Global Health and Travel

GETTING FIXED
ASIA’S PAIN
MANAGEMENT
DILEMMA
Asian patients travel
within the region for
quality orthopaedic care
The region struggles for
relief from chronic pain
SAVING FACE
Sino-Korean joint
ventures bring Korean
plastic surgery prowess
to China
May - June 2015
OUR VISION
Ms. Sherene Azli
CEO, Malaysia Healthcare Travel Council (MHTC)
speaks on Malaysia Healthcare
GlobalHealthAndTravel.com
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Pain Management
Medical
Asia’s Pain
Management
Dilemma
remove long-standing barriers to the distribution of palliative care medicines that could
relieve suffering for millions of people with chronic pain
D
r. Savita Butola, chief medical officer of the
FHQ Border Security Force Hospital in New
Delhi, India, recalled vividly the memory of a
37-year old woman who made the three-day
journey by bus and train from Kishanganj
in the Indian state of Bihar to New Delhi
up to twice a month, just so she could relieve her pain for a
little while. Dr. Butola met the woman, as well as many other
patients like her, while completing her palliative care clinical
training at Indian Rotary Cancer Institute at the All India
Institute of Medical Sciences (AIIMS) in New Delhi in 2011.
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The patient suffered from advanced rectal carcinoma
with a rectovaginal fistula, which was so painful she was not
even able to squat while using the toilet. The closest access
to morphine, the only medication available that could make
her pain bearable, was 1,200 kilometers away in New Delhi
– forcing her and her husband, a casual labourer, to endure
the torturous two-day, two-night journey from Bihar in a
second-class, unreserved train compartment. En route, the
couple slept on the train platform and on the pavement
outside the hospital in New Delhi because they could not
always get a room in the patient’s rest house.
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“She had four children, the youngest only two years
old. She had to leave them behind in her village with her
mother every time she came to collect her morphine. And
that meant a trip, at least every 15 to 30 days,” Dr. Butola
wrote in a 2012 narrative published in the Journal of Pain
and Palliative Care Pharmacotheraphy. As a result of the bimonthly odyssey, the patient’s husband would lose six to
seven days’ work for each trip.
“It still makes me angry to think of these patients,” she
continued. “Why can they not get morphine somewhere
close to their villages? Or even within their states?”
Dr. Butola’s memoir echoes the concerns of palliative
care providers – doctors who aim to reduce the symptoms
and severe pain caused by chronic diseases like cancer – that
access to morphine, listed as an “essential medicine” by the
WHO, is still severely restricted to the point of being largely
unavailable in many parts of Asia.
Statistics show vast inequities in access to
palliative care between Asia and the West
By WHO estimates, a staggering 60 percent of people who die
in developing countries each year – around 33 million people
– are in need of palliative care. The organization further
stipulated in a 2014 report that only one in ten patients who
need palliative care receive it, and 80 percent of the need for
palliative care comes from developing countries.
2012 data from the Pain Policy Studies Group (PPSG) at
the University of Wisconsin reinforces that international
drug control efforts have largely crippled access to
morphine and morphine equivalents in developing
countries throughout Asia. In addition, access remains
moderate or low in some richer or middle-income countries
like Singapore, China, and Thailand.
Consumption of opioid medications in the West dwarfs
amounts consumed in most Asian countries – Americans,
the data suggests, consumed almost eight times as much
morphine or morphine equivalents annually in 2012
compared to people in Hong Kong; 14 times as much as
Malaysians; 57 times as much as Vietnam and over 3000
times as much as India.
“Patients around the region often do not get access to
effective pain management therapies, especially when
compared to those patients living in the Western world,”
says Dr. Ho Kok Yuen, president of The Pain Association of
Singapore. “The main culprits are various, including a lack
of education on the capacity of modern medicine to treat
pain adequately, strict regulations for opioids and a strong
suspicion against pain relieving medicine because of their
addictive nature.”
Part of the reason that worldwide morphine access is so
skewed towards Western countries, palliative care advocates
say, is due to the modern international framework for
global opioid consumption, control and distribution
patterns set up by the United Nations’ Single Convention
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42 Medical Feature.indd 43
on Narcotic Drugs (1961), which advocates consider to be the
start of the Western-led ‘War on Drugs’.
Dr. Katherine Pettus, advocacy officer for the International
Association of Hospice and Palliative Care (IAHPC), argued
in an op-ed for ehospice.com that the Single Convention,
which required ratifying states to pass laws prohibiting the
manufacture, distribution, and consumption of narcotic
drugs, had the “unintended consequence” of making
morphine, listed by the WHO as an ‘essential medicine’,
“virtually unavailable” in nearly 140 countries.
In a 2014 article for Pacific Standard, Helen Redmond
writes that although the Single Convention had the
stated intention to promote the medical use of narcotics
“indispensable for the relief of pain in suffering”, in reality,
the role of the International Narcotics Control Board in
cracking down on international trade of illicit narcotics has
conflicted with states’ role in securing a sufficient supply
of morphine and other opioids for medical use. Redmond
further points out that a “complex” control regulatory
system enforced by the INCB, where governments are
required to keep accurate statistics of the amount of
narcotics needed for general use, as well as provide data
on narcotic consumption and manufacture, creates an
environment in which only developed countries have the
necessary infrastructure to comply.
OPIOID CONSUMPTION 2012
(Morphine Equivalence mg/Person)
Data Sources and information: Opioid consumption data – International
Narcotics Control Board (values represent the aggregate morphine equivalence
consumption of fentanyl, hydromorphone, morphine, oxycodone and pehidine).
Population data – the United Nations World Population Prospects 2010 Revision.
Pain & Policy Studies Group, UWCCC/WHO Collaborating Center, 2012
800
700
USA
600
743.19 mg/person
Australia
481.9 mg/person
France
212.84 mg/person
Hong Kong SAR 96.23 mg/person
500
Malaysia
400
300
200
52.82 mg/person
Vietnam
13.5 mg/person
Singapore
8.92 mg/person
China
7.75 mg/person
Thailand
4.13 mg/person
Cambodia
1.16 mg/person
Philippines
0.56 mg/person
India
0.239 mg/person
Laos
0.17 mg/person
100
0
WESTERN COUNTRIES CONSUME THE VAST MAJORITY OF THE
WORLD’S OPIOID MEDICATIONS, DESPITE THE TREMENDOUS
NEED IN ASIA AND THE DEVELOPING WORLD FOR PALLIATIVE
CARE MEDICINES
March
April2015
2014
May - -June
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Pain Management
Medical
BASIC ORAL MORPHINE IS LISTED AS AN “ESSENTIAL
MEDICINE” BY THE WHO, YET, IT IS NOT EASILY ACCESSIBLE
IN HOSPITALS AND CLINICS IN MANY ASIAN COUNTRIES
However, Dr. Jim Cleary, director of the University of
Wisconsin’s Pain Policy Study Group, says the INCB isn’t the
main problem, arguing that states can apply to the INCB to
receive more morphine if they deem it to be necessary. “My
feeling is that the INCB has little role in this war on drugs,”
he says. “What they [the INCB] have left out is they haven’t
put enough focus on their in-country visits to make sure
that access to opioids is important.” He emphasises for these
INCB in-country visits, “who invited to the table is left up to
the host nation, rather than the INCB themselves.”
Historical factors, lack of education remain
major barriers to improved access
Although international institutions such as the INCB may
have a damaging affect on developing’ countries ability
to freely purchase and distribute morphine and other
opioids, historical attitudes shaped by the past horrors
of widespread opium abuse, particularly in some Asian
countries like India, Vietnam, Cambodia, and China, have
also made policymakers and regulators squeamish about
easing restrictions on opioid licensing and incorporating
opioid training into national medical education programs,
which affects doctors’ practices in the public and private
sectors alike, according to the nonprofit advocacy group
Human Rights Watch.
These attitudes are reflected in a 2011 report by the group,
which noted that the state of availability of education on
pain management in Asian countries was particularly
troubling. In a survey of 12 major countries in Asia,
including India, China, Vietnam, Indonesia and even some
more developed countries like South Korea and Japan, the
report noted that no compulsory education on palliative
care is required in undergraduate medical programs, and
in China, it was also not available in postgraduate medical
curriculums. Doctors in all Asian countries surveyed, the
report noted, said that morphine was particularly harder
to access outside major cities – indicating a further gap
between access in urban and rural areas.
These trends have also been noticed in studies
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by the private sector, particularly pharmaceutical
companies. A 2014 survey of 1,158 physicians and 2,495
patients throughout Asia by pharmaceutical company
Mundipharma, which manufactures cancer pain drugs,
found that only six percent of Asian cancer patients had
been treated by a pain specialist. Additionally, of the 463
physicians surveyed who were involved in treating cancer
pain, only 30 percent considered their training on opioids to
be adequate, although 84 percent agreed that opioids should
be a first-line therapy for cancer pain.
Raman Singh, president of emerging markets for
Mundipharma, says that the knowledge it gained has
helped it to better formulate continuing medical education
(CME) programs that train doctors how to better use opioid
medications to treat chronic pain, particularly cancer pain.
“There is an unmet need to address the gap in
physicians’ training, better access to palliative drugs and
also patient education,” Singh told Global Health and
Travel. “Disinformation and the negative perception about
controlled drugs can increase the barriers and hinder
people’s access to the necessary types of treatment; hence,
open discussions regarding pain management is a leap
towards achieving adequate pain relief.”
He adds that in emerging markets, particularly in
Asia, CMEs can drive changes in attitudes, but the results
presented to purchasers of pharmaceuticals, including
private hospitals, has to be evidence-based. “In emerging
markets, a lot is driven through hospitals. And in private
hospitals, while it could be a business of maximising
margins, most of the time it’s still the evidence that actually
drives [sales],” he says.
Meanwhile, Singh does not discount the roles that
regulators play in increasing access to opioids in Asia. “A
lot of regulators are still in the mindset of the good old
morphine days, when a lot of abuse used to happen, and
they’re quite sensitive,” he says. “Treatment paradigms
have shifted, and the new medicines are a lot more tamper
resistant or tamper proof than they used to be.”
Dr. M.R. Rajagopal, chairman of Pallium India and
one of the key advocates working with the Indian federal
government to change its drug laws to allow greater access
to opioids for medical use, says that the biggest barrier to
“There is an unmet need to address the gap in
physicians’ training, better access to palliative drugs
and also patient education. Disinformation and the
negative perception about controlled drugs can
increase the barriers and hinder people’s access to the
necessary types of treatment; hence, open discussions
regarding pain management is a leap towards
achieving adequate pain relief”
- Raman Singh, president of emerging markets,
Mundipharma
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providing more access to pain relief is trying to change
medical professionals’ attitudes towards pain management.
“Generations of doctors have not seen morphine – they are
mortally scared of morphine. Morphine carries with it the
stigma of addiction, and doctors fear it will stop respiration.
This is a very widespread fear,” Dr. Rajagopal says.
He adds that broader education on palliative care, not just
education about morphine, is essential to proper treatment.
“Only about two-thirds of all pain is responsive to
morphine, which means that to treat pain adequately in one
person, he may have two pains that respond to morphine
and another kind of pain that doesn’t respond, so you have
to mix certain kinds of painkillers in such a fashion that
the patient gets pain relief,” he says. “Unless this is taught
to medical students and nursing students, they are unable
to use it effectively. They just try to use it without training,
which may either cause a problem to the patient, make
the patient delirious, or it may be ineffective. Therefore,
professional education is the biggest need.”
Vietnam: Making a Comeback
Vietnam, a country with a colonial past that has been involved
in the opium trade since the 19th century and suffered from
rampant opium and heroin trafficking during the Vietnam
War, maintains a persistent fear remains among patients
and physicians alike in regards to opioid use for palliative
care. This historical context, later reinforced by the Ho Chi
Minh communist regime’s propaganda, has led opioids to
be considered a “social evil” in the country, according to a
2014 study in Journal of Pain and Symptom Management coauthored by Dr. Eric L. Krakauer, assistant professor of global
health and social medicine at Harvard Medical School.
Corresponding fears behind the dangers of opioid use
subsequently led to debilitating restrictions imposed by the
country’s Ministry of Health. As a result of these factors,
the study said, by 2004 Vietnam’s morphine consumption
ALTHOUGH INDIA AND SOUTHEAST ASIAN COUNTRIES LIKE
MYANMAR AND LAOS PRODUCE LARGE QUANTITIES OF OPIUM
POPPIES, ACCESS TO OPIOID MEDICATIONS FOR PALLIATIVE
CARE USE IS SEVERELY RESTRICTED
was “minimal,” and morphine use ranked 122 out of 155
countries for which data was available at that time.
Things took a turn for the better in 2005. In the wake of
the funds for palliative care provided by the US Congress,
the Vietnamese Ministry of Health set up a working group in
charge of analysing palliative care services and needs around
the country. This process led to a liberalisation of regulations
for opioid prescription that came into effect in 2008.
The results were staggering. Between 2005 and 2012,
opioid consumption per person increased by more than
forty times, spiking from 0.32 to 13.5 mg. This was the fastest
growing rate among Asia-Pacific countries at that time.
Despite these undeniable improvements, the study
stresses that there is still a long way to go for Vietnam to
reach “universal access to effective pain relief.” Opiophobia
is still widespread among clinicians, officials and patients,
while district hospital pharmacies are still forbidden from
dispensing opioids to the public, even if no pharmacy in the
district stocks opioids.
A 2013 study jointly conducted by HealthBridge
Foundation of Canada and the Research Center for Rural
Population and Health at Thai Binh Medical University
reinforces that lack of access to palliative care for cancer
patients is not just an issue in Vietnam’s public hospitals,
but private hospitals as well. Among 410 patients
interviewed in the study, only 13.7 percent received
palliative care services from private hospitals and 4.3
percent of patients said that a private doctor was their
source of information about options for palliative care.
Malaysia: Changing Attitudes Towards Pain
Management
STUDIES SHOW THAT MANY DOCTORS IN VIETNAM ARE
RELUCTANT TO PRESCRIBE OPIOIDS, IN PART DUE TO THE
COUNTRY’S PAST STRUGGLES WITH OPIUM ABUSE
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The current situation in Malaysia reflects the point that
lack of opioids is not the only barrier to adequate pain
management. Data from the INCB shows that opioid
consumption has been constantly rising since the 1980s,
thus suggesting that the country has been able to expand
the flow of opioids.
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Pain Management
Medical
MALAYSIA
Opioid Consumption in Morphine Equivalence (ME) minus Methadone,
mg per person
ME (mg/capita)
6—
4—
2—
Morphine
Oxycodone.ME
Fentanyl.ME
10
20
11
20
12
09
20
08
20
07
20
06
20
05
Hydromorphone.ME
20
04
20
03
20
02
20
01
20
00
20
99
20
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
Pethidine.ME
19
90
19
89
19
88
19
87
19
86
19
85
19
84
19
83
19
82
19
81
19
19
19
80
0—
Total.ME
SOURCES: INTERNATIONAL NARCOTICS CONTROL BOARD; WORLD HEALTH ORGANIZATION POPULATION DATA
BY: PAIN & POLICY STUDIES GROUP, UNIVERSITY OF WISCONSIN/WHO COLLABORATING CENTER, 2014
ALTHOUGH MALAYSIA’S USE OF MORPHINE EQUIVALENT DRUGS FOR PALLIATIVE CARE HAS RISEN STEADILY IN THE LAST TEN YEARS,
DOCTORS’ ADVERSE ATTITUDES TOWARDS PRESCRIBING OPIOIDS, A LACK OF EDUCATION ABOUT PALLIATIVE CARE AND OPIOID USE,
AND REGIONAL DIFFERENCES IN CULTURAL ATTITUDES SURROUNDING PAIN REMAIN BARRIERS TO IMPROVING PALLIATIVE CARE
Dr. Mary Cardosa, a consultant anaesthesiologist and pain
specialist at Hospital Selayang, in Selangor and head of the
pain management subspecialty of the Malaysia Ministry
of Health’s Anaesthesiology program, says that doctors’
education and attitudes remain a barrier to improved access.
“In Malaysia we don’t have a lot of restrictions on the use of
drugs. Any doctor can prescribe opioids, so the challenges [have
to do with] doctors’ knowledge and experience [along with] fear
of opioids [as they are believed to potentially lead to] side effects
like respiratory depression, addiction or even death,” Cardosa
told Global Health and Travel in a phone interview.
According to a 2014 study published in The Oschner
Journal, a survey among Malaysian physicians found out
that 46 percent of them lack a proper training to treat
severe cancer pain, while 64 percent of doctors are worried
about unwanted side effects caused by the administration
of opioids. As a result, only 24 percent of patients who
experienced cancer pain were treated with opioids.
Aside from misconception on opioids, some practitioners
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in Malaysia do not pay great attention to allaying pain as
they believe it is not a primary medical concern, Dr. Cardosa
says. “In order to improve pain management it is crucial to
change the attitude among healthcare providers so that they
become aware of the necessity to treat pain,” she says.
In order to raise awareness on the necessity to improve
pain management, Malaysia’s Ministry of Health has
been advocating for the concept of a “pain free hospital”
since 2011. Through this initiative, a series of hospitals are
engaged in a holistic approach to relieve pain by combining
mainstream treatments with non-pharmacological ones,
such as traditional and complementary medicine.
Initially, the pilot programme encompassed only three
hospitals, but it later expanded to other facilities through
training workshops led by pain specialists and aimed to
educate healthcare providers on their duty to relieve pain.
The bottom line was to consider pain as the fifth vital
sign – as important as much as pulse and respiratory rate,
temperature and blood pressure.
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Workshops focused on educating patients as well in
order to get them actively involved in managing their
own pain. The goal was make them as much independent
from formal medical services as possible and embrace the
use of non-pharmacological therapies such as relaxation
techniques, meditation and breathing exercises. According
to Dr. Cardosa, self-management is very beneficial both on a
physical and psychological level.
“We recognise that there are traditional medical systems
that our population has always accepted, like acupuncture
and Malay massage, and we see them as a complementary
tool to Western medicine [when it comes to treat pain],” Dr.
Cardosa says.
India: A Potential Breakthrough on the Horizon
Through advocacy efforts by Pallium India and other
NGOs, as well as the documented success in Kerala, a major
breakthrough to opioid access in India may be on the horizon.
In 2014, India’s parliament voted to amend the 1985 Narcotic
Drugs and Psychotropic Substances Act (NDPS), India’s major
drug law, to provide better access to pain medications. The
amendments promised, among other things, a simplified,
central agency that would be responsible for drug licensing
– eliminating additional levels of bureaucracy at the state
and local levels to obtain morphine licenses. However,
according to Dr. Rajagopal, who was directly involved in
drafting amendments to the drug law, the timeline for
implementation of the new policy is still unclear.
“The official steps that need to get done are not
complete,” Dr. Rajagopal says.
Nevertheless, Dr. Rajagopal remains optimistic that
the legislative action will be the start of a long process of
national reform.
“Changing the regulatory barriers alone does not mean
access to pain relief. There is a huge need for professional
education and for public acceptance – so that still needs to
be unblocked,” he says. “We have a long struggle ahead, but
one very significant barrier has been overcome.”
Given the current lack of a national cohesive strategy on
palliative care, the Indian state of Kerala took it upon itself
to develop its own comprehensive palliative care policy.
Although it was formally implemented in 2008, the strategy
had been in the works since 1993 and was spearheaded
by NGO involvement, particularly the Pain and Palliative
Care Society (PPCS) of Calicut, despite limited government
support. Currently, palliative care centres are found in every
district of the state; and in some districts, multiple centres,
sometimes dozens of them, have been established.
The secret behind Kerala’s success, Dr. Suresh Kumar of
the Institute of Palliative Medicine in Kerala wrote in a 2007
report, is a “community-based” model where volunteers
willing to devote at least two hours a week caring for the sick
are trained to become palliative care providers. This model,
Dr. Kumar says, eventually replaced the earlier “hierarchical
doctor-led structure” for palliative care. With this communitybased infrastructure in place relieving strain on the system,
eventually in 2008, Kerala became the first Indian state to adopt
a state-level palliative care policy that included amending drug
regulations to make morphine readily available to providers.
“The partnership of the State with civil society is now seen by
many as a means through which a raft of societal and political
ills can be addressed,” Dr. Kumar wrote in his report. GHT
PALLIUMINDIA.ORG
PAINPOLICY.WISC.EDU
MUNDIPHARMA.COM.SG
JPSMJOURNAL.COM
WHO.INT
INFORMA.COM/JOURNAL/PPC
INDIA’S PARLIAMENT TOOK STEPS LAST YEAR TO REFORM THE COUNTRY’S NATIONAL DRUG CONTROL LAWS TO PROVIDE
BETTER ACCESS TO PAIN MEDICATIONS. UNDER THE AMENDED LAW, THE CENTRAL GOVERNMENT WILL BE RESPONSIBLE FOR
OPIOID DRUG LICENSING, ELIMINATING RED TAPE AT THE STATE AND LOCAL LEVELS. ADVOCATES SAY IMPLEMENTATION WILL
BE A SLOW PROCESS
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