve access to analgesics, including improved education and accountability, reviewing laws and policies, and strengthening healthcare facilities. The report is available to download in full, free of charge, at http://www.worldday.org/documents/access_to_pain_relief.pdf. Details of members of the World Day organizing group can be found at http://www.worldday.org/partners.asp.

 

World Hospice and Palliative Care Day is cosponsored by WHO and has been developed by the Worldwide Palliative Care Alliance (a network of national hospice and palliative care organizations) and other global partners. Help the Hospices is a UK charity for the hospice movement that supports more than 220 local hospices in their vital work on the front line of caring for people who face the end of life. Although the UK government contributes an average of 32% of running costs for adult hospices in England and 22% for children's, the rest must be obtained through charitable fundraising. For more information on Help the Hospices, visit http://www.helpthehospices.org.uk.