WHO CC for Training and Policy on Access to Pain Relief, India Side Event - International Doctors for Healthier Drug Policies Commission on Narcotics Drugs, UN, Vienna

1. Striving for equity in
the treatment of pain
Nandini Vallath
WHO CC for Training and Policy on Access to Pain Relief, India
Side Event - International Doctors for Healthier Drug Policies
Commission on Narcotics Drugs, UN, Vienna

2. Pain management requires Opioid
medications
WHO 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.

3. Opioids in Acute
& Chronic Pain
Cancer
Non-Cancer

4. 120 countries with grossly inadequate
access and availability
HRW Survey

6. • 96% adults and 99% children who require opioids DO
NOT have access to it
Unbearable Pain ….Human Rights Watch report – 2010
Duthey B, Scholten W: J of Pain and Symptom management 2013
http://www.nacoonline.org/QuickLinks/HIVData
1/6th of world’s population

7. Inequity in the treatment of pain
Does drug policy have a role?

8. Inequity in the treatment of pain
• India a major producer
• Regulatory obstacles became
obvious in the 1990s
• Doctors  Taxation
department

9. Central Bureau of Narcotics
Ministry of Finance
National Competent Authority

10. 18th -19th century
Opium as trade crop
• Need for monopoly
dictated the policy
language
19th -20th century
Opioids as drug for abuse
• Need to eradicate drug
abuse dictated the
policy language

11. Medical use
NOT within
policy
language
Poor stocking
Under-treatment
Fear
Poor demand
Prohibitory orientation of policies
impacted Knowledge, Attitudes,
Priorities and AVAILABILITY
Lack of Job
mandate for
NCA
for ensuring
availability
Complex
procurement,
procedures,
prescriptions
Doctors
No Training,
Experience in
using Opioids
Misconceptions
about opioid
benefits / risks
Threat of
Harsh
punishments

12. 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
1231-03-2016
Availability of essential
narcotics is NOT a
mandate at any of NCA
office!!

13. Post NDPS Act 1985, Morphine
consumption in india ↓ by 97% [716 Kg  18 Kgs]
Dr Nandini Vallath 13

14. J Cleary et al Annals of Oncology - Vol 24 (11) Dec 2013

15. 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

16. 18th -19th century
Opium as trade crop
• Need for monopoly
dictated the policy
language
19th -20th century
Opioids as drug for abuse
• Need to eradicate drug
abuse dictated the
policy language
20th -21st century
Opioids as medicine
• Need to improve access
for medical use to
dictate policy language

17. Step1
Supportive Policy

18. Supportive
policies
Ensured and
SAFE access and
availability of
essential drugs
Poor access and
availability of
essential drugs
We are here..
Many other countries

19. 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

20. Teachers

21. Policy Analysis

22. Government
Civil Society Alliance

23. Litigation
Draft Proposal
of
National Program for Palliative
Care
for
12th plan (2012-17)
Directorate General of Health Services
Ministry of Health & Family Welfare

24. 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

26. March 2016 - India
• The Revised Rules following the 2014 Act amendment not released
• Old barriers with New look

27. Unmet need for pain relief Continues
Study 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

28. Quality of Death Index
Wide availability of opioid analgesics-
was a constant element in countries
with high Indices
India
Ref: Economist Intelligence Report

29. Reoriented drug policy for all member-
states

30. 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
?

31. Striving for equity in the treatment
of pain
•Yes, we should have supportive drug policy
•What more should we do to overcome the
inequity?

32. Perceptions far more
powerful …than substance
of the law

33. 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

34. 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

35. Expression of Purpose at the Highest level

36. Perception Purpose at the NCA
Revenue, Finance, Police, Crime, Home,
Foreign affairs, Economic development,
Drug enforcement, internal affairs
DEPARTMENT OF HEALTH

37. 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 plans
National Competent Authority
Should have Opioid Availability as their job mandate

38. 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

39. Review of Policy Tools
Intent, priorities, language of the National Drug Control Strategy
With Specific Provisions and plans towards balance

40. MODEL POLICY??
The Participatory and inclusive
consultative process

41. 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

42. 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?

43. 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

44. Supportive
policies
Interagency
collaboration
Participatory,
inclusive
consultative
processes
Enlightened
implementation,
monitoring
Ensured and SAFE
access and
availability of
essential drugs
Poor access and
availability of
essential drugs

45. Agencies of
the UN unite
Conventions
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

46. More and more of Justice …..less and less of Rules
International
Community
NCA

47. 31-03-2016 47
UNGASS 2016
For Freedom from Pain
Thank You
aanandini@gmail.com