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Introduction to Treat the Pain

Introduction to Treat the Pain. 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.

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Introduction to Treat the Pain

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  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 Source: 2010 WHO cause of death and INCB reports (www.gapri.org)

  3. Scoping the problem 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% Untreated deaths in pain Source: 2010 WHO cause of death and INCB reports (www.gapri.org)

  4. There is a great disparity in access to pain relief Low and middle-income countries 70% of cancer deaths 99% of HIV deaths just 7% of medicinal opioids US, Canada, UK, Australia11% of cancer deaths <1% of HIV deaths 67% of medicinal opioids 4 4

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

  6. Progress against goals 9% 12% Untreated deaths in pain • 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

  7. Global Access to Pain Relief Initiative (GAPRI) Goal Universal access to essential pain medicines by 2020 Strategy Develop high-profile projects in countries with large unmet need; prompt change in neighboring countries and adoption by other organizations Objectives 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

  8. Nigeria: 3 kg MOH Pharmacy Dept places order with international supplier and NAFDAC approves importation 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 Drugs received by Central Medical Stores in Lagos Mechanism of access What does it take to get morphine in Nigeria? Registered pharmacist, on behalf of a health facility, gets approval from state MOH Patient receives monitoring and follow-up Registered pharmacist, on behalf of a health facility, gets approval from Central Medical Stores Lagos Patient fills prescription Clinician asks about pain Registered pharmacist picks up drugs at Central Medical Stores Lagos Powder is reconstituted into solution Clinician writes prescription Patient reports pain

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

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

  11. GAPRI Fellowship Program: Nigeria Population: 155 million Deaths in pain: 177,000 Coverage: <1% 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

  12. Supply Project: Uganda Population: 33 million Deaths in pain: 69,000 Coverage: 4% 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

  13. Pain Free Hospital Initiative: India Population: 1.2 billion Deaths in pain 694,000 Coverage: 11% GAPRI is working with partners in India to implement the Pain-Free Hospital Initiative • 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

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