The low opioid consumption in Italy depends on late palliative care

Abstract

In response to disturbing rises in prescription opioid abuse, the Food and Drug Administration has proposed the implementation of aggressive risk evaluation and mitigation strategies. In Europe, the extent of the availability and misuse of prescription opioids were difficult to assess from the data currently available, due in large part to the considerable differences that exist in prescribing patterns and regulations. Indeed, new data released to the public painted a shocking picture of unnecessary pain on a global scale. Governments around the world are leaving hundreds of millions of cancer patients to suffer needlessly because of their failure to ensure adequate access to pain-relieving drugs [1.Cherny N.I. Baselga J. de Conno F. et al.Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Europe: a report from the ESMO/EAPC Opioid Policy Initiative.Ann Oncol. 2009; (615–626)Google Scholar]. However, drug availability is not necessarily a guarantee for an appropriate opioid use. In Italy, for example, legislation changed the prescription modalities and there is now a large availability of opioids, which are free of charge for patients. Unfortunately, the effects of the new law, licensed in 2010, were limited, resembling a previous one. Opioid consumption is still poor, particularly in the Southern Italy, and recognition of pain is suboptimal [2.I Marino. Attuazione della legge 15.03.2010, n. 38 in materia di ‘terapia del dolore’ presso le strutture ospedaliere. Commissione parlamentare di inchiesta sull'efficacia e l'efficienza del SSNGoogle Scholar]. The reasons for this predictable failure rely on the low level of knowledge and cultural barriers of health professionals on the use of opioids. But another reason is that consultants of the Minister of Health circumscribed palliative care in the limited range of home care and hospice care, which means in the Italian reality, about 20 days before death [3.Mercadante S. Vitrano V. Palliative care in Italy: problems areas emerging from the literature.Minerva Anestesiol. 2010; 76: 1060-1071PubMed Google Scholar], assuming that palliative care is equivalent to end-of-life care. This is in contrast to the definition of WHO: ‘Palliative care is … applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications'. Moreover, such experts ignored recent scientific evidence which showed that patients receiving early palliative care had less aggressive care at the end of life and longer survival [4.Temel J. Greer J. Muzikansky A. et al.Early palliative care for patients with metastatic non-small-cell lung cancer.N Eng J Med. 2010; 363: 733-742doi:10.1056/NEJMoa1000678Crossref PubMed Scopus (5031) Google Scholar]. Most experts strongly suggest to spread palliative care in other settings, other than traditional home care and hospice, to intercept oncologic patients in their disease trajectory early, for example in high-volume oncologic departments, rather than restricting the action area only in the last weeks of life [5.Bruera E. Hui D. Palliative care units: the best option for the most distressed.Arch Intern Med. 2011; 171: 1601Crossref PubMed Scopus (14) Google Scholar]. Early referral to an interdisciplinary supportive/palliative care team should be recommended. Politicians, commissions and experts should be aware of these scientific indications to plan projects that may have an impact on opioid consumption. The author has declared no conflicts of interest.