UNODC Consultation Tackles Impediments to Availability & Rational Use of Essential Palliative Care Medicines

By Katherine Pettus, PhD
IAHPC Senior Director of Advocacy & Partnerships

Recognizing that inadequate access to essential palliative care medicines is far too common, particularly outside Europe and North America, the United Nations Office of Drugs and Crime recently convened a Technical Consultation on "Diversion of Controlled Medicines: Prevent, Detect, Respond."

Jean-Luc Lemahieu, director of the Division for Policy Analysis and Public Affairs at UNODC, spelled out the meeting’s purpose, saying, "One of the unintended consequences of regulating the drug market through the drug control conventions, was the overzealous interpretation to protect the health of the wider population. Unfortunately, such a blanket approach has negatively affected many others relying on these substances for medical purposes."

The problem: Many essential medicines are withheld from people who need them, such as palliative care patients with common symptoms, including severe pain and breathlessness. This, despite the fact that they appear on the World Health Organization's list of essential medicines required for public health.

Complicating factors:

• The WHO list includes some medicines with psychoactive properties that are also included in the schedules of the three international drug control conventions, which most governments have also signed onto. This confers what is called a dual obligation under international law: to ensure adequate access while preventing diversion that results in public health harms. 
• Governments systematically misunderstand and misapply the international drug control conventions they have bound themselves to implement. Few have implemented national drug control laws mandating adequate access to those medicines. 

IAHPC participation: IAHPC research advisor Dr. Tania Pastrana, presented the latest global data on serious health-related suffering (SHS) relative to the low rates of access to essential controlled medicines in low and middle-income countries. My presentation cited evidence that morphine is not among the most diverted medicines internationally. Its low street price reflects its low value to traffickers and diverters compared to benzodiazepines and oxycodone. This makes it a good candidate for public procurement and prescription by appropriately trained professionals in the health sector. 

Common goals: The wide variety of professionals in the room seemed to agree on common goals. 

1. That essential medicines listed in the schedules of the drug control conventions should reach people who are in severe pain and need palliative care, surgery, or treatment for mental health or substance use disorder. 
2. That the success of this depends on policies and practices that keep the public safe from what the treaties call "the scourge of addiction."

Opioids are powerful medicines that are beneficial and lifesaving when used correctly. Participants agreed on principle that the well-founded fear of illicitly produced and trafficked fentanyl associated with the North American opioid crisis should be met with effective prevention initiatives and law enforcement that does not deprive legitimate patients of necessary pain relief, and promotes stewardship and rational use of controlled medicines. 

Some important take-aways: 

• A clear and consistent definition of diversion, as well as detailed country and substance-specific evidence, is necessary to understand the scope of the problem.
• The atmosphere of fear and mistrust associated with controlled medicines includes doctors’ fears that they will be criminally punished for prescribing opioids for seriously ill patients, even those who are dying. As a result, many opioids that are available in the health system go unprescribed. Fear of prescribing reinforces the barrier of fear of diversion. 
• The International Atomic Energy Agency predicts that, in coming decades, given the state of radiotherapy and lack of radiographic equipment in Africa, most cancer patients, if not diagnosed "too late," will need either surgery or palliative care. Both require regular access to morphine, which is largely unavailable on the continent.

An expected outcome of the consultation: A "living" (periodically updated) educational handbook on identification and prevention of diversion. Participants requested that it be explicitly framed as a tool to help national authorities ensure safe and adequate access to controlled medicines.

This effort, which also has a monitoring and evaluation component, could be the first step toward a collective effort to draft a much needed UNODC model drug control law, which national governments can adapt to their particular contexts. 

Read Katherine's full report on the consultation.

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Spanish association celebrates World Day & HatsOn4CPC

SECPAL's hats were on for children's palliative care on October 11! Photo used with permission.

The Spanish Palliative Care Association (SECPAL) celebrated World Hospice and Palliative Care Day and #HatsOn4CPC Day (Hats on for Children's Palliative Care) on October 11 in Madrid with a wonderful program at the Caixa Foundation. The celebration included compelling in-person testimonies of families and individuals who had received or are receiving palliative care. 

SECPAL President Dr. Elia Martinez introduced the program with a review of the past 10 years of palliative care development in Spain. Although there is a national law, not all provinces have implemented it, and availability is patchy or nonexistent in some areas, particularly the most rural provinces. The program continued with an academic lecture on the bioethics of palliative care by Dr. Jacinto Cantera, who emphasized non-abandonment, the obligation to treat patients with dignity and relieve their suffering when cure is no longer possible, and to always treat refractory suffering, including with palliative sedation. 

Dr. Cantera’s lecture was followed by a showing of Vivants, a French documentary film about a palliative care doctor in France, and a post-screening discussion with the protagonists and filmmaker. The intense and informative morning ended with an interactive and hilarious presentation by Fernando Tobias Moreno on the benefits of attention and the harm of constant distraction as a result of mobile phone use. A candle burned throughout on the stage in memory of late Dr. Juan Pablo Leiva, the former president of SECPAL who died a year ago to the day. 

I will be presenting in person at the SECPAL annual conference next week in Málaga. 

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Reminder

On October 29, 2024, World Day of Care and Support, the IAHPC is presenting a free webinar reviewing the state of caregiving in Africa, India, Canada, and Europe with panelists Dr. Eve Namisango (Africa, APCA), Dr. Aneka Paul (India), Dr. Luc Deliens, Dr. Louise D'Eer (Belgium), and Ms. Laurel Gillespie (Canada, CHPCA). Register here.