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Opioids in Palliative Care: Not What People Want, What People Need
Many developing countries do not have substantial health care systems, and a third of the world’s population cannot even afford essential medicine (Access). In order to “replace” these expensive essential medications, people create counterfeit drugs as a less expensive option. More than 50% of the global drug market is comprised of these counterfeit drugs, which then results in more resistant strains of diseases (Glass). More specifically, countries with unstable health care systems do not have well developed palliative care systems. Only twenty countries around the world have a firmly established palliative care system, and those are mainly found in high-income countries. Palliative care is the specific care implemented when the care given is not used in the prevention or cessation of the disease, but rather it is used to prolong life and help deal with the pain. Some diseases that require palliative care include: cancer, HIV/AIDS, Multiple Sclerosis, and Parkinson’s disease. Opioids and other pain medications are an important aspect of palliative care. Opioids cost only pennies to make, yet more than 150 countries do not have these medications available to the five million patients with life-threatening diseases. Many people have to deal with pain in other ways other than with pain medications. As stated, lack of opioids does not come from insufficient funding, but more from a lack of knowledge regarding the safe use of opioids (Brooks). Many doctors are afraid of drug wars starting or an addiction forming due to the use of opioids since many medical professionals are not educated about how to safely use and prescribe opioids. The regulation and education of pharmaceutical medications and safe prescribing of opioids could greatly increase how many families can provide palliative care for their loved ones.
Palliative care throughout developing countries is quite different from palliative care in developed countries, which have many resources at their disposal. One way that palliative care is viewed in different ways in developing countries than in developed countries is that “...There is still a lack of government policies that recognize palliative care as an essential component of health care” (Silbermann). Additionally, culture, tradition, and religion are crucial reasons for why palliative care is still misunderstood in developing countries (Silbermann). Islamic societies are more accepting of death, and therefore they coexist with the inevitability of it while Western societies try to fend off death and prolong life. Although Islamic societies accept the unwavering fact of death, they are still encouraged to seek treatment. However, physicians are still required to be respectful of all health beliefs, practices, and needs concerning all of the different faiths and cultures while practicing safe and healthy medicinal habits. There are existing taboos and stigmas that make treatment difficult; therefore, all families, healthcare professionals, and religious leaders need to be educated well. “The use of drugs that might affect consciousness is strictly prohibited in Islam” (Silbermann), which would strictly inhibit the amount of medications available for physicians whilst they are trying to potentially ease someone’s ending days. In some developing countries, non-governmental organizations, which are dispersed throughout the country, provide palliative care to their citizens (Yeager). These non-governmental organizations are mostly private organizations, which means they are more expensive than if it were public healthcare.
It is incredibly important to have developed palliative care treatments and facilities in order to have a palliative care system that is trusted and well-known, making it so that people actually want to go get treatment for the end of their life. Most palliative care estimates are based on death rates, meaning that the patients suffering earlier on in their illness are not being counted as being in need of palliative care (Reville). In order for palliative care to be fully improved, people need to get help in the earlier stages of the diagnosis, increasing the reliability and helpfulness of the system overall. Palliative care also needs to be integrated into the larger overall healthcare system, and not kept in its own separate subgroup. In China and India, the world’s most populous nations, palliative care is finally advancing from localized provisions to being integrated into the healthcare system (Reville). However, only 20 countries have palliative care integrated well into their healthcare system, but those are mostly all high-income countries (Ford). 80% of the world’s need for these services are in low- and middle- income countries, meaning that none of the countries that desperately need palliative care are receiving the care. Palliative care “...offers relief of physical, psychological, and spiritual pain at the end of life…” (Ford), showing that it affects more than just the physical aspect of diseases. It is a crucial part of healthcare that is under appreciated, and it needs to be increased everywhere. Out of 60 million patients in need of palliative care, only three million patients actually receive the care needed, and most of these patients only receive care at the end of their life (Ford). People who do not have access to substantial palliative care and medications have to use other methods of “pain management”. People resort to suicide in order to get out of their relentless pain. One Ukrainian man sleeps with a pistol underneath his pillow in case the pain gets too unbearable, and he decides to take his own life (Brooks). People suffering from terminal illnesses should not have to resort to deciding between suicide and living in pain. Therefore, palliative care needs to be integrated into the healthcare system, and there needs to be developed palliative care treatments and facilities to improve the quality of the care.
Private and public health care differ in various ways, however each can help, but also harm, the palliative care systems throughout developing countries. Public health care is provided by the government, while private health care is provided through “for profit” hospitals and self practicing professionals (Basu). This means that only those with a substantial salary can afford private sector healthcare, while more of the impoverished population can afford public healthcare. Private practitioners gave lower quality care than public care (Basu). For example, they had less correct diagnoses, treatments, poor prescription practices, and prescribing of unnecessary antibiotics. They try to diagnose more people in less time, increasing not only their patient numbers, but the number of mistakes they can make as well. These mistakes cause drug-resistant strains of diseases to develop, making the diseases that much more difficult to battle. On the other hand, public practitioners were documented to have a lack of drug accessibility, service provision, and technologies which were found in the private sector. All in all, the private sector is more of an expensive treatment option than the public sector, which would make it difficult for those with a lower income to seek the help they need, but the public sector gives better quality of care.
Palliative care and medications need to be more accessible to everyone in the world in order to give the help to those who require it. There are many different barriers that affect palliative care, but there may be simple and manageable ways to overcome these barriers. Some major barriers include: lack of health policies, relevant training, accessibility of essential drugs, geographic accessibility, medical availability, affordability, and lack of trust between healthcare providers and patients (Jacobs, Silberman). Barriers concern both sides of the process, both supply and demand, but there are options out there in order to disintegrate these obstacles. Demand barriers can be reduced by: franchising, social marketing, preventative and curative interventions, health equity funds, community-loan funds, and conditional cash transfers. Conditional cash transfers are when money is transferred to households over a time period in which health behaviors are being upheld. Supply barriers can be reduced by: regulation of private and public sectors, emergency transport, maternity waiting houses, an essential health service package, heeding to culturally sensitive health care, and need-based financing. All barriers need to be overcome to fully create the palliative care system developing countries deserve, but it will take time, money, and effort to create effective and efficient solutions which benefit all parties.
Generic medications can be an effective way to create good access to essential medications in countries where money is hard to come by and people live on the minimum (Access). In the U.S., generic medications are less expensive than name-brand medications, and they work just as well as the expensive name-brand medications (Falcon). Generic competition has lowered antiretrovirals from $10,000 in 2000 to $67 in 2014 (Access). This statistic shows that people can get the same treatment they need, but for less money, which is a good solution for people who are living in developing countries where most people are impoverished. Creating programs between developed and developing countries can help make the transition from name-brand to generic medications much easier. A prime example of this is how a U.S. based pharmaceutical company agreed to license hepatitis C medications to India-based manufacturers, which means that 91 developing countries can produce and sell more affordable versions (Access). This method affects both the licensing companies and the developing country manufacturers. The licensing companies can put on tight restrictions to prevent export and limit the license periods, and in addition, they can make a profit, since “Delaying generic competition...leads to higher medicines prices and reduces patient access to medicines” (Access). In addition, generic medications may help to eliminate harmful counterfeit drugs from the system (Mysorekar), which will be discussed in more depth later on in the paper.
Another way to increase access to medications is through the use of Molecular Pharming. Molecular Pharming is the production of recombinant pharmaceuticals through plant technology (Ma). Growing plants and making medications based off of plants is significantly less expensive in the earlier stages of production, a better option than a cell fermentation facility. The manufacturing process, which is plant cultivation, is attractive since basic agricultural skills are available worldwide, making it easy to cross geographical barriers.
Regulations and safe usage of opioids are a necessity in trustworthy and effective palliative care. Some rules and regulations are already trying to be put in place in developing countries. Ten African countries forbid physicians to prescribe opioids to a patient for more than two weeks at a time, and Ghana limits doses to two days (Reville). In addition, there are specific prescription forms physicians need to fill out for opioid scripts. However, some of these policies are contradictory, making it that much harder to prescribe opioids (Reville). Through the International Pain Policy Fellowship, the IPPF, two Ministry of Health officials helped to revise opioid prescriptions regulations (Krakauer). Some revisions included: the maximum prescription period was 7 days, but it is now 30 days; the maximum dose was 30mg/day, but is now unlimited; the required prescription record retention was five years, but it is now two years; the plan for morphine availability was non-existent, but now it is in every district; and the restriction based on diagnosis was if the patient did not have cancer or AIDS, then no opioids were prescribed, but now if the patient does not have cancer or AIDS, then opioids are prescribed for up to 7 days. These revisions can help to make access to opioids easier, especially with physicians suffering from opiophobia. Opiophobia is when a doctor is fearful of prescribing opioid medications to their patients. Vietnam is a prime example of how a country based on opiophobia can improve accessibility to opioids with specific regulations. The revision removed restrictions on pharmacies allowed to dispense opioids, and revised that, if a district does not have a pharmacy that stocks opioids, the local hospital must stock opioids.
The United States have certain regulations in place, and those regulations could be modified to help developing countries (Falcon). The Drug Enforcement Administration (DEA) in the U.S. schedules drugs in relation to their addiction level. The schedules are as followed: Schedule I: High addiction potential and, mostly, illegal (i.e. Heroin, Morphine); Schedule II: Slightly less of an addiction potential (i.e. Oxycodone); Schedule III: Moderate addiction potential (i.e. Percocet); and Schedule IV & V: Low addiction potential. The DEA keeps track of how often, and which, scheduled drugs, are given out. To decrease the risk of addiction, there are pain management centers all around which help keep patients on their medications as prescribed. The DEA also has specific regulations regarding the production of new medications. One of the major regulations revolves around medications that create a sense of euphoria in the trial patients. If a trial medication shows signs of euphoria, the trial medication undergoes a recreational drug trial to see the total effect of the medication, so that even if it ends up in the hands of a drug addict, they will not become addicted.
Counterfeit medications are extremely harmful to those who use them, and regulations can be created to stop the making and usage of these harmful drugs. People have acknowledged the lack of access to opioids worldwide, and have even labeled it as a “pandemic”, showing that access to opioids is a need, and this problem is not being adequately solved (Reville). Counterfeit medications are a major problem since they are less expensive than regular medications, and people are not aware that they are ingesting counterfeit medications, More than 50% of the global drug market is made up of counterfeit medications (Glass). Counterfeit medications are not the solution to the lack of opioid availability, since they are incredibly harmful and ineffective. Some effects of counterfeit medications are: increased mortality, drug resistance, reduced confidence/loss of trust in health care system, economic consequences, severe side effects, and wastage. Counterfeit medications are extremely hard to distinguish from regular medications since counterfeit drugs are packaged just like brand medications, so the medications can be easily switched out, and pharmacists most likely will not be able to spot anything wrong (Mysorekar). If regular medications were designed a certain way, similarly to how money is created, it could make it harder to counterfeit drugs.
There are many other ways palliative care can increase in developing countries. Increased training programs in developing countries will significantly help palliative care overall. Many healthcare workers are fearful to use opioid medications and to practice palliative care medicine, mainly because they are not properly trained. They are afraid that their patients will become addicted to the medications they prescribed since they do not know what the opioids really do or how they work. The main reason that health workers in developing countries are scared to use opioid medications is due to the fact that they are fearful of causing an addiction in the patient (Silberman). To help quell these fears, the Middle East Cancer Consortium (MECC) in Larnaca is in a cooperative training program with the Children’s Hospitals & Clinics of Minnesota, which resides in the U.S.A.. With more adequate training, physicians will not be as fearful to prescribe opioids, medications which may prove to be life-changing for patients in immense pain and desperate need for relief. Furthermore, training programs between developed and developing countries can play a major role in expanding knowledge of palliative care (Jack). By partnering up developed and developing countries together, they can share the gained knowledge and resources and improve palliative care globally.
Increased attention towards palliative care can then help to increase funding and supplies (Mills). Several debates concerning health care increase attention to the importance of institutions, organizations, and resources, which is needed for countries who have a lacking palliative care system (Mills). In response to the debates, countries and their partners begin to develop new and easier ways to organize, finance, and deliver health care. Moreover, increased attention means that people are more aware that there are problems in the health industry that need to be addressed since people are suffering through terminal illnesses without any sort of pain management or help in any way. It calls people to action, making them help the world out in even the smallest way.
The use of traditional medications can be integrated into palliative care to give a cost-effective and different type of way to give the care needed (Thorsen). Traditional medicine includes a spiritual healer/traditional healer and herbal medicine. The importance of traditional medicine has led to the integration of traditional medicine into public healthcare. It is reported that up to 80% of people within developing countries are using traditional methods of healing. The use of traditional medicines within public healthcare may help to work with some of the religious and cultural barriers that stop some people from accepting the help that they need. It can help cross barriers since it is a cost-efficient way for poor countries and people to obtain the help that they deserve and need. However, although traditional medicine could be quite helpful, some individuals are opposed to the idea, therefore, having it as an option would benefit both since people could choose what type of help they want. Richer people were turned off by the thought of using traditional medicine and self-treatment. Nonetheless, traditional medications can be a life-saving option for patients in developing countries as it is cost-effective, and it also follows some cultural barriers that may arise.
Creating stronger palliative care systems will positively impact not only those developing countries in need but also the entire world. By increasing education and training, more doctors and patients will be aware of the need for end of life care. Doctors will not be as hesitant to prescribe much needed pain medications to those who need it, since they will be educated in how to safely monitor the use of those medications. Different methods of more brutal and lethal pain management options will not be needed, making the end of someone’s life much more manageable and comfortable. In addition, creating more cost effective medicines will greatly improve life in developing countries. There will be less risk of counterfeit drugs being manufactured, and therefore, there will be less of a chance for more resistent strains of diseases to develop. Generic medications can be a cost effective solution to creating the essential medicines that would greatly influence life in developing countries. Barriers can be overcome in order to help get resources to the countries in need, whether it be supplies to palliative care, essential medicines, or just more teaching opportunities. Overall, distributing the knowledge of opioids, essential medicines, generic medicines, and palliative care to developing countries can help to increase end of life care and make terminal illnesses even just a bit easier to live with. In conclusion, regulations and education from developed countries can help to create safer and less expensive palliative care systems in countries that need them most.