1. “” “Balance” Jim Cleary, MD Associate Professor of Medicine Director, Palliative Care Medicine, UW Hospital & Clinics Director, WHO Collaborating Center for Pain Policy and Palliative Care

2. Establishes a Framework to: 1.Prevent abuse and diversion, and 2.Ensure the availability of drugs for medical purposes

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6. 6 “Balance”

7. “ the medical use of narcotic drugs continues to be indispensable for the relief of pain and suffering… adequate provision must be made to ensure the availability of narcotic drugs for such purposes. ” (Preamble, p. 13)

8. “ The low levels of consumption of opioid analgesics for the treatment of pain in many countries, in particular in developing countries, continue to be a matter of serious concern to the Board. The Board again urges all Governments concerned to…take steps to improve the availability of those narcotic drugs for medical purposes… ” (INCB 2007 Annual Report, p. 20) INCB Concern

9. Why is opioid use so low?  1995 Survey of government drug control authorities – 65 countries  Impediments to opioid availability: Fear of addiction Lack of training Excessively restrictive laws and regulations Fear of legal consequences Insufficient amount of opioids Cost of opioids Inadequate health care resources Lack of national policy, guidelines International Narcotics Control Board. (1996). Report of the International Narcotics Control Board for 1995: Availability of Opiates for Medical Needs. New York, NY: United Nations.

10. Why is opioid use so low?  2006 Survey of Health care workers, and hospice/PC staff in Asia, Africa and Latin America Adams, V. (2007). Access to Pain Relief – an essential human right. Help the Hospices, Worldwide Palliative Care Alliance. Barriers to accessing oral morphine: Excessively strict national drug laws and regulations; Fear of addiction; Poorly developed health care systems; Lack of knowledge

11. Barriers 1) Opioid Regulatory Policy 2) Drug Distribution System 3) Cost of Opioid Analgesics 4) Knowledge & Attitudes

12. For governments and health professionals Explains need, rationale and imperative 16 criteria Simplified Checklist 22 Languages Achieving Balance in National Opioids Control Policy: Guidelines for Assessment (2000) 12

13. “ Balance ” is the Fundamental Principle National policy should establish a drug control system that prevents diversion and ensures adequate availability for medical use Drug control measures should not interfere with medical access to opioid

14. Документ № WHO/EDM/QSM/2000.4 СТАТУС ДОКУМЕНТА: ЗАГАЛЬНИЙ WORLD HEALTH ORGANIZATION ВСЕСВІТНЯ ОРГАНІЗАЦІЯ ОХОРОНИ ЗДОРОВ’Я НАРКОТИЧНІ ТА ПСИХОТРОПНІ ПРЕПАРАТИ ДОСЯГНЕННЯ ВІДПОВІДНОСТІ НАЦІОНАЛЬНИХ ПОЛІТИК КОНТРОЛЮ ЗА ЗАСТОСУВАННЯМ ОПІОЇДІВ РЕКОМЕНДАЦІЇ ЩОДО ОЦІНЮВАННЯ WORLD HEALTH ORGANIZATION ВСЕСВІТНЯ ОРГАНІЗАЦІЯ ОХОРОНИ ЗДОРОВ’Я Arabic Bulgarian Chinese English French German Hindi Indonesian Italian Lithuanian Mongolian www.painpolicy.wisc.edu Polish Portuguese Romanian Russian Serbian Spanish Swahili Tagalog Turkish Ukrainian Vietnamese

15. WHO Public Health Model __________________________ Drug Availability Education Policy

16. Consumption of Morphine 1980 - 2003 East vs. West Europe (mg/capita/yr) mg/capita 16

17. Joranson, Lancet 2006 World Health Organization Collaborating Center for Pain Policy and Palliative Care