GETTING FIXED ASIA’S PAIN MANAGEMENT DILEMMA Asian patients travel within the region for quality orthopaedic care The region struggles for relief from chronic pain SAVING FACE Sino-Korean joint ventures bring Korean plastic surgery prowess to China May - June 2015 OUR VISION Ms. Sherene Azli CEO, Malaysia Healthcare Travel Council (MHTC) speaks on Malaysia Healthcare GlobalHealthAndTravel.com GHT 022 Cover Final.indd 1 22/05/2015 2:30 PM Pain Management Medical Asia’s Pain Management Dilemma remove long-standing barriers to the distribution of palliative care medicines that could relieve suffering for millions of people with chronic pain D r. Savita Butola, chief medical officer of the FHQ Border Security Force Hospital in New Delhi, India, recalled vividly the memory of a 37-year old woman who made the three-day journey by bus and train from Kishanganj in the Indian state of Bihar to New Delhi up to twice a month, just so she could relieve her pain for a little while. Dr. Butola met the woman, as well as many other patients like her, while completing her palliative care clinical training at Indian Rotary Cancer Institute at the All India Institute of Medical Sciences (AIIMS) in New Delhi in 2011. 42 Global Health and Travel 42 Medical Feature.indd 42 May - June 2015 The patient suffered from advanced rectal carcinoma with a rectovaginal fistula, which was so painful she was not even able to squat while using the toilet. The closest access to morphine, the only medication available that could make her pain bearable, was 1,200 kilometers away in New Delhi – forcing her and her husband, a casual labourer, to endure the torturous two-day, two-night journey from Bihar in a second-class, unreserved train compartment. En route, the couple slept on the train platform and on the pavement outside the hospital in New Delhi because they could not always get a room in the patient’s rest house. www.GlobalHealthAndTravel.com 26/05/2015 2:44 PM “She had four children, the youngest only two years old. She had to leave them behind in her village with her mother every time she came to collect her morphine. And that meant a trip, at least every 15 to 30 days,” Dr. Butola wrote in a 2012 narrative published in the Journal of Pain and Palliative Care Pharmacotheraphy. As a result of the bimonthly odyssey, the patient’s husband would lose six to seven days’ work for each trip. “It still makes me angry to think of these patients,” she continued. “Why can they not get morphine somewhere close to their villages? Or even within their states?” Dr. Butola’s memoir echoes the concerns of palliative care providers – doctors who aim to reduce the symptoms and severe pain caused by chronic diseases like cancer – that access to morphine, listed as an “essential medicine” by the WHO, is still severely restricted to the point of being largely unavailable in many parts of Asia. Statistics show vast inequities in access to palliative care between Asia and the West By WHO estimates, a staggering 60 percent of people who die in developing countries each year – around 33 million people – are in need of palliative care. The organization further stipulated in a 2014 report that only one in ten patients who need palliative care receive it, and 80 percent of the need for palliative care comes from developing countries. 2012 data from the Pain Policy Studies Group (PPSG) at the University of Wisconsin reinforces that international drug control efforts have largely crippled access to morphine and morphine equivalents in developing countries throughout Asia. In addition, access remains moderate or low in some richer or middle-income countries like Singapore, China, and Thailand. Consumption of opioid medications in the West dwarfs amounts consumed in most Asian countries – Americans, the data suggests, consumed almost eight times as much morphine or morphine equivalents annually in 2012 compared to people in Hong Kong; 14 times as much as Malaysians; 57 times as much as Vietnam and over 3000 times as much as India. “Patients around the region often do not get access to effective pain management therapies, especially when compared to those patients living in the Western world,” says Dr. Ho Kok Yuen, president of The Pain Association of Singapore. “The main culprits are various, including a lack of education on the capacity of modern medicine to treat pain adequately, strict regulations for opioids and a strong suspicion against pain relieving medicine because of their addictive nature.” Part of the reason that worldwide morphine access is so skewed towards Western countries, palliative care advocates say, is due to the modern international framework for global opioid consumption, control and distribution patterns set up by the United Nations’ Single Convention www.GlobalHealthAndTravel.com 42 Medical Feature.indd 43 on Narcotic Drugs (1961), which advocates consider to be the start of the Western-led ‘War on Drugs’. Dr. Katherine Pettus, advocacy officer for the International Association of Hospice and Palliative Care (IAHPC), argued in an op-ed for ehospice.com that the Single Convention, which required ratifying states to pass laws prohibiting the manufacture, distribution, and consumption of narcotic drugs, had the “unintended consequence” of making morphine, listed by the WHO as an ‘essential medicine’, “virtually unavailable” in nearly 140 countries. In a 2014 article for Pacific Standard, Helen Redmond writes that although the Single Convention had the stated intention to promote the medical use of narcotics “indispensable for the relief of pain in suffering”, in reality, the role of the International Narcotics Control Board in cracking down on international trade of illicit narcotics has conflicted with states’ role in securing a sufficient supply of morphine and other opioids for medical use. Redmond further points out that a “complex” control regulatory system enforced by the INCB, where governments are required to keep accurate statistics of the amount of narcotics needed for general use, as well as provide data on narcotic consumption and manufacture, creates an environment in which only developed countries have the necessary infrastructure to comply. OPIOID CONSUMPTION 2012 (Morphine Equivalence mg/Person) Data Sources and information: Opioid consumption data – International Narcotics Control Board (values represent the aggregate morphine equivalence consumption of fentanyl, hydromorphone, morphine, oxycodone and pehidine). Population data – the United Nations World Population Prospects 2010 Revision. Pain & Policy Studies Group, UWCCC/WHO Collaborating Center, 2012 800 700 USA 600 743.19 mg/person Australia 481.9 mg/person France 212.84 mg/person Hong Kong SAR 96.23 mg/person 500 Malaysia 400 300 200 52.82 mg/person Vietnam 13.5 mg/person Singapore 8.92 mg/person China 7.75 mg/person Thailand 4.13 mg/person Cambodia 1.16 mg/person Philippines 0.56 mg/person India 0.239 mg/person Laos 0.17 mg/person 100 0 WESTERN COUNTRIES CONSUME THE VAST MAJORITY OF THE WORLD’S OPIOID MEDICATIONS, DESPITE THE TREMENDOUS NEED IN ASIA AND THE DEVELOPING WORLD FOR PALLIATIVE CARE MEDICINES March April2015 2014 May - -June Global Health and Travel 43 26/05/2015 2:44 PM Pain Management Medical BASIC ORAL MORPHINE IS LISTED AS AN “ESSENTIAL MEDICINE” BY THE WHO, YET, IT IS NOT EASILY ACCESSIBLE IN HOSPITALS AND CLINICS IN MANY ASIAN COUNTRIES However, Dr. Jim Cleary, director of the University of Wisconsin’s Pain Policy Study Group, says the INCB isn’t the main problem, arguing that states can apply to the INCB to receive more morphine if they deem it to be necessary. “My feeling is that the INCB has little role in this war on drugs,” he says. “What they [the INCB] have left out is they haven’t put enough focus on their in-country visits to make sure that access to opioids is important.” He emphasises for these INCB in-country visits, “who invited to the table is left up to the host nation, rather than the INCB themselves.” Historical factors, lack of education remain major barriers to improved access Although international institutions such as the INCB may have a damaging affect on developing’ countries ability to freely purchase and distribute morphine and other opioids, historical attitudes shaped by the past horrors of widespread opium abuse, particularly in some Asian countries like India, Vietnam, Cambodia, and China, have also made policymakers and regulators squeamish about easing restrictions on opioid licensing and incorporating opioid training into national medical education programs, which affects doctors’ practices in the public and private sectors alike, according to the nonprofit advocacy group Human Rights Watch. These attitudes are reflected in a 2011 report by the group, which noted that the state of availability of education on pain management in Asian countries was particularly troubling. In a survey of 12 major countries in Asia, including India, China, Vietnam, Indonesia and even some more developed countries like South Korea and Japan, the report noted that no compulsory education on palliative care is required in undergraduate medical programs, and in China, it was also not available in postgraduate medical curriculums. Doctors in all Asian countries surveyed, the report noted, said that morphine was particularly harder to access outside major cities – indicating a further gap between access in urban and rural areas. These trends have also been noticed in studies 44 Global Health and Travel 42 Medical Feature.indd 44 May - June 2015 by the private sector, particularly pharmaceutical companies. A 2014 survey of 1,158 physicians and 2,495 patients throughout Asia by pharmaceutical company Mundipharma, which manufactures cancer pain drugs, found that only six percent of Asian cancer patients had been treated by a pain specialist. Additionally, of the 463 physicians surveyed who were involved in treating cancer pain, only 30 percent considered their training on opioids to be adequate, although 84 percent agreed that opioids should be a first-line therapy for cancer pain. Raman Singh, president of emerging markets for Mundipharma, says that the knowledge it gained has helped it to better formulate continuing medical education (CME) programs that train doctors how to better use opioid medications to treat chronic pain, particularly cancer pain. “There is an unmet need to address the gap in physicians’ training, better access to palliative drugs and also patient education,” Singh told Global Health and Travel. “Disinformation and the negative perception about controlled drugs can increase the barriers and hinder people’s access to the necessary types of treatment; hence, open discussions regarding pain management is a leap towards achieving adequate pain relief.” He adds that in emerging markets, particularly in Asia, CMEs can drive changes in attitudes, but the results presented to purchasers of pharmaceuticals, including private hospitals, has to be evidence-based. “In emerging markets, a lot is driven through hospitals. And in private hospitals, while it could be a business of maximising margins, most of the time it’s still the evidence that actually drives [sales],” he says. Meanwhile, Singh does not discount the roles that regulators play in increasing access to opioids in Asia. “A lot of regulators are still in the mindset of the good old morphine days, when a lot of abuse used to happen, and they’re quite sensitive,” he says. “Treatment paradigms have shifted, and the new medicines are a lot more tamper resistant or tamper proof than they used to be.” Dr. M.R. Rajagopal, chairman of Pallium India and one of the key advocates working with the Indian federal government to change its drug laws to allow greater access to opioids for medical use, says that the biggest barrier to “There is an unmet need to address the gap in physicians’ training, better access to palliative drugs and also patient education. Disinformation and the negative perception about controlled drugs can increase the barriers and hinder people’s access to the necessary types of treatment; hence, open discussions regarding pain management is a leap towards achieving adequate pain relief” - Raman Singh, president of emerging markets, Mundipharma www.GlobalHealthAndTravel.com 26/05/2015 2:45 PM providing more access to pain relief is trying to change medical professionals’ attitudes towards pain management. “Generations of doctors have not seen morphine – they are mortally scared of morphine. Morphine carries with it the stigma of addiction, and doctors fear it will stop respiration. This is a very widespread fear,” Dr. Rajagopal says. He adds that broader education on palliative care, not just education about morphine, is essential to proper treatment. “Only about two-thirds of all pain is responsive to morphine, which means that to treat pain adequately in one person, he may have two pains that respond to morphine and another kind of pain that doesn’t respond, so you have to mix certain kinds of painkillers in such a fashion that the patient gets pain relief,” he says. “Unless this is taught to medical students and nursing students, they are unable to use it effectively. They just try to use it without training, which may either cause a problem to the patient, make the patient delirious, or it may be ineffective. Therefore, professional education is the biggest need.” Vietnam: Making a Comeback Vietnam, a country with a colonial past that has been involved in the opium trade since the 19th century and suffered from rampant opium and heroin trafficking during the Vietnam War, maintains a persistent fear remains among patients and physicians alike in regards to opioid use for palliative care. This historical context, later reinforced by the Ho Chi Minh communist regime’s propaganda, has led opioids to be considered a “social evil” in the country, according to a 2014 study in Journal of Pain and Symptom Management coauthored by Dr. Eric L. Krakauer, assistant professor of global health and social medicine at Harvard Medical School. Corresponding fears behind the dangers of opioid use subsequently led to debilitating restrictions imposed by the country’s Ministry of Health. As a result of these factors, the study said, by 2004 Vietnam’s morphine consumption ALTHOUGH INDIA AND SOUTHEAST ASIAN COUNTRIES LIKE MYANMAR AND LAOS PRODUCE LARGE QUANTITIES OF OPIUM POPPIES, ACCESS TO OPIOID MEDICATIONS FOR PALLIATIVE CARE USE IS SEVERELY RESTRICTED was “minimal,” and morphine use ranked 122 out of 155 countries for which data was available at that time. Things took a turn for the better in 2005. In the wake of the funds for palliative care provided by the US Congress, the Vietnamese Ministry of Health set up a working group in charge of analysing palliative care services and needs around the country. This process led to a liberalisation of regulations for opioid prescription that came into effect in 2008. The results were staggering. Between 2005 and 2012, opioid consumption per person increased by more than forty times, spiking from 0.32 to 13.5 mg. This was the fastest growing rate among Asia-Pacific countries at that time. Despite these undeniable improvements, the study stresses that there is still a long way to go for Vietnam to reach “universal access to effective pain relief.” Opiophobia is still widespread among clinicians, officials and patients, while district hospital pharmacies are still forbidden from dispensing opioids to the public, even if no pharmacy in the district stocks opioids. A 2013 study jointly conducted by HealthBridge Foundation of Canada and the Research Center for Rural Population and Health at Thai Binh Medical University reinforces that lack of access to palliative care for cancer patients is not just an issue in Vietnam’s public hospitals, but private hospitals as well. Among 410 patients interviewed in the study, only 13.7 percent received palliative care services from private hospitals and 4.3 percent of patients said that a private doctor was their source of information about options for palliative care. Malaysia: Changing Attitudes Towards Pain Management STUDIES SHOW THAT MANY DOCTORS IN VIETNAM ARE RELUCTANT TO PRESCRIBE OPIOIDS, IN PART DUE TO THE COUNTRY’S PAST STRUGGLES WITH OPIUM ABUSE www.GlobalHealthAndTravel.com 42 Medical Feature.indd 45 The current situation in Malaysia reflects the point that lack of opioids is not the only barrier to adequate pain management. Data from the INCB shows that opioid consumption has been constantly rising since the 1980s, thus suggesting that the country has been able to expand the flow of opioids. May - June 2015 Global Health and Travel 45 26/05/2015 2:45 PM Pain Management Medical MALAYSIA Opioid Consumption in Morphine Equivalence (ME) minus Methadone, mg per person ME (mg/capita) 6— 4— 2— Morphine Oxycodone.ME Fentanyl.ME 10 20 11 20 12 09 20 08 20 07 20 06 20 05 Hydromorphone.ME 20 04 20 03 20 02 20 01 20 00 20 99 20 98 19 97 19 96 19 95 19 94 19 93 19 92 19 91 Pethidine.ME 19 90 19 89 19 88 19 87 19 86 19 85 19 84 19 83 19 82 19 81 19 19 19 80 0— Total.ME SOURCES: INTERNATIONAL NARCOTICS CONTROL BOARD; WORLD HEALTH ORGANIZATION POPULATION DATA BY: PAIN & POLICY STUDIES GROUP, UNIVERSITY OF WISCONSIN/WHO COLLABORATING CENTER, 2014 ALTHOUGH MALAYSIA’S USE OF MORPHINE EQUIVALENT DRUGS FOR PALLIATIVE CARE HAS RISEN STEADILY IN THE LAST TEN YEARS, DOCTORS’ ADVERSE ATTITUDES TOWARDS PRESCRIBING OPIOIDS, A LACK OF EDUCATION ABOUT PALLIATIVE CARE AND OPIOID USE, AND REGIONAL DIFFERENCES IN CULTURAL ATTITUDES SURROUNDING PAIN REMAIN BARRIERS TO IMPROVING PALLIATIVE CARE Dr. Mary Cardosa, a consultant anaesthesiologist and pain specialist at Hospital Selayang, in Selangor and head of the pain management subspecialty of the Malaysia Ministry of Health’s Anaesthesiology program, says that doctors’ education and attitudes remain a barrier to improved access. “In Malaysia we don’t have a lot of restrictions on the use of drugs. Any doctor can prescribe opioids, so the challenges [have to do with] doctors’ knowledge and experience [along with] fear of opioids [as they are believed to potentially lead to] side effects like respiratory depression, addiction or even death,” Cardosa told Global Health and Travel in a phone interview. According to a 2014 study published in The Oschner Journal, a survey among Malaysian physicians found out that 46 percent of them lack a proper training to treat severe cancer pain, while 64 percent of doctors are worried about unwanted side effects caused by the administration of opioids. As a result, only 24 percent of patients who experienced cancer pain were treated with opioids. Aside from misconception on opioids, some practitioners 46 Global Health and Travel 42 Medical Feature.indd 46 May - June 2015 in Malaysia do not pay great attention to allaying pain as they believe it is not a primary medical concern, Dr. Cardosa says. “In order to improve pain management it is crucial to change the attitude among healthcare providers so that they become aware of the necessity to treat pain,” she says. In order to raise awareness on the necessity to improve pain management, Malaysia’s Ministry of Health has been advocating for the concept of a “pain free hospital” since 2011. Through this initiative, a series of hospitals are engaged in a holistic approach to relieve pain by combining mainstream treatments with non-pharmacological ones, such as traditional and complementary medicine. Initially, the pilot programme encompassed only three hospitals, but it later expanded to other facilities through training workshops led by pain specialists and aimed to educate healthcare providers on their duty to relieve pain. The bottom line was to consider pain as the fifth vital sign – as important as much as pulse and respiratory rate, temperature and blood pressure. www.GlobalHealthAndTravel.com 26/05/2015 2:45 PM Workshops focused on educating patients as well in order to get them actively involved in managing their own pain. The goal was make them as much independent from formal medical services as possible and embrace the use of non-pharmacological therapies such as relaxation techniques, meditation and breathing exercises. According to Dr. Cardosa, self-management is very beneficial both on a physical and psychological level. “We recognise that there are traditional medical systems that our population has always accepted, like acupuncture and Malay massage, and we see them as a complementary tool to Western medicine [when it comes to treat pain],” Dr. Cardosa says. India: A Potential Breakthrough on the Horizon Through advocacy efforts by Pallium India and other NGOs, as well as the documented success in Kerala, a major breakthrough to opioid access in India may be on the horizon. In 2014, India’s parliament voted to amend the 1985 Narcotic Drugs and Psychotropic Substances Act (NDPS), India’s major drug law, to provide better access to pain medications. The amendments promised, among other things, a simplified, central agency that would be responsible for drug licensing – eliminating additional levels of bureaucracy at the state and local levels to obtain morphine licenses. However, according to Dr. Rajagopal, who was directly involved in drafting amendments to the drug law, the timeline for implementation of the new policy is still unclear. “The official steps that need to get done are not complete,” Dr. Rajagopal says. Nevertheless, Dr. Rajagopal remains optimistic that the legislative action will be the start of a long process of national reform. “Changing the regulatory barriers alone does not mean access to pain relief. There is a huge need for professional education and for public acceptance – so that still needs to be unblocked,” he says. “We have a long struggle ahead, but one very significant barrier has been overcome.” Given the current lack of a national cohesive strategy on palliative care, the Indian state of Kerala took it upon itself to develop its own comprehensive palliative care policy. Although it was formally implemented in 2008, the strategy had been in the works since 1993 and was spearheaded by NGO involvement, particularly the Pain and Palliative Care Society (PPCS) of Calicut, despite limited government support. Currently, palliative care centres are found in every district of the state; and in some districts, multiple centres, sometimes dozens of them, have been established. The secret behind Kerala’s success, Dr. Suresh Kumar of the Institute of Palliative Medicine in Kerala wrote in a 2007 report, is a “community-based” model where volunteers willing to devote at least two hours a week caring for the sick are trained to become palliative care providers. This model, Dr. Kumar says, eventually replaced the earlier “hierarchical doctor-led structure” for palliative care. With this communitybased infrastructure in place relieving strain on the system, eventually in 2008, Kerala became the first Indian state to adopt a state-level palliative care policy that included amending drug regulations to make morphine readily available to providers. “The partnership of the State with civil society is now seen by many as a means through which a raft of societal and political ills can be addressed,” Dr. Kumar wrote in his report. GHT PALLIUMINDIA.ORG PAINPOLICY.WISC.EDU MUNDIPHARMA.COM.SG JPSMJOURNAL.COM WHO.INT INFORMA.COM/JOURNAL/PPC INDIA’S PARLIAMENT TOOK STEPS LAST YEAR TO REFORM THE COUNTRY’S NATIONAL DRUG CONTROL LAWS TO PROVIDE BETTER ACCESS TO PAIN MEDICATIONS. UNDER THE AMENDED LAW, THE CENTRAL GOVERNMENT WILL BE RESPONSIBLE FOR OPIOID DRUG LICENSING, ELIMINATING RED TAPE AT THE STATE AND LOCAL LEVELS. ADVOCATES SAY IMPLEMENTATION WILL BE A SLOW PROCESS www.GlobalHealthAndTravel.com 42 Medical Feature.indd 47 May - June 2015 Global Health and Travel 47 26/05/2015 2:45 PM
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