Global Challenges in Cancer Pain S. Lawrence Librach MD,CCFP,FCFP Professor, Department of Family & Community Medicine Sun Life Financial Chair & Director, Joint Centre for Bioethics, University of Toronto Cancer Pain Physician, Princess Margaret Hospital, Toronto

Objectives 1.Cancer pain management as a human right 2.Relationship with industry & pain

Pain Management as a Human Right IASP Montreal Declaration IASP Montreal Declaration  Declaration that access to pain management is a fundamental human right  Means that there is an ethical & probably legal requirement to act

IASP Montreal Declaration Pain management is inadequate in most of the world because of: Pain management is inadequate in most of the world because of:  Inadequate access to treatment  Failure to recognize that chronic pain is a serious chronic health problem

IASP Montreal Declaration Pain management is inadequate in most of the world because of: Pain management is inadequate in most of the world because of:  Major deficits in knowledge of health care professionals regarding the mechanisms & management of pain  Chronic pain with or without diagnosis is highly stigmatized

IASP Montreal Declaration Pain management inadequate in most of the world because: Pain management inadequate in most of the world because: Most countries have no national policy at all or very inadequate policies regarding the management of pain as a health problem, including an inadequate level of research & education Most countries have no national policy at all or very inadequate policies regarding the management of pain as a health problem, including an inadequate level of research & education  Pain Medicine is not recognized as a distinct specialty with a unique body of knowledge & defined scope of practice founded on research & comprehensive training programs

IASP Montreal Declaration Pain management is inadequate in most of the world because: Pain management is inadequate in most of the world because:  World Health Organization (WHO) estimates that 5 billion people live in countries with low or no access to controlled medicines and have no or insufficient access to treatment for moderate to severe pain  There are severe restrictions on the availability of opioids & other essential medications, critical to the management of pain

Pain Management as a Human Right Human Rights Watch Human Rights Watch  Global State of Pain Treatment & Access to Palliative Care as a Human Right

Pain Management as a Human Right-HRW Every year, tens of millions of people around the world with life-threatening illnesses suffer unnecessarily from severe pain and other debilitating symptoms because they lack access to palliative care, an inexpensive health service that aims to improve the quality of life of people with serious health conditions Every year, tens of millions of people around the world with life-threatening illnesses suffer unnecessarily from severe pain and other debilitating symptoms because they lack access to palliative care, an inexpensive health service that aims to improve the quality of life of people with serious health conditions

In Central America and the Caribbean, about half of the countries consume so few opioid medications that even if all were used exclusively to treat patients with terminal cancer and HIV for pain, less than a third of them could receive adequate treatment (Belize, El Salvador, Honduras, Nicaragua, Saint Kitts and Nevis, Trinidad and Tobago, Jamaica, Dominican Republic, and Haiti) In Central America and the Caribbean, about half of the countries consume so few opioid medications that even if all were used exclusively to treat patients with terminal cancer and HIV for pain, less than a third of them could receive adequate treatment (Belize, El Salvador, Honduras, Nicaragua, Saint Kitts and Nevis, Trinidad and Tobago, Jamaica, Dominican Republic, and Haiti)

**T&T has 1/20 the population of Canada

INCB Report Need to achieve a balance between ensuring availability of internationally controlled substances for medical and scientific purposes and preventing their diversion and abuse Need to achieve a balance between ensuring availability of internationally controlled substances for medical and scientific purposes and preventing their diversion and abuse

INCB Report The Board considers all levels of consumption of narcotic drugs below 200 S-DDD per million inhabitants per day inadequate. However, this does not imply that levels above 200 S-DDD can be considered adequate as the determination of whether availability of internationally controlled substances required for treatment is sufficient depends on the specific morbidity data The Board considers all levels of consumption of narcotic drugs below 200 S-DDD per million inhabitants per day inadequate. However, this does not imply that levels above 200 S-DDD can be considered adequate as the determination of whether availability of internationally controlled substances required for treatment is sufficient depends on the specific morbidity data

Websites  Multiple videos & reports  Video “Life Before Death” s/AnnualReports/AR10_Supp_E.pdf s/AnnualReports/AR10_Supp_E.pdf s/AnnualReports/AR10_Supp_E.pdf s/AnnualReports/AR10_Supp_E.pdf

PAIN AND INDUSTRY: ETHICS

How to dance with porcupines: rules and guidelines on doctors’ relations with drug companies BMJ 2003 How to dance with porcupines: rules and guidelines on How to dance with porcupines: rules and guidelines on doctors’ relations with drug companies doctors’ relations with drug companies

Pharmaceutical Industry & Opioid Availability Expensive sustained-release opioids seem to be making an appearance on formularies when cheaper alternatives like immediate- release & injectable morphine & hydromorphone are not allowed or in very limited supply in many countries Expensive sustained-release opioids seem to be making an appearance on formularies when cheaper alternatives like immediate- release & injectable morphine & hydromorphone are not allowed or in very limited supply in many countries  Sometimes companies abandon markets

Influence of Pharmaceutical Industry on Pain Professionals Clinical research funding in pain to a great extent funded by industry Clinical research funding in pain to a great extent funded by industry Conference support by industry is absolutely necessary for those conferences to take place Conference support by industry is absolutely necessary for those conferences to take place  Glossy booths for industry Speakers bureaus & consultant contracts Speakers bureaus & consultant contracts

Influence of Pharmaceutical Industry on Pain Professionals Articles mostly funded by industry & many ghostwritten Articles mostly funded by industry & many ghostwritten Research often multicentric & may be in jurisdictions where research ethics boards or independent boards have lower standards Research often multicentric & may be in jurisdictions where research ethics boards or independent boards have lower standards Data not made available to researchers Data not made available to researchers

Summary There is much to do in relieving cancer pain There is much to do in relieving cancer pain Pain relief is a human right Pain relief is a human right Availability of opioids around the globe is an issue Availability of opioids around the globe is an issue The availability of opioids in T&T is very limited & needed drugs are all generic The availability of opioids in T&T is very limited & needed drugs are all generic