"Perspectives of former International Pain Policy Fellows" Prof. Snežana Bošnjak, MD, PhD Institute for Oncology and Radiology of Serbia (IORS) Belgrade, Serbia Institute for Oncology and Radiology of Serbia (IORS) Belgrade, Serbia

Dual nature of opioids Essential medicines Moderate to severe pain Tx of opioid dependence Accessible Narcotics Potential to be abused Inaccessible Controlled

Action plan: identify issues Oral morphine unavailable Neglected need for / concerns about morphine Lack of recognition that it is Government`s obligation to ensure that opioids are available and accessible for patients (dual obligation) Overly restrictive policies that govern the use of opioids Oral morphine unavailable Neglected need for / concerns about morphine Lack of recognition that it is Government`s obligation to ensure that opioids are available and accessible for patients (dual obligation) Overly restrictive policies that govern the use of opioids

Create demand for morphine Educate that oral morphine is Indispensable for Tx of moderate to severe cancer pain Appropriate for every phase of the disease Safe when used as recommended by available guidelines Convenient: variety of formulations Educate that oral morphine is Indispensable for Tx of moderate to severe cancer pain Appropriate for every phase of the disease Safe when used as recommended by available guidelines Convenient: variety of formulations

Create demand for morphine Change negative attitude Address concerns about addiction, tolerance, side effects of morphine Address fears that morphine implies the final stage of the disease Change negative attitude Address concerns about addiction, tolerance, side effects of morphine Address fears that morphine implies the final stage of the disease

Create demand for morphine Inform about moral obligation to prevent people from suffering if suffering is preventable Inform about right to pain relief as a human right Request help from Ombudsman Inform about moral obligation to prevent people from suffering if suffering is preventable Inform about right to pain relief as a human right Request help from Ombudsman

Counter-Campaign: why morphine? Why spending money on morphine, when the drug is not “popular” any more There are other, “less frightening” alternatives to morphine The consumption of morphine is declining all over the world Why spending money on morphine, when the drug is not “popular” any more There are other, “less frightening” alternatives to morphine The consumption of morphine is declining all over the world

Textbook Pharmacotherapy of cancer pain

Professionals Patient / family

Educative poster on right to pain relief as a human right

Educative poster on opiophobia for patients

Working with Government How to balance obligation to protect against abuse and dependence with the equally important responsibility to ensure opioids for pain relief and effective palliative care ? Inform about legal, political, public health and moral grounds for dual obligation Explore possibility to participate in decision- making bodies How to balance obligation to protect against abuse and dependence with the equally important responsibility to ensure opioids for pain relief and effective palliative care ? Inform about legal, political, public health and moral grounds for dual obligation Explore possibility to participate in decision- making bodies

Change overly restrictive drug control policies Drug regulators educated that the main (only?) goal of drug control policies is to prevent abuse and dependence No provision that recognizes that opioids are absolutely necessary for the relief of pain & suffering Presentation, communication, negotiation skills Be prepared, work with PPSG staff, use available resources (WHO 2011 policy guidelines) Drug regulators educated that the main (only?) goal of drug control policies is to prevent abuse and dependence No provision that recognizes that opioids are absolutely necessary for the relief of pain & suffering Presentation, communication, negotiation skills Be prepared, work with PPSG staff, use available resources (WHO 2011 policy guidelines)

Building support (internal) Interviews with practicing clinicians, pharmacists, patients/families, caregivers Interviews with government drug regulators Professional societies (oncology, hematology, pharmacology, pain) NGOs Pharmaceutical companies Influential individuals who have had recent positive experiences w/opioid use Media Interviews with practicing clinicians, pharmacists, patients/families, caregivers Interviews with government drug regulators Professional societies (oncology, hematology, pharmacology, pain) NGOs Pharmaceutical companies Influential individuals who have had recent positive experiences w/opioid use Media

Building support (external) PPSG mentor (s) Other mentors: WHO, IAHPC, EAPC, OSI, HRW International experts / initiatives / resources Your colleague Fellows ATOME project –Member of AAB –Member of WHO 2011 guidelines development group PPSG mentor (s) Other mentors: WHO, IAHPC, EAPC, OSI, HRW International experts / initiatives / resources Your colleague Fellows ATOME project –Member of AAB –Member of WHO 2011 guidelines development group

Conclusion Identify issues Develop possible solutions Seek collaboration and partnership Build support Capitalize on opportunity Identify issues Develop possible solutions Seek collaboration and partnership Build support Capitalize on opportunity