Organized by the Center of Studies for Law, Justice and Society, the International Association for Hospice and Palliative Care, Harm Reduction International, and Universidad de la Sabana y Observatorio Colombiano de Cuidados Paliativos
Isabel Perreira (International Drug Policy Consortium): Our law in Colombia includes all services, however there is unmanaged pain for many populations which directly infringes on health and right from torture. We started the research on five core cities which have heroine consumption both small and intermediate, and found minimal palliative care as opposed to the likes of what was evident in Bogota. One programme we have been involved in, consisted of speaking with local and Health authorities who have been working towards methadone programmes so people can access treatment in a safer way. This has been ongoing since 2012, with each city making progress to heroine within the country.
In terms of barriers to accessing methadone, the first issue in Colombia is that we don’t have liquid presentation of methadone. Second in terms of convenience, though the law states opioid should be available 24/7, for people using heroine there are strict schedules as to when people can receive medication. This becomes a burden upon people who have got back into employment and a challenging means to ensure availability to those in need. Some methadone programmes do not allow women for reasons unjustified completely, with data showing that in terms of accessing controlled substances, women are a much smaller population who hardly access treatment at all. For palliative care, we must consider going about demographic transition and what happens when there is a rural inequality in terms of access. In Bogota for example you may find a specialist, then if you go to smaller cities you may not find such. The system means regional authorities have the task of providing OST, and whilst the national regulatory distributes to regional territories, the regional territories lacking institutional capacity do not buy the opioids and therefore for this reason very little or no opioid prescriptions are available.
In terms of palliative care, in homes it is essential for the person or family to have end of life in a secure place, yet due to demanding regulatory frameworks, this is often prohibited and a great issue. We need more presentation available in the country to provide better resources for heroine users. Finally, the role of doctors and health practitioners for both communities of care, it must be addressed how to best engage in conversation about opioids and managing health difficulties of a complex manner, in a way that has a human side. For many populations opioid is central but is not everything. The social services must consider the likes of end of life in order to reach the humanity of people. We must think beyond opioids and how to build these conversations with people suffering.
Helosa Broggato: We must talk about the global situation on access to opioids. The current global situation on global medicines, finds that only 21% of people have access to low medicines, with even less availability in low-economic countries. Pain care is an essential element to health coverage, and opioids are necessary to manage pain with dramatic injury, surgery, opioid agonistic treatments and harm reduction approaches. In terms of the distribution of morphine equivalents, the lack of distribution can be found when comparing the US and Haiti. In Haiti only 5.3MG per capita are available, whereas in the US 55,000 (the lack of availability also a comparable situation in Africa and India), what does this mean for people in pain in LEDC’s?. It is a humanitarian failure, one reason for this situation, public policies focus on health outcomes on extending life and productivity rather than on alleviating pain and ensuring dignity. Currently such approach is reflecting drug policies that show an unbalanced approach to availability of controlled medicines and preventing use of the same medicines. There is also misinformation about opioids which generates fear of prescribing them, and providing adequate amounts to each available country.
A significant barrier to access for pain medication and opioids, are restricted laws and regulation, red tapes, bureaucratic processes and lack of education. There is also a high turnover in people in high government positions and lack of budget resources. A common challenge in all countries is the understaffed teams in local authorities, with many responsibilities such as monitoring not only controlled medicines. It’s true there are improvements and in some countries legislation has seen changes, but changing legislation is important but not enough. We must work to understand the day to day life of individuals. National authority regulators post-research and stakeholders alike demonstrate their views about regulation and opioids. Normally national authorities need to ensure access to pain medication as it is their responsibility. In practice they are concerned that eliminating barriers could lead to diversion, this reflects drug control treaties that are focused on illicit use rather than the balance of good. If countries want to achieve DSG 3.8 (Universal health coverage) they must address this issue.
Marta Ximena Leon (Pain and Palliative Care Group): The number one symptom for medical consultation is pain. We must notice it is important to treat pain in a way that strikes the concept of balance between availability and accessibility to opioid use, and prevention of issue and diversion so that we can have sufficient opioid to treat individuals. The experience in Colombia is of very Low opioid consumption. As of 2006, just 3.6mg per capita of morphine was available, this in comparison to a much greater global average consumption standing at approximately 45mg. The general indicator for a nations ability for effective pain control is in the availability for opioid consumption. We must look for core solutions and diagnose what’s going on.
In terms of solutions, a workshop in 2007 where the WHO and ourselves brought together from different regions, many stakeholders including; physicians, insurance companies, ministry of health, along with many people belonging to pharmacies to understand what was going on in the regions. After there important consultations we had changes in proposals, changes in resolucion 1478 for schedule 24/7, and we worked on these changes and resolutions as a result of working with many stakeholders.
We have witnessed growth in use per capita and opioid big cities (availability) yet very little in rural regions. During another workshop to tackle the issue, we asked why do patients in Colombia have difficulties to access opioids for medical use? We are a country with a wide portfolio of opioids, we have a law to guarantee the distribution 24 hours a day for accessibility and availability, we have low cost opioids that are included in the benefit plan, meaning free for patients.
In terms of other surveys we conducted for physicians and regional authorities around the country, some of the core issues raised were with regards to ; public policies, education, budget, cultural and community and services. Though there is an unequal distribution of opioids in Colombia, it is a lot better than in 2006 which had succumb to much political and economic influence. We must work towards prioritising the concept of balance and a need to cooperate with all the stakeholders and propose solutions. One solution group may not cover the entire perspective and this will make solutions more real for opioids for medical use.
Naomi Burke-Shyne: We also use opioids to treat dependence disorder, as not all drug-use demands treatment. When somebody is in need of medication we look to opioid substitution as a means to avoid hepatitis C and stay healthy, enabling individuals to stabilize their lives through a medical option rather than buying drugs on the street not knowing the substance. There is no universal definition of harm reduction, but we demand a non-discriminatory approach. Opioid substitutions and methadone should be made available and should be produced by national authorities. Methadone is the most prescribed substance around the world, and we have witnessed how heroine assisted therapy is reducing illicit heroine use around the world. From a global perspective, a number of countries in which OST is available is increasing, around the world we identify countries that can provide these services (Vietnam is a great example of political will and scaling up harm therapy) but there are still shortages of data.
Generally we see that it’s 2.5x more costly to put someone in rehab rather than on path to the right support. For every 1 dollar spent on therapy, 4-5 dollars are saved from the Australian expenditure. The middle-east has had the largest increase in OST availability, with now more than 7,000 centres providing to 65,000 people. Latin America however has one of the lowest OST provisions. In terms of barriers you can look at access to medicines, and the severity of regulation that demands a specific qualification in order to prescribe methadone, and generally we are seeing women and migrants around the world struggling to access these resources. There is also a great concern around the worry of addiction which in actuality is instead placing a major barrier to development. When medically prescribed, the risk of dependence is proven to be a great amount lower, with many countries providing OST resources which are government funded. To conclude, we’re looking at a patient based response, a health based response and we urge member states to take these matters seriously.
Q&A
Q) I’m thrilled to see access to medicines involved with harm reduction, Marta could you address the barrier of training physicians? For people who are dependent, does the end of life becomes more complex?
Marta Ximena Leon: In universities around the world training care is not in the curriculum of professionals for pain and palliative care. We are fearful for prescribing substitutions. All curriculum based pain and palliative care should have a place for the many changes and a growing population and much more pain suffered. We need people who are trained to manage pain and all other symptoms. Physicians are afraid as we are not trained and it’s a barrier we must overcome. We do need to use opioids because we need to treat the pain in the patient and ensure a good quality of life. People must be treated by physicians who are trained, and the reason it is so important that it is done is a responsible way. We especially see opioids as important at the end of life, in line with quality of life.
Q) is there any relation between distribution and lack of training?
Marta Ximena Leon: Medicines and training are core. If no one is willing to prescribe them people will not use them. In some places there is strict regulation in terms of who is going to provide, in Colombia it is good because general physicians can provide also, howeber at universities, they are not provided with such curriculum to ensure the competency to do so.
Isabel Perreira: In terms of training; professionals need to know the way to prescribe and when. Currently we see an interpretation of regulation by physicians in the most strict way possible, for example methadone treatment.
Helosa Broggato: Sometimes we look at regulations in different countries, sometimes perfect, but there is a generally varied mentality to prescribe differs across regions. It is a matter of not only changing regulations, but also changing mentalities.