1. International Pain Policy Fellowship, Cohort III
Country Report : Sri Lanka

2. Cancer Pain and Palliative Care
Country Report
For
SRI LANKA
Part I
Cancer Pain and Palliative Care
Dr. N. Jeyakumaran MD Consultant Clinical Oncologist. Teaching Hospital, Jaffna Sri Lanka

3. Sri Lanka 20.2 Million Total Land area : 65,610 Sq km Population : Sri

4. Sri Lanka
Nine Provinces.
Nine Cancer Units

5. Cancer Pain and Palliative Care
Management mainly at Cancer Hospitals.
One Cancer Unit in each province.
Varying pattern of pain management policies.
Pain Management.
Mainly By…
Oncologists.
Anaethetists.
WHO Pain Management.
Radiation treatment.
IV preparations.

7. Cancer Incidence in Sri Lanka
No / 100,000

8. Cancer Pattern (1985 – 2005) Year Sex Number % CR ASR 1985 Male 2 564
51.2
31.7
34.9
Female
2 448
48.8
31.5
39.4
Total
5 012
31.6
37.6
1990
2 979
49.1
34.4
38.6
3 084
50.9
37.0
46.9
6 063
35.7
43.1
1995
3 450
47.1
37.3
43.6
3 875
52.9
58.6
7 325
40.4
2000
5 130
47.0
52.0
63.7
5 795
53.0
61.1
84.9
10 925
56.4
74.6
2005
6 058
45.3
62.3
68.1
7 314
54.7
73.4
73.3
13 372
67.9
70.6

9. Leading Cancer sites overall (2005)No CR
ASR
Breast
1908
9.7
Lip Oral Cavity & Pharynx
1617
8.2
8.7
Esophagus
1022
5.2
5.6
Cervix Uteri
881
4.5
4.6
Trachea Bronchus & Lungs
832
4.2
Thyroid
752
3.8
3.6
Colon & Rectum
741
Lymphoma
604
3.1
3.3
Ovary
596
3.0
Leukaemia
570
2.9
 All Sites
 13372
 67.9
 70.6

11. Leading Cancer sites in Male (2005)
Rank
Male
Site No CR
ASR 1
Lip Oral Cavity & Pharynx
1240
12.7
14.1 2
Trachea Bronchus & Lung
666
6.9
7.7 3
Esophagus
498
5.1
5.8 4
Colon & Rectum
388
4.0
4.4 5
Lymphoma
360
3.7
3.9 6
Larynx
324
3.3 7
Leukaemia
313
3.2 8
Prostate
303
3.1
3.5 9
Unknown Primary Site
257
2.7
2.9 10
Brain
171
1.8
 All Sites
 6058
 62.3
 68.1

13. Leading Cancer sites in Female (2005)
Rank
Female
Site No CR
ASR 1
Breast
1859
18.7
18.3 2
Uterine Cervix
881
8.9 3
Ovary
496
5.9 4
Thyroid
3592
5.6 5
Oesophagus
524
5.5 6
Lip Oral Cavity & Pharynx
377
3.8 7
Colon & Rectum
353
3.6 8
Leukaemia
257
2.8
2,8 9
Lymphoma
243
2.5 10
Uterus
237
12.4
2.4
 All Sites
 73.4
 73.3

16. Source :
GLOBOCAN 2008 Estimates

17. Source :
GLOBOCAN 2008 Estimates

20. Proportionate mortality rate
Cancer Mortality Data (1985 – 2003)
Year
No. of Cancer Deaths
Crude Death Rate
Proportionate mortality rate
1985
4416
27.9
4.5
1990
4479
26.4
4.6
1995
5710
31.5
5.5
2000
7,842
41.1
6.7
2001
8063
42.9
7.1
2002
7986
42.0
2003
8,396
43.8
7.3
2004
9,127
47.0
7.9
2005
9,403
47.9
2006
10,386
52.3
8.8

21. National Cancer Control Programme. (NCCP)
Director - NCCP.
Policy - Is being drawn.
Cancer Prevention & Control Strategies
Primary Prevention
Early Detection & Screening
Diagnosis and Treatment
Rehabilitation & Palliative Care
Cancer Surveillance (Cancer Registry)
Cancer Research

22. Role of Govt. in Pain Relief…
Education:
Specialist Training.
Palliative Care included.
Analgesics including Opioids.
Given Free of charge in all Hospitals
Policy towards improved Health Care

23. Pain Management at Cancer Hospitals
Most Cancer Patients present at Late Stages.
Govt. of Sri Lanka provides free Health Care.
Pain Management.
WHO method.
WHO Ladder is followed.
Opioid available in Cancer Hospitals.
Few hospices.
Training Programmes.
Need to be organized.

24. Availability of Pain Relief and Palliative Care Services
Places of Treatment.
At all Cancer Units.
At the Hospices.
Drugs:
Mild Analgesics.
Moderate Analgesics.
Strong Analgesics.
Adjuvant drugs.
For Children.
Oral solutions – Not available.

25. Hospices

28. Sathya Sai Suva Sevana

30. Play Therapy
Play therapy is used to help meet the emotional needs of children who have an cancer that requires hospitalization. Being in the hospital is stressful for children and their families. Sometimes, children feel scared, confused, and out of control. Play therapy is used to help children understand and cope with illness, surgery, hospitalization, treatments, and procedures

31. Art Therapy

32. Art Therapy

33. Partners in Palliative Care
Training institutions.
Postgraduate Institute of Medicine.
Professional Organizations.
Sri Lanka Medical Association.
Sri Lanka College of Oncologists.
NGO
Sri Lanka Cancer Society.
Cancer Aid for North and East.
International Partners
WHO Palliative Care Centre.
Kerala Palliative Care Centre.
PPSG.
Pallium India & Trivendram Centres .

34. Part II HIV/AIDS & Palliative Care
Dr. Suraj Perera MBBS, MSc, MD
Consultant Community Physician
National Cancer Control Programme,
Ministry of Health , Sri Lanka

35. Number of HIV cases reported up to end of 2011 Sri Lanka
Period
Male
Female
Total %  
13  3 
16 
1.1  
76 
31 
107 
7.3  
101 
80 
181 
12.4  
173 
137 
310 
21.2  
344 
238 
582 
39.8   
159 
108 
267 
18.2 
Total 
866 
597 
1463 
100.00 
Source : National STD/AIDS Control Programme, Ministry of Health, Sri Lanka

36. Trend of reported deaths due to AIDS in Sri Lanka 1987-2009
Source: National STD/AIDS Control Programme, Sri Lanka. (2010).

37. Estimated number of adults and children living with HIV, new infections and AIDS deaths, 1990-2009
Source: Prepared by based on UNAIDS (2010). Global Report: UNAIDS Report on the Global AIDS Epidemic.

38. National STD/AIDS Control Programme Ministry of Health
Anti Venereal Disease Campaign - established in
With the advent of HIV/AIDS the Anti VD Campaign was restructured as the National STD/AIDS Control Programme (NSACP) in 1985, even before the first case of HIV infection was reported in Sri Lanka.
Dr. Nimal Edirisinghe, Director
National STD/AIDS Control Programme
Ministry of Health
No. 29, De Saram place, Colombo 10, Sri Lanka
(94) , (94) / (94)

39. Objectives for pain relief and palliative care in National STD/AIDS Control Programme
“To maintain the provision of HIV treatment, care and support services for people living with and affected by HIV/AIDS and occupational post exposure prophylaxis (oPEP) for health care workers (HCWs) through the service delivery points of the National STD/AIDS control Programme or other relevant government health facilities in quality assured manner.”
“To coordinate with and support institutions within and outside the Ministry of Health in the expansion of appropriate, high quality HIV treatment, care and support services for people living with and affected by HIV/AIDS and for oPEP in Sri Lanka.”

40. Availability of pain relief and palliative care services in the country for HIV/AIDS patients
Pain relief medications are available for HIV/AIDS patients.
But patients are not experiencing any ‘significant pain’ during their HIV/AIDS journey from diagnosis to death according to the verbal communication of staff of inward facility for AIDS Patients in Sri Lanka .

41. Part III : Opioid Availability

42. Opioid Availability - National Competent Authority (NCA)
Medical Supplies Division (MSD), Ministry of Health
Director / Medical Supplies Division, Ministry of Health submits annual estimates of medical requirements of narcotic drugs including Morphine

43. Calculating Annual estimates for Opoids
Medical Supplies Division (MSD) of Ministry of Health calculates annual estimates based on estimates send by the Directors of Hospitals in the line Ministry and Provincial Ministries of Health
Additional 10% is added, based on previous year consumption
MSD provides annual statistics to INCB

44. Palliative Care Pain Relief Drugs in Essential Medicines List
Morphine & Tramadol is included (National Essential Medicine List Sri Lanka , 2009)

45. Opoid Analgesics available in Sri Lanka
Opioid analgesic
Dosage Form
Generic / Trade Name
Manufacturer
Morphine
10mg tablet ‘
‘DURAMOR 10’
Biological E Ltd, India
30 mg tablet
Morphine Sulphate
Belco Pharma Ltd, India
‘ANAMORPH’
Sigma Pharmacetical Pty Ltd, Australia
30 mg tablet CR
‘DURAMOR 30’
‘RELIMAL CR 30’
Pharmachemie BV Netherlands
15mg/ml injection
Belco Pharma ltd, India
S GmbH/Germany Hospira Australia pty Ltd Hameln Pharmaceutical, Australia

46. Opoid Analgesics available in Sri Lanka
Opioid analgesic
Dosage Form
Generic / Trade Name
Manufacturer
Fentanyl
100mcg/2 ml injection
Fentanyl citrate
S GmbH/Germany Hospira Australia pty Ltd Hameln Pharmaceutical, Germany
0.05mg/ml injection
FENTANYL JANSSEN
Janssen Pharmaceutica,, Belgium
0.1mg/2 ml injection
TALGESIL
Duo Pharma (M) Sdn, B hd, Malaysia
Pethidine
50mg /ml injection
Belco Pharma Ltd, India
NEON Laboratories, India
75mg / 1.5 ml injection

47. Additional Opioids which are needed
Oral morphine liquid form
Fentanyl dermal patches

48. Availability of Morphine
Sufficiently available most of the times at the Cancer Units. But the instant release Morphine tablets some times are out of stock.
Hospices receive oral morphine stocks from near by Cancer Units. Injectables are bought from Medical Supplies division.
The duration of Morphine prescribed is from one week – one month

49. Prescribing Morphine
Any registered Medical Practitioner at the Sri Lanka Medical Council (SLMC) can prescribe
No special prescription forms required
No special training required.
Nurses are not allowed to prescribe

50. Prescribing Morphine
It is usually started using WHO Pain ladder concept from mild pain medicines to Strong Opioids .
Then doses are increased to achieve a good pain relief.
But when prescribing Morphine to take home the duration varies from 1 – 4 weeks from one cancer unit to other.
As long as the patient is not having much side effects, full course is given depending on the availability of drugs.

51. Prescribing Morphine
As Oral morphine is only available in the Government sector, when prescribe on a particular date, on the same day patient has to get the drug free of charge from the hospital pharmacy.
( This applies to all medications).

52. Prescribing Morphine
If a doctor violates general prescribing principles for any medications, he/ she can be called for explanations by the Ministry of Health Administration or Sri Lanka Medical Council.
Regulation does not require reporting names of patients who receive opioid prescriptions to the government.

53. Prescribing Morphine
Ministry of Health, Sri Lanka provide free health care through government hospitals through out the country . Therefore cost is not a factor for prescription of Opioids

54. Supply Chain of Opioids in Sri Lanka
Medical Supplies Division (MSD) of Ministry of Health purchased all controlled drugs through the State Pharmaceutical Corporation (SPC) through competitive bidding via Global Tenders
MSD directly supplies drugs to all hospitals (Teaching, Provincial General Hospitals, Special Hospitals including National Cancer Institute, Maharagama) belong to Line Ministry of Health.
Drugs to hospitals belong to Provincial Ministries of Health are provided through the Regional Medical Supplies Divisions (RMSD) of 25 districts.

55. Mg/capita Consumption of Morphine, Sri Lanka, 1980-2009
Sources: International Narcotics Control Board; World Health Organization population data
By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2011

56. Mg/capita Consumption of Fentanyl, Sri Lanka, 1980-2009
Sources: International Narcotics Control Board; World Health Organization population data
By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2011

58. THANK YOU