Cancer Control Opportunities in Low- and Middle-Income Countries (2007) / Chapter Skim
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7 Palliative Care
7 Palliative Care
Pages 225-252
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From page 225... ...
In many low-income countries treatment may be almost nonexistent for the large majority. To the extent that cancer care is available, and particularly where governments are developing and implementing programs, they should, of course, include palliative care as an essential component.
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Because pain control is so central to palliative care, much of the remainder of the chapter is devoted to understanding the role of pain control in palliative care for
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fig 7-1 cancer, and to ways in which pain control can be expanded to form the core of expanded palliative care, which is taken up at the end of the chapter. STATUS OF PALLIATIVE CARE IN AFRICA The earliest developments in palliative care began about 25 years ago.
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From page 228... ...
2. Localized service provision: isolated palliative care and hospice services available in local areas; often heavily dependent on outside donors; no significant impact on broader national policy; oral morphine availability extremely limited.
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In 2000, the advisory team was replaced by a Palliative Care Country Team, which includes all the stakeholders, including the government, funders, and educators, as well as Hospice Uganda. A barrier to pain relief in rural areas, in particular, was the legal requirement common to many countries that morphine be prescribed by a physician.
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· Government support is essential, both for lowering legal barriers to the use of oral morphine and for support of the concept of palliative care. Hospice Uganda has successfully begun a long process of assimilating palliative care into the lives of Africans in all types of places.
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. The prevalence of cancer pain syndromes differs between high- and low-income countries.
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CANCER CONTROL OPPORTUNITIES TABLE 7-1 Cancer-Related Chronic Pain Syndromes Tumor-Related Syndromes Bone pain Multifocal or generalized bone pain Vertebral syndromes Back pain and epidural compression Pain syndromes of the bony pelvis and hip Headache and facial pain Intracerebral tumor Leptomeningeal metastases Base of skull metastases Orbital syndrome Parasellar syndrome Middle cranial fossa syndrome Jugular foramen syndrome Occipital condyle syndrome Clivus syndrome Sphenoid sinus syndrome Painful cranial neuralgias Glossopharyngeal neuralgia Trigeminal neuralgia Tumor involvement of the Tumor-related peripheral neuropathy peripheral nervous system Cervical plexopathy Brachial plexopathy Paraneoplastic painful peripheral neuropathy Pain syndromes of the viscera Hepatic distention syndrome and miscellaneous tumor- Midline retroperitoneal syndrome related syndromes Chronic intestinal obstruction Peritoneal carcinomatosis Malignant perineal pain Malignant pelvic floor myalgia Ureteric obstruction Cancer Therapy-Related Syndromes Postchemotherapy pain Chronic painful peripheral neuropathy syndromes Avascular necrosis of femoral or humeral head Plexopathy associated with intra-arterial infusion Gynecomastia with hormonal therapy for prostate cancer Chronic postsurgical pain Postmastectomy pain syndrome syndromes Postradical neck dissection pain Postthoracotomy pain Postoperative frozen shoulder Phantom pain syndromes Stump pain Postsurgical pelvic floor myalgia Chronic postradiation pain Radiation-induced peripheral nerve tumor syndromes Radiation-induced brachial and lumbosacral plexopathies Chronic radiation myelopathy Chronic radiation enteritis and proctitis Burning perineum syndrome Osteoradionecrosis SOURCE: Based on Foley (1979; 1994)
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. Most cancer pain is directly related to the tumor itself, including 85 percent of patients referred to an inpatient cancer pain consultation service, and 65 percent of patients seen in an outpatient cancer center pain clinic in the 1970s in the United States (Foley, 1979)
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The two elements that determine the number of cancer pain-days in a population are (1) the numbers of people dying painful deaths and (2)
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WHO Cancer Pain Relief Guidelines: The Three-Step Analgesic Ladder The WHO Cancer Unit created a Cancer Pain Relief Program, including guidelines for the treatment of cancer pain (WHO, 1990, 1996)
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There are no recommended standard or maximum doses for opioid drugs -- starting doses of oral morphine may be as little as 5 mg and therapeutic doses for severe pain may go up to more than 1,000 mg every 4 hours. The correct dose is the dose that relieves the pain.
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amitriptyline imipramine paroxetine Antipsychotic haloperidol Anticonvulsants (adjuvant analgesics) gabapentin valproic acid carbamazepine Corticosteroids prednisone prednisolone dexamethasone Anxiolytics diazepam clonazepam lorazepam midazolam Psychostimulants methylphenidate pemoline SOURCE: Foley et al.
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Most recent clinical trials have compared newer opioid formulations with morphine and other analgesics. A Cochrane Collaboration systematic review, Oral Morphine for Cancer Pain (Wiffen, 2003)
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In the real world, many people with cancer never reach the formal health care system, and if they do, they have late-stage disease and severe pain that requires oral morphine, which is largely unavailable in the health care systems of LMCs as well as some more developed countries. ADEQUACY OF AND BARRIERS TO PAIN CONTROL IN LMCS The adequacy of pain control in populations is not easily measured.
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analyzed the costs and costeffectiveness of pain medications, including oral morphine, in three LMC countries: Uganda, Romania, and Chile. Based on this analysis, the cost of oral morphine ranged from $216 to $420 (Table 7-4)
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PALLIATIVE CARE TABLE 7-3 Morphine Consumption by Country According to Income Level, per Capita, 2004 Morphine mg/capita Low Lower Middle Upper Middle High 0.01 Burkina Faso Cameroon Estonia Burundi Cambodia Central African Republic Congo, Dem.
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Malaysia Macao Poland Malta Romania Netherlands Seychelles Antilles Slovak New Caledonia Republic Portugal South Africa Singapore Uruguay Slovenia >10.020.0 Belgium Germany Ireland Netherlands Spain United Kingdom >20.0 Australia Austria Canada Denmark France Iceland New Zealand Norway Sweden Switzerland United States SOURCE: Pain and Policy Studies Group, University of Wisconsin/WHO Collaborating Center (2006)
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Uganda Chile Romania Total incremental annual cost of oral morphine $4.2 m $1.0 m $2.2m (US$ millions) Incremental annual cost per capita $0.18 $0.06 $0.10 Incremental number of pain-days per year avoided 3.6 m 0.9 m 1.9 m with oral morphine Incremental cost per person-day of pain avoided $1.17 $1.17 $1.17 Incremental cost per year of pain-free life added $420 $420 $420 SOURCE: Reprinted, with permission, from Foley et al.
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These same the local leaders also become involved in the advocacy work necessary to obtain opioid pain medications and to address the barriers to patient access. Improving Pain Control as the Entry Point in Improving Palliative Care In the many countries that lack adequate pain control and palliative care, the basic reasons tend to be similar: low priority of pain relief and palliative care in the national health care system, lack of knowledge about how to treat pain on the part of health care practitioners, patient fears and misunderstanding of the medications (including opioid analgesics)
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Many forms, some requiring special stamps, had to move from the hospice physician to the district oncology hospital, to the district health department, and finally to the patient's family physician, who would write a triplicate prescription for the pharmacy, where all the paperwork came together. Modern cancer pain management was basically precluded.
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Ironically, much of the world's morphine supply originates in legal poppy cultivation in India, but only a trickle was used domestically. It was during the period of declining consumption that international efforts to promote pain control and palliative care programs began to reach India.
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The state government simplified the licensing process and agreed that oral morphine could be available to palliative care centers with at least one doctor having at least one month of practical experience in palliative care;
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staff training about pain control and morphine; and (3) assurance of a continuous supply of oral morphine.
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Among the elements of palliative care, pain control is the most essential. Severe pain is common at the end stages of many cancers, degrading quality of life for the patient and family.
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1988. Multidimensional measurement of cancer pain: Comparisons of U.S.
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1999. Pain assessment and cancer pain syndromes.
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1990. Cancer Pain Relief and Palliatie Care, Technical Report Series 80.
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