1. Introduction to Treat the Pain

2. The problem of unrelieved pain Globally, 7.3 million people die of cancer or HIV each year in moderate or severe pain More than 2.9 million die without pain relief 99.9% of these deaths are in low and middle-income countries 2 Source: 2010 WHO cause of death and INCB reports (www.gapri.org)

3. There are 2.9 million deaths from HIV or cancer in untreated pain each year Sub-Saharan Africa: 41% South Asia: 29% East Asia & Pacific: 16% Europe & Central Asia, Latin America & Caribbean, Middle East & North Africa, North America: 14% Scoping the problem 3 Source: 2010 WHO cause of death and INCB reports (www.gapri.org) Untreated deaths in pain

4. 44 Low and middle-income countries 70% of cancer deaths 99% of HIV deaths just 7% of medicinal opioids US, Canada, UK, Australia 11% of cancer deaths <1% of HIV deaths 67% of medicinal opioids There is a great disparity in access to pain relief

5. Untreated deaths in pain 5 60% of the unmet need is in 10 countries Source: 2010 WHO cause of death and INCB reports (www.gapri.org) * * * * Denotes GAPRI partner countries

6. 9% 12% Untreated deaths in pain Progress against goals 2010: 2.9 million untreated deaths in pain and going down Global coverage rate is 60% 100%-high income 57%-middle income 8%-low income 6

7. Goal Objectives Strategy 1. Strengthen government leadership by providing staff (fellows) and technical assistance directly to health ministries 2. Reduce cost and improve availability of medicines by negotiating with suppliers and providing technical assistance to buyers 3. Improve clinical and regulatory policies and practice by advocating on international, national, and facility levels 4. Improve skills and motivation of individual clinicians by improving access to information and to other clinicians interested in pain treatment Develop high-profile projects in countries with large unmet need; prompt change in neighboring countries and adoption by other organizations Universal access to essential pain medicines by 2020 7 Global Access to Pain Relief Initiative (GAPRI)

8. National Agency for Food and Drug Administration and Control (NAFDAC), with input from Federal Ministry of Health (FMOH), submits annual estimate to International Narcotics Control Board (INCB) INCB approves morphine quantity MOH Pharmacy Dept places order with international supplier and NAFDAC approves importation Drugs received by Central Medical Stores in Lagos Registered pharmacist, on behalf of a health facility, gets approval from Central Medical Stores Lagos Powder is reconstituted into solution Clinician asks about pain Patient reports pain Clinician writes prescription Patient fills prescription Patient receives monitoring and follow-up Nigeria: 3 kg What does it take to get morphine in Nigeria? Registered pharmacist, on behalf of a health facility, gets approval from state MOH Registered pharmacist picks up drugs at Central Medical Stores Lagos Mechanism of access 8

9. National Agency for Food and Drug Administration and Control (NAFDAC), with input from Federal Ministry of Health (FMOH), submits annual estimate to International Narcotics Control Board (INCB) INCB approves morphine quantity MOH Pharmacy Dept places order with international supplier and NAFDAC approves importation Drugs received by Central Medical Stores in Lagos Registered pharmacist, on behalf of a health facility, gets approval from Central Medical Stores Lagos Powder is reconstituted into solution Clinician asks about pain Patient reports pain Clinician writes prescription Patient fills prescription Patient receives monitoring and follow-up Nigeria: 3 kg Why isn’t it working? Registered pharmacist, on behalf of a health facility, gets approval from state MOH Registered pharmacist picks up drugs at Central Medical Stores Lagos MOH is not ordering; last order expired before use Users did not know morphine was available Approvals took a very long time; required several days in Lagos Difficult for facilities far from Lagos Limited capacity for reconstitution outside of large facilities; lack of quality control Lack of awareness from patients; lack of trained clinicians Patients pay for drugs 9

10. National Agency for Food and Drug Administration and Control (NAFDAC), with input from Federal Ministry of Health (FMOH), submits annual estimate to International Narcotics Control Board (INCB) INCB approves morphine quantity MOH Pharmacy Dept places order with international supplier and NAFDAC approves importation Drugs received by Central Medical Stores in Lagos Registered pharmacist, on behalf of a health facility, gets approval from Central Medical Stores Lagos Powder is reconstituted into solution Clinician asks about pain Patient reports pain Clinician writes prescription Patient fills prescription Patient receives monitoring and follow-up Nigeria: 3 kg What can GAPRI do? Registered pharmacist, on behalf of a health facility, gets approval from state MOH Registered pharmacist picks up drugs at Central Medical Stores Lagos MOH is not ordering; last order expired before use Users did not know morphine was available Approvals took a very long time; required several days in Lagos Difficult for facilities far from Lagos Limited capacity for reconstitution outside of large facilities; lack of quality control Lack of awareness from patients; lack of trained clinicians Patients pay for drugs Drug forecast and stock monitoring Supplier identification and negotiation Communication of availability Streamline approvals Track and monitor stocks Integrate pain treatment into HIV and cancer care Collaborate with NGOs to improve awareness Improve distribution 10

11. 11 GAPRI Fellowship Program: Nigeria Three-year partnership with the Federal Ministry of Health (FMOH) Placed a consultant in the Department of Food and Drug Services, FMOH as Special Assistant to the Director for Access to Pain Relief Procured first batch of morphine in 4 years, improving distribution, training clinicians Working with HIV and cancer communities to integrate pain relief Population: 155 million Deaths in pain: 177,000 Coverage: <1%

12. Supply Project: Uganda 12 In 2010 GAPRI negotiated a deal between government and an NGO to create a national morphine production program Government certified production facility at Hospice Africa Uganda now producing morphine for the entire country Current cost is 2 USD for a week of treatment – reducing the government’s cost by 40% Increased stability of supply and expanded patient access Morphine is now free for all patients Population: 33 million Deaths in pain: 69,000 Coverage: 4%

13. 13 Pain Free Hospital Initiative: India A one-year hospital-wide quality improvement initiative in 3 hospitals  Improve knowledge and skills to assess and treat pain  Raise awareness about untreated pain  Improve availability of essential pain medicines  Measure and document activities and their impact GAPRI is working with partners in India to implement the Pain-Free Hospital Initiative Population: 1.2 billion Deaths in pain 694,000 Coverage: 11%