Re: A Pediatric Cancer Pain Program in Jordan

Abstract

Considering the Special Article, “Action Research: Developing a Pediatric Cancer Pain Program in Jordan,” co-authored by G. Allen Finley, Paula Forgeron, and Maha Arnaout,1Finley G.A. Forgeron P. Arnaout M. Action research: developing a pediatric cancer pain program in Jordan.J Pain Symptom Manage. 2008; 35: 447-454Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar we wish to remind readers of the principles depicted in the World Health Organization (WHO) document entitled “Achieving Balance in National Opioids Control Policy”2World Health Organization Achieving balance in national opioids control policy.http://www.who.int/medicinedocs/pdf/whozip39e/whozip39e.pdfGoogle Scholar for opioid and psychotropic drugs for assessment of guidelines, to enlighten the efforts for new programs to be adopted in Jordan as well. To start with, of principal opioid drugs in Jordan, it is important to note the average daily consumption of opioids per million inhabitants during the years 1994–1998: 277 for codeine, 23 for morphine, 150 for dextropropoxyphene, 149 for diphenoxylate, and 26 for pethidine (meperidine), for a total of 625. With these numbers from WHO, Jordan is 66th in ranking among 160 countries, of which Ireland, Denmark, and Switzerland are the first three, with more than 25,000 daily doses per million inhabitants. The medical need for opioid analgesics is certain; however, using the guidelines for evaluation of national drug control policies is also certainly needed. And the availability of opioid drugs is to be guided by national policy that should be consistent with international conventions on opioid drugs. The central principle here refers to the “balance” that represents a dual imperative of governments to establish a system of control to prevent abuse, trafficking, and diversion of opioid drugs, while at the same time, ensuring their medical availability. The guidelines2World Health Organization Achieving balance in national opioids control policy.http://www.who.int/medicinedocs/pdf/whozip39e/whozip39e.pdfGoogle Scholar may be summarized as follows:1)Governments should examine their drug control policies for the presence of overly restrictive provisions that may impact their health care system in the delivery of pain relief, and take corrective action as needed.2)National drug control policies should recognize that opioids are absolutely necessary for medical care, in particular for relief of pain and suffering.3)National drug control policies should recognize the obligation of governments to ensure adequate opioid availability for all medical and scientific needs.4)Governments should designate an authority for ensuring adequate availability of opioids for medical care.5)Governments should develop, using information from relevant sources, a practical method to estimate realistically the medical and scientific needs for opioids.6)Governments should furnish to the International Narcotics Control Board (INCB) annual estimates of the quantities of narcotic drugs needed for medical and scientific purposes for the following year.7)Governments should furnish a supplementary estimate to the INCB if it appears that the availability of narcotic drugs will fall short of medical needs, or to meet emergency needs or exceptional medical demand.8)Governments should submit annual statistical reports to the INCB on the production, manufacture, trade, use, and stocks of narcotic drugs.9)Governments should establish a dialogue with health care professionals about the legal requirements for prescribing and dispensing narcotic drugs.10)National drug control authorities and health care professionals should cooperate to ensure the availability of opioid analgesics for medical and scientific purposes, including for the relief of pain.11)Governments should ensure, in cooperation with licensees, that the procurement, manufacture, and distribution of opioid medications are accomplished in a timely manner so that there are no shortages of supply and that such medications are always available to patients when they are needed.12)Governments should permit and encourage the distribution and availability of opioid medications throughout the country, to maximize physical access of pain relief medications while maintaining adequate controls to prevent diversion and abuse.13)Governments should establish and promote a national cancer control program that includes cancer pain relief and palliative care as a priority for health care resources, including education about the WHO analgesic method and provision of pain relief and palliative care.14)Terminology in national drug control policy should not have the potential to confuse the medical use of opioids for pain with drug abuse or drug dependence.15)In their efforts to prevent diversion, governments should avoid undue restrictions impacting on patient care decisions that are ordinarily medical in nature. Decisions such as the amount of drug prescribed and duration of treatment should be made by the physician and be based on individual patient needs.16)National drug control policy should avoid prescription requirements that may unduly restrict physician and patient access to pain relief. We advise the Jordanian experts to answer the following questions before creating a committee, including the National Competent Authority, or asking health professionals for updating policies:1)Has the government conducted an examination to determine if there are overly restrictive provisions in national (and state level, if applicable) drug control policies that impede prescribing, dispensing the needed medical treatment of patients with narcotic drugs, or their availability and distribution for such purposes, and made the necessary adjustments?2)Is there a provision in national drug control policies that recognizes that opioid drugs are absolutely necessary for the relief of pain and suffering?3)Is there a provision in national drug control policies that establishes that it is the government's obligation to make adequate provisions to ensure the availability of opioid drugs for medical and scientific purposes, including for the relief of pain and suffering?4)Has the government established an administrative authority for implementing the obligation to make adequate provision to ensure the availability of opioid drugs for medical and scientific purposes, including licensing, estimates, and statistics, and are there adequate personnel (employees) available for implementation of this responsibility?5)Does the government have a method to estimate realistically the medical and scientific needs for opioid drugs that are needed for pain relief and palliative care, and has the government critically examined its method for assessing medical needs for opioid drugs as requested by the INCB? Has the government established a satisfactory system to collect information about medical needs for opioid analgesics from relevant facilities?6)Does the government furnish annual estimates to the INCB of needs for opioid drugs for the next year in a timely manner?7)If it appears that the medical need for opioid analgesics will exceed the estimated amount, which has been approved and confirmed by the INCB, is it government policy to furnish a request for a supplementary estimate?8)Does the government submit to the INCB in a timely manner the required annual statistical reports respecting production, manufacture, trade, use, and stocks of opioid drugs?9)Has the government informed health professionals about the legal requirements for the use of opioid drugs and provided an opportunity to discuss mutual concerns, and has the government identified and addressed concerns of health care professionals regarding being investigated for prescribing opioids?10)Is there cooperation between the government and health care professionals to ensure the availability of opioid analgesics for medical and scientific purposes?11)Has the government taken steps, in cooperation with licensees, to ensure that there are no shortages of supply of opioid medications caused by inadequate procurement, manufacture, and distribution systems?12)Do national drug control policies provide for licensing of adequate number of individuals and entities to support a distribution system that will maximize physical access of pain relief medications?13)Has the government established a national cancer control program to which it allocates health care resources, and has the government taken steps to ensure the practice of the WHO analgesic method for cancer pain relief by continuing education programs and by its inclusion in medical, pharmacy, and nursing curricula?14)Is there terminology in national drug control policy that has the potential to confuse the medical use of opioids for pain with drug dependence?15)Are there provisions in national drug control policy that restrict the amount of drug prescribed or the duration of treatment?16)Are there prescription requirements in national drug control policy that may unduly restrict physician and patient access to pain relief?