Bulletin of the World Health Organization

Push for palliative care stokes debate

With the ageing of populations and a heavy burden of noncommunicable diseases around the world, there is a high but unmet demand for palliative care in many countries. Gary Humphreys reports.

Bulletin of the World Health Organization 2013;91:902-903. doi: http://dx.doi.org/10.2471/BLT.13.021213

Palliative care, broadly defined as care designed to prevent or relieve suffering in patients facing the problems associated with life-threatening illness, has long been a neglected field.

An estimated 40 million people worldwide need palliative care every year, according to the Global atlas of palliative care which is due to be published by the World Health Organization (WHO) in collaboration with the Worldwide Palliative Care Alliance. Of those, about 21 million people need palliative care at the end of their lives, more than 90% of them as a result of noncommunicable diseases.

“The majority of people who need palliative care live in low- and middle-income countries where there is little or no access to even basic palliative care services and where the majority die in needless pain and suffering,” says Dr Shanthi Mendis, acting director of the Management of Noncommunicable Diseases department at WHO.

“An estimated 42% of countries have no palliative care services whatsoever, while a further 30% have limited service delivery that reaches only a small percentage of the population,” Mendis says.

WHO is submitting a report to its Executive Board on the growing need for palliative care services, a need that it says is partly due to the ageing of populations and the increase in the prevalence of noncommunicable diseases.

Woman receiving palliative care in India
WHO/Chris de Bode
Woman receiving palliative care in India

Indeed, the WHO global action plan for the prevention and control of noncommunicable diseases 2013–2020 includes palliative care among the policy areas proposed to Member States. This year, a resolution on universal health coverage adopted at the World Health Assembly lists palliative care among the quality affordable services to be provided by health systems, at all levels of care, to the whole population.

According to the report, the reasons for the unmet need for palliative care include: a lack of awareness, inadequate government policies and a lack of appropriately trained staff and adequate facilities. Also, access to the opioid analgesics needed for the relief of moderate to severe pain is limited in many countries.

It is not the first time that WHO highlights the importance of palliative care. In 2005, the WHO secretariat submitted a report to its governing bodies, the Executive Board and World Health Assembly, entitled Cancer Prevention and Control (58.16) that underscored the importance of providing palliative care along with cancer prevention, detection and treatment services.

The upcoming report to be submitted to WHO’s Executive Board meeting, which will be held from 20 to 25 January, broadens the scope of past efforts to address the need for palliative care – not only for cancer patients but also for patients with other chronic conditions, such as AIDS and multidrug-resistant tuberculosis.

“Palliative care needs to be part of the continuum of care. WHO and most of its Member States have defined systematic programmes and approaches for preventive and curative care,” says Kees de Joncheere, the director of Essential Medicines and Health Products, the WHO department that houses the Access to Controlled Medication Programme. “But when curative care fails or is likely to fail, few countries have systematic palliative care approaches for dealing with this situation.”

A study published in June in the Journal of Pain and Symptom Management found that only 20 countries had fully integrated palliative care into their health-care systems.

The forthcoming report on palliative care was prompted by a request by one of WHO’s Member States, Panama. “This is an important issue for us,” says Dr Gaspar Da Costa, national coordinator of the Palliative Care Programme of Panama, adding that the first palliative care initiative in his country was a nongovernmental organization providing hospice services set up and run by the Catholic church in 1992.

Da Costa notes that there have been several initiatives in his country since. “In 2010, we established a national palliative care programme. So we felt we should add our grain of salt to the discussion.”

For Professor Lukas Radbruch, Chair of the International Association for Hospice and Palliative Care, the WHO report for the Executive Board is a welcome development, but he cautions against too much optimism, citing concerns about the lack of progress in improving access to opioids.

“Palliative care is about more than just pain management, but pain management is of fundamental importance,” Radbruch says.

To effectively manage the type of pain that is commonly associated with terminal illness, a variety of powerful opioid analgesics – pain-killers derived from opium or synthetic opioids – should be available to patients in need, according to Guidelines for the pharmacological treatment of persisting pain in childhood illnesses released last year – WHO’s most recent guidelines on pain control.

An estimated 80% of cancer patients, 80% of AIDS patients, 67% of patients with chronic cardiovascular diseases and 67% of patients with chronic obstructive pulmonary diseases experience moderate or severe pain at the end of their lives, according to a study published in the Journal of Pain and Symptom Management in January 2006. In some cases, the only effective way to manage this pain is with morphine and related analgesics.

“We have the medicines we need to manage pain in palliative care and we know how to deliver them,” says Willem Scholten, a former WHO staff member who is now an independent consultant specializing in pharmaceutical regulation and drug control policies. “And yet many countries choose not to use them.”

The 1961 and 1971 United Nations (UN) conventions on international drug control, on which most national regulations for medicines with the potential for diversion and misuse are based, recognize that access to such medicines is indispensable for medical needs and should not be unduly restricted.

This year, the WHO essential medicines list was revised to include a section on essential palliative care medicines: “We hope that, in recognition of the UN conventions on these medicines, all countries will make them available to those in need,” de Joncheere says.

Attitudes may be changing given the increasing calls from international bodies for governments to review relevant policies on morphine procurement and distribution.

For example, in 2010, the UN Commission on Narcotic Drugs adopted a resolution on promoting the adequate availability of internationally controlled licit drugs for medical and scientific purposes while preventing their diversion and abuse. The resolution supported an earlier International Narcotics Control Board recommendation promoting greater access to narcotic drugs and psychotropic substances.

For many years WHO has advocated for the appropriate access to opioids and, in 2011, it published the second edition of Ensuring balance in national policies on controlled substances to provide guidance on assessing the availability of controlled medicines in Member States.

For Scholten, striking the right balance is key. “You have to weigh the concerns about diversion and misuse against the real need for pain relief – access to pain relief should be seen as a fundamental human right,” he says.

However, there are concerns about the risks of widespread medical use of strong opioids, beyond the misuse of these medicines by recreational drug users, including the risk that patients prescribed strong opioid analgesics for moderate to severe pain can become dependent on them and, in some cases, die of an overdose.

“For example, in the US a three-fold increase in opioid prescribing since 1999 has been associated with a four-fold increase in prescription opioid overdose deaths, which at 16 000 per year represent more than twice the number of heroin and cocaine deaths combined,” says Dr Nicolas Clark, medical officer with the Management of Substance Abuse team at WHO. “The challenge for regulators and physicians alike is to balance the risks and benefits of opioid use.”

Panama’s struggle is a case in point. Despite legislative changes in 2010 that allowed for increased prescription of opioids there, access to opioids is still difficult.

“We see that the procedures in place are cumbersome,” says Da Costa, “and this acts as a barrier to the use of opioids.” The Government of Panama is now working on a draft law for the management of opioids that, in the words of Da Costa, “reflects real need and the current reality”.