nandini vallathvienna final
TRANSCRIPT
Striving for equity in the treatment of
pain Nandini Vallath
WHO CC for Training and Policy on Access to Pain Relief, IndiaSide Event - International Doctors for Healthier Drug Policies
Commission on Narcotics Drugs, UN, Vienna
Pain management requires Opioid medicationsWHO Model List of
Essential Medicines
Zech DF et al - Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study. Pain. 1995.63(1):65-76.
Opioids in Acute
& Chronic Pain
Cancer
Non-Cancer
120 countries with grossly inadequate access and availability
HRW Survey
• 96% adults and 99% children who require opioids DO
NOT have access to it
Unbearable Pain ….Human Rights Watch report – 2010Duthey B, Scholten W: J of Pain and Symptom management 2013
http://www.nacoonline.org/QuickLinks/HIVData
UNMET NEED FOR PAIN RELIEF1/6th of world’s population
Inequity in the treatment of pain
Does drug policy have a role?
Inequity in the treatment of pain
• India a major producer
• Regulatory obstacles became obvious in the 1990s
• Doctors Taxation department
Central Bureau of Narcotics Ministry of Finance
National Competent Authority
18th -19th centuryOpium as trade crop
• Need for monopoly dictated the policy language
19th -20th centuryOpioids as drug for abuse
• Need to eradicate drug abuse dictated the policy language
Medical use NOT within
policy language
Poor stockingUnder-treatment FearPoor demand
Prohibitory orientation of policies
impacted Knowledge, Attitudes,
Priorities and AVAILABILITYLack of Job mandate for NCAfor ensuring availability
Complex procurement, procedures,prescriptions
Doctors No Training, Experience in using Opioids
Misconceptions about opioid benefits / risks
Threat of Harsh punishments
International Narcotics Control Board
Central Bureau of Narcotics Ministry of Finance
Production at Govt. Factories
Quotas to Manufacturers
Opioid Consumption
Mandate for Regulations
Pain Relief Providers
Narcotics Control Bureau Ministry of Home Affairs
Enforcement of drug laws
Distribution System in India
1203/05/2023
Availability of essential narcotics is NOT a
mandate at any of NCA office!!
Post NDPS Act 1985, Morphine consumption in india ↓ by 97% [716 Kg 18 Kgs]
Dr Nandini Vallath 13
J Cleary et al Annals of Oncology - Vol 24 (11) Dec 2013
Basis for National Drug Policies
• Ensure availability of drugs for medical and scientific
use
• “the medical use of narcotic drugs continues to be
indispensable for the relief of pain and suffering… adequate
provision must be made to ensure the availability of narcotic
drugs for such purposes.” Preamble, p. 13
• Prevent against diversion and abuse
• “addiction to narcotic drugs constitutes a serious evil for the
individual and is fraught with social and economic danger to
mankind…” Preamble, p. 13
18th -19th centuryOpium as trade crop
• Need for monopoly dictated the policy language
19th -20th centuryOpioids as drug for abuse
• Need to eradicate drug abuse dictated the policy language
20th -21st centuryOpioids as medicine
• Need to improve access for medical use to dictate policy language
AMENDED
Step1 Supportive Policy
Supportive policies
Ensured and SAFE access and availability of essential drugs
Poor access and availability of essential drugs
We are here..
Many other countries
What did it take for policy reform in India?
• Acknowledging Untreated pain as a major public health issue
• Awareness of the contribution of policy language to availability
• 25 years of efforts
• Support ……lots and lots of it
Teachers
Policy Analysis
GovernmentCivil Society Alliance
Litigation
Draft Proposalof
National Program for Palliative Care
for12th plan (2012-17)
Directorate General of Health ServicesMinistry of Health & Family Welfare
2014 Amendment of NDPS Act
Transformation of mindset of key policy makers - the notion that
ensuring opioid availability is an essential objective of the national
narcotic control policy
March 2016 - India
• The Revised Rules following the 2014 Act amendment not released
• Old barriers with New look
Unmet need for pain relief ContinuesStudy at Cancer Centres: Kolkata, Hyderabad, Ahmedabad, Cuttack
79.7% of the patients who came in with pain received inadequate or NO pain management
30%
Authors: M R Rajagopal, Gayatri Palat, Joseph Amon, Diederik Lohman
Quality of Death Index
Wide availability of opioid analgesics-
was a constant element in countries
with high Indices
India
Ref: Economist Intelligence Report
Reoriented drug policy for all member-states
What if all member states have policies with appropriate language ……??
Ensured and SAFE access and availability of essential drugs
Poor access and availability of essential drugs
?
Striving for equity in the treatment of pain •Yes, we should have supportive drug policy
•What more should we do to overcome the
inequity?
Perceptions far more powerful …than substance of the law
Process towards equity
• Changing the perception of the purpose of drug policy
• Culture and mandates of competent authorities
• Reflect the spirit of policy reform in the functioning units
• Interagency collaboration, Participatory, inclusive consultative
processes
Perception of Purpose at the Highest level
Illicit use medical use
In the 5 UN Drug reports……Out of the total 256 times of mentioning “opioids”
"opioids for medical use” is mentioned 9 times
HRW
Expression of Purpose at the Highest level
Perception Purpose at the NCA
Revenue, Finance, Police, Crime, Home,
Foreign affairs, Economic development,
Drug enforcement, internal affairs
DEPARTMENT OF HEALTH
Reorientation of Policy Mandate The Convention to articulate specific
provisions to ensure availability
Reorient National Drug Policy Identify negative language, themes Add
Specific strategies, action plansNational Competent AuthorityShould have Opioid Availability as their job mandate
Process towards equity
• Changing the perception of purpose of drug policy
• Culture and mandates of competent authorities
• Reflect the spirit of policy reform in the functions
• Interagency collaboration, Participatory, inclusive consultative
processes
Review of Policy Tools
Intent, priorities, language of the National Drug Control Strategy
With Specific Provisions and plans towards balance
MODEL POLICY??
The Participatory and inclusive
consultative process
Process towards equity
• Changing the perception of purpose of drug policy
• Culture and mandates of competent authorities
• Reflect the spirit of policy reform in the functions of the competent
authorities
• Interagency cooperation and collaborative action
• Participatory Inclusive consultative processes
Resources
• WHO guidelines for Ensuring balance in national policies
• WHO, UNODC and UNAIDS Technical Guides
• WHO/INCB Guidance for estimates
• World Health Assembly Resolution on Palliative Care
• International Community as Regional consultative Bodies?
Strong Licit Drug Distribution System
Level 6. PATIENTS
Level 2: National Competent Authority
Level 3. Importer/Manufacturers/Distributors
Level 1: International Narcotics Control Board
Level 4. Hospitals/Pharmacies/Hospice/PC programs
Level 5. Physicians/Pharmacists/Other
X
Supportive policies
Interagency collaborationParticipatory, inclusive consultative processes
Enlightened implementation, monitoring
Ensured and SAFE access and availability of essential drugs
Poor access and availability of essential drugs
Agencies of the UN uniteConventions
Clear Purpose of drug policy
Medical Availability a Job Mandate of NCA
Functioning supply and distribution
systems
Simple procedures for
access
Knowledge in SAFE medical
usage of opioids
Penalties proportionate
to offence
More and more of Justice …..less and less of Rules
International Community
NCA