Availability Of Opioid Analgesics Research Articles

Barriers of Access to Opioid Medicines within the Context of Palliative Care in Latin America: The Perception of Health Professionals.

Background: Different sets of barriers have been identified to explain the difficulties in the access and availability of opioid analgesics in palliative care, particularly in low- and middle-income countries, including Latin America. Objective: To validate a structured questionnaire for the access to opioid medicines and to investigate the perception of health professionals regarding access barriers to opioid analgesics in 17 countries of the Latin American Region. Design: Survey to identify the domains and barriers of access to opioid medicines according to health professionals, including physicians, nurses, and pharmacists affiliated to institutions that provide palliative care in Latin America between August 2019 and October 2020. Results: We analyzed responses from 426 health professionals. The median age was 44 years old (ranging from 23 to 73 years) with an average experience in palliative care of 10 years (range: 1-35), 71.8% were women, and 49.8% were affiliated to specialized health care facilities of urban areas (94.6%). The main barriers perceived to be extremely relevant by the respondents were "belief that patients can develop addiction" and "financial limitations of patients" for the patient's domain and the "appropriate education, instruction, and training of professionals" for health professional's domain. Conclusions: It is necessary to develop strategies to strengthen less-developed health systems of the region to review legal frameworks, ensure integrated palliative care systems, and deploy multidisciplinary strategies for sensitizing, training, and raising the awareness of patients, caregivers and, particularly, health professionals regarding appropriate prescription and rational use of opioid analgesics.

Palliative Care in the Republic of Kazakhstan: Current Situation and Legal Regulation

It is known that diseases do not choose either the geography, age, or gender of the patient. And when the patient faces with terrible incurable or progressive diseases, the task arises not only to stop pain, but also to provide maximum supportive psychological assistance to both the patient and his/her relatives. Issues related to the provision of palliative care are relevant for many countries: this is a problem of not one single country or even a group of countries.
 Talking about palliative care, we mean comprehensive care for a patient diagnosed with an incurable disease, including: assessment and control of chronic pain; evaluation and control of other severe symptoms of developing disease and side effects of drugs; nursing and family training in nursing skills; psychological support for the patient and his/her family members; social and legal assistance.

Pattern of Opioid Analgesic Prescription for Adults by Dentists in Nova Scotia, Canada.

Global consumption of prescription opioid analgesics has increased dramatically in the past 2 decades, outpacing that of illicit drugs in some countries. The increase has been partly ascribed to the widespread availability of prescription opioid analgesics and their subsequent nonmedical use, which may have contributed to the epidemic of opioid abuse, addiction, and overdose-related deaths. International studies report that dentists may be among the leading prescribers of opioid analgesics, thus adding to the societal impact of this epidemic. Between 2009 and 2011, dentists in the United States prescribed 8% to 12% of opioid analgesics dispensed. There is little information on the pattern of opioid analgesic prescription by dentists in Canada. The aim of this study was to examine the pattern of opioid analgesics prescription by dentists in Nova Scotia (NS), Canada. This retrospective observational study used the provincial prescription monitoring program's record of oral opioid analgesics and combinations dispensed to persons 16 y and older at community pharmacies that were prescribed by dentists from January 2011 to December 2015. During the study period, more than 70% of licensed dentists in NS wrote a prescription for dispensed opioid analgesics, comprising about 17% of all opioid analgesic prescribers. However, dentists were responsible for less than 4% of all prescriptions for dispensed opioid analgesics, prescribing less than 0.5% of the total morphine milligram equivalent (MMEq) of opioid analgesics dispensed over the 5 y. There was a significant downward trend in total MMEq of dispensed opioid analgesics prescribed by dentists from about 2.23 million MMEq in 2011 to 1.93 million MMEq in 2015 (r = -0.97; P = 0.006). Opioid prescription is common among dentists, but their contribution to the overall availability of opioid analgesics is low. Furthermore, there has been a downward trend in total dispensed MMEq of opioid analgesics prescribed by dentists. Knowledge Transfer Statement: This study will serve to inform dentists and policy makers on the types and dosage of opioid analgesics being prescribed by dentists. The study may prompt dentists to reflect on and adjust their practice of opioid analgesic prescription in view of the current opioid analgesic epidemic.

Overview of palliative care in Latin America

In 1985, approximately 50 million people died in the world of which 37.9 million were in developing countries, where cancer was the cause in 10% of the cases. In these developing countries, most cancer resources are destined to curative treatments, which do not always have the best results. Roughly 12.7 million new cases are diagnosed globally each year; without substantial improvement in cancer control, it is predicted that this worldwide annual toll will rise to 21.3 million new cancer cases and 13.1 million deaths by 2030. That is why education, along with rules to facilitate the availability of opioid analgesics and the development of health programs, is one of the basic pillars for implementing a successful palliative care program, which is available for the entire population. Palliative care aims to relieve suffering and improve the quality of life for patients with advanced illnesses and their families through specific knowledge and skills, including communication with patients and family members; management of pain and other symptoms; psychosocial, spiritual, and bereavement support; and coordination of an array of medical and social services.

Curtailing Diversion and Abuse of Opioid Analgesics Without Jeopardizing Pain Treatment

OPIOID ANALGESICS ARE AMONG THE MOST EFFECtive medications for pain management (including noncancer pain), but they are also associated with serious and increasing public health problems, such as abuse (ie, use for nonmedical purposes), addiction, and deaths from opioid overdose (excluding heroin). Both immediate and extended opioid release formulations, including methadone, are abused and contribute to overdose. For example, since 2002, the US prevalence of high school seniors reporting past-year nonmedical use of opioids has been 8% to 10% for hydrocodone and 4% to 5% for oxycodone. After excluding alcohol and tobacco, the prevalence of hydrocodone abuse is second only to marijuana abuse. Concurrently, there has been a 5-fold increase in drug treatment admissions for pharmaceutical opioids between 1998 and 2008, from 19 941 to 121 091. In addition, emergency department visits related to pharmaceutical opioids have increased from 144 644 to 305 885, between 2004 and 2008, and unintentional opioidrelated overdose deaths have increased from about 3000 to 12 000 between 1999 and 2007. Opioid overdose is now the second leading cause of unintentional death in the United States, second only to motor vehicle crashes, which prompted the Centers for Disease Control and Prevention to label pharmaceutical opioid overdose as a national epidemic. Some of the increased abuse of opioid analgesics likely reflects the misguided belief that, because these medications are prescribed by physicians, they are safer than illicit drugs. However, it is also likely that part of this increased abuse is due to much greater access to and availability of opioid analgesics. This is likely to reflect more aggressive management of noncancer pain, facilitated in part by the “regulatory” mandate from the Joint Commission to screen and manage pain, but also by the lingering concerns regarding the safety of nonopioid analgesics, particularly those classified as nonsteroidal anti-inflammatory drugs. Given the escalation in the prescription of opioid medications; the recognition that some patients misrepresent genuine pain to obtain, misuse, and divert these medications; and the corresponding prevalence of serious or even lethal public health problems, suggestions should be considered for improving current noncancer pain management in primary health care settings that could decrease diversion, abuse, and overdose of opioid medications. The first general suggestion is to enhance and update clinical teaching and training practices for physicians, nurses, dentists, and pharmacists in the areas of pain management, opioid pharmacology, and abuse/addiction, perhaps through interactive Web-based training. Given that pain is among the most common diagnoses in medicine (with prevalence estimates for chronic noncancer pain ranging from 4% to 40% in primary care settings), that there have been significant research advances in understanding pain and addiction, that there are many new formulations and types of opioid and nonopioid analgesics, and that the current education of pain management for health professionals has been deemed insufficient, a more comprehensive and contemporary training curriculum for prescribers seems warranted. Guidelines recently developed by the American Academy of Pain Medicine should be broadly adopted as a means to harmonize best practices among physicians and dentists regarding the initial prescription of opioids and the subsequent monitoring and management of patients with chronic noncancer pain. Harmonization of best-practice recommendations for the initiation of opioid medications should include the following: (1) standardized screening procedures and special provisions for managing pain in those most at risk for abuse and dependence, including adolescents and young adults, individuals with a current or previous substance use disorder (including nicotine and alcohol), and individuals with a family history of substance use disorders; (2) indications for when and for how long to prescribe nonopioid analgesics, nonpharmacological methods, or both for pain control vs when and for how long to prescribe opioid analgesics; (3) indications for when shortvs long-acting opioids should be prescribed; and (4) rea-

The Medical Consumption of Opioids in Colombia, 1997–2007

ABSTRACTThe 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.

Do International Model Drug Control Laws Provide for Drug Availability?

A preliminary review of the United Nations Office on Drugs and Crime (UNODC) model drug control laws was conducted by the Pain & Policy Studies Group (PPSG) to determine whether the models provided governments with language they can use to carry out the obligation to ensure adequate availability of opioid analgesics for the relief of pain and suffering, specified in the Single Convention on Narcotic Drugs, 1961 as amended, and as recommended by the International Narcotics Control Board in 1995. The results showed that current model laws lack the drug availability provisions. Based on initial positive feedback from the International Narcotics Control Board, the UNODC, and the World Health Organization, the PPSG developed preliminary recommendations based on existing provisions in the Single Convention. The PPSG's main recommendation is that updated model laws are needed and that consideration should be given as to how to achieve this objective. The assessment is offered as a starting point for discussion. The World Health Organization (WHO) considers opioid analgesics to be essential for the treatment of pain, but there are great disparities in their availability among countries of the world, leading to needless pain and suffering. Over a period of 15 years of study and efforts to rectify these disparities, the PPSG has found that national narcotics control laws often do not contain provisions that recognize the dual obligation of governments under the international drug control conventions not only to control narcotic drugs but also to make them adequately available for medical and scientific purposes. International drug control organizations develop and publish model narcotics laws and regulations for governments to use. If these models convey the dual obligations of governments, the models would be considered “balanced,” and national governments would have model policy language not only for control of licit drugs, but also for their availability. Most governments have already adopted laws to implement the Single Convention; however, it is not known if they followed the Single Convention itself or model laws. The PPSG conducted this preliminary assessment of whether the models published by the United Nations Office on Drugs and Crime are balanced, using as a guide the 1995 recommendations of the International Narcotics Control Board (www.incb.org/pdf/e/ar/1995/suppl1en.pdf) and the 2000 WHO publication Achieving Balance in National Opioids Control Policies: Guidelines for Assessment (www.painpolicy.wisc.edu/publicat/00whoabi/00whoabi.htm).

Health Care Providers' Assessments of the Quality of Advanced-Cancer Care in Latin American Medical Institutions: A Comparison of Predictors in Five Countries: Argentina, Brazil, Cuba, Mexico, and Peru

This paper describes an innovative Pan-American survey on advanced-cancer care and examines the quality-of-care provided by Latin American institutions. A convenience sample of 777 physicians and nurses who treat cancer patients in Argentina, Brazil, Cuba, Mexico, and Peru were surveyed. Providers were identified through mass mailings, distribution at professional meetings and conferences, collaboration with regional institutions, professional organizations, and PAHO and online posting. Multiple linear regression analyses were conducted to identify predictors of quality-of-care assessments in each country. The five predictive models were subsequently compared descriptively. Higher access to care ratings and greater availability of end-of-life services corresponded with improved institutional quality-of-care ratings for all five countries. Barring respondents from Cuba, providers from the other four nations who practice in public institutions rated the quality of advanced-cancer care in their own institutions lower than those practicing in private hospitals or specialized cancer centers. Other institutional quality-of-care predictors included type of city, affordability-of-care ratings, availability of opioid analgesics, where patients die, barriers to cancer pain management, and the provider's specialty and gender. These findings highlight the need for providing accessible care and services to improve the quality of advanced-cancer care in Latin American institutions. Efforts should be aimed at improving the care offered in public institutions and addressing other types of disparities that may exist within countries by creating supportive and palliative cancer care programs that are accessible and affordable to those most in need.

Opioid Analgesics and Rates of Fatal Drug Poisoning in the United States

To determine whether the variability in rate of sale of prescription opioid analgesics is related to the variability in rates of drug poisoning mortality among states in the United States in 2002. Drug poisoning deaths were defined as unintentional deaths or those of undetermined intent whose underlying cause was coded to "narcotics" (X42) or "other and unspecified" drugs (X44) in the National Vital Statistics System. Per capita sales of ten opioid analgesics from the Drug Enforcement Administration and combined sales in morphine equivalents were correlated with drug poisoning mortality rates by state using multivariate linear regression. Regression coefficients between mortality rates and sales rates were adjusted for race (percent white, percent black) and age (percent aged 24 years or younger, and percent aged 65 years and older). There was over a ten-fold variability in sales of some opioid analgesics. Combined sales ranged 3.7-fold, from 218 mg per person in South Dakota to 798 mg per person in Maine. Drug poisoning mortality varied 7.9-fold, from 1.6/100,000 in Iowa to 12.4/100,000 in New Mexico. Drug poisoning mortality correlated most strongly with non-OxyContin oxycodone (r=0.73, p<0.0001), total oxycodone (r=0.68, p<0.0001), and total methadone (r=0.66, p<0.0001) in the multivariate analysis. A scatterplot demonstrated a linear relationship between total opioid analgesic sales and drug poisoning mortality. The extent of opioid analgesics use varies widely in the United States. Variation in the availability of opioid analgesics is related to the spatial distribution of drug poisoning mortality by state.

Clinical and analytical features of a new case of LCAT deficiency

To determine whether the variability in rate of sale of prescription opioid analgesics is related to the variability in rates of drug poisoning mortality among states in the United States in 2002.Drug poisoning deaths were defined as unintentional deaths or those of undetermined intent whose underlying cause was coded to “narcotics” (X42) or “other and unspecified” drugs (X44) in the National Vital Statistics System. Per capita sales of ten opioid analgesics from the Drug Enforcement Administration and combined sales in morphine equivalents were correlated with drug poisoning mortality rates by state using multivariate linear regression. Regression coefficients between mortality rates and sales rates were adjusted for race (percent white, percent black) and age (percent aged 24 years or younger, and percent aged 65 years and older).There was over a ten-fold variability in sales of some opioid analgesics. Combined sales ranged 3.7-fold, from 218 mg per person in South Dakota to 798 mg per person in Maine. Drug poisoning mortality varied 7.9-fold, from 1.6/100,000 in Iowa to 12.4/100,000 in New Mexico. Drug poisoning mortality correlated most strongly with non-OxyContin® oxycodone (r=0.73, p<0.0001), total oxycodone (r=0.68, p<0.0001), and total methadone (r=0.66, p<0.0001) in the multivariate analysis. A scatterplot demonstrated a linear relationship between total opioid analgesic sales and drug poisoning mortality.The extent of opioid analgesics use varies widely in the United States. Variation in the availability of opioid analgesics is related to the spatial distribution of drug poisoning mortality by state.

Lithuania: Status of Cancer Pain and Palliative Care

Lithuania: Status of Cancer Pain and Palliative Care

Availability of Opioid Analgesics in Africa

Availability of Opioid Analgesics in Africa