Opioid Availability and Palliative Care in Nepal: Influence of an International Pain Policy Fellowship
Globally, cancer incidence and mortality are increasing, and most of the burden is shifting to low- and middle-income countries (LMICs), where patients often present with late-stage disease and severe pain. Unfortunately, LMICs also face a disproportionate lack of access to pain-relieving medicines such as morphine, despite the medical and scientific literature that shows morphine to be effective to treat moderate and severe cancer pain. In 2008, an oncologist from Nepal, one of the poorest countries in the world, was selected to participate in the International Pain Policy Fellowship, a program to assist LMICs, to improve patient access to pain medicines. Following the World Health Organization public health model for development of pain relief and palliative care, the Fellow, working with colleagues and mentors, has achieved initial successes: three forms of oral morphine (syrup, immediate-release tablets, and sustained-release tablets) are now manufactured in the country; health-care practitioners are receiving training in the use of opioids for pain relief; and a new national palliative care association has developed a palliative care training curriculum. However, long-term implementation efforts, funding, and technical assistance by governments, philanthropic organizations, and international partners are necessary to ensure that pain relief and palliative care become accessible by all in need in Nepal and other LMICs.
According to the World Health Organization (WHO), noncommunicable diseases (NCDs)—cancer, diabetes, cardiovascular disease, and chronic respiratory diseases—are the leading cause of death globally, totaling more than all other causes combined.1 Low- and middle-income countries (LMICs) bear almost 80% of that burden.1 Cancer alone claimed seven million lives in 2008, and 25 million more are living with the disease.2 Complicating these dire statistics are health-care systems and governments lacking adequate resources and expertise to care for their citizens. Despite good intentions, many countries lack basic palliative care services3, 4 and the essential medicines necessary to provide these services. Specifically, there is a lack of access to and, therefore, consumption of morphine in LMICs,5, 6, 7 despite the medical and scientific literature that shows morphine to be effective to treat moderate and severe pain.8, 9 The WHO has included morphine in its Model List of Essential Medicines since 1977.10