World Health Organization Collaborating Center for Policy and Communications in Cancer Care University of Wisconsin-Madison, USA

First Annual Report 1996

David E. Joranson, MSSW
Director

Introduction
Purpose

• Mission of the Pain & Policy Studies Group
• Terms of reference for the Collaborating Center
• International, multidisciplinary cooperation
• Staff of the PPSG-WHO Collaborating Center

Policy Activities

• International
• Latin America
• Asia
• Europe

Communications Activities

• Publication of Cancer Pain Release
• Creation of a Worldwide Web Site
• Evaluation of the Communication Network

Future Directions
Needs of the Center
References
Appendices

In September 1996, the Pan American Health Organization (PAHO) established the Collaborating Center for Policy and Communications in Cancer Care at the Pain & Policy Studies Group (PPSG) at the University of Wisconsin. The Center supports the World Health Organization (WHO) cancer program, particularly in the area of pain relief and palliative care.(1,2,3,4,5) The PPSG is part of the Cancer Control Program at the University of Wisconsin Comprehensive Cancer Center, which in turn is part of the Medical School.

The offices of the PPSG are located on the campus of the University of Wisconsin, 1900 University Avenue, Madison, Wisconsin, USA, 53705. Our websites may be found at http://www.medsch.wisc.edu/painpolicy, and http://www.medsch.wisc.edu/WHOcancerpain.

This report reviews the Center's work in policy and communications in 1996, as well as previous international activities that were conducted under the auspices of the Pain Research Group, WHO Collaborating Center for Symptom Evaluation in Cancer Care, which was directed by Dr. Charles S. Cleeland until September, 1996.

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Purpose

1. To study public policy in relation to pain management; develop programs to harmonize controlled substances and professional practice policy with medical knowledge and clinical practice about the use of controlled drugs, in particular the opioid analgesics, for relief of pain in cancer and other medical conditions, and
2. To provide a global communications mechanism for physicians, nurses, pharmacists, researchers, government officials and other health professionals interested in cancer pain relief and palliative care.

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1. To develop methods to identify impediments to the availability of opioid analgesics; compare national approaches to opioid analgesic regulation; develop procedures to monitor the medical use and diversion of opioids before and after national cancer pain and palliative care policies are implemented.
2. Develop WHO Demonstration Projects to make opioids available for cancer pain relief while minimizing diversion.
3. To monitor development of national cancer pain relief and palliative care programs according to WHO's three measures of national policy, opioid availability and educational programs.
4. To maintain a communication network for the WHO Cancer Pain Relief and Palliative Care Program, including publication of a WHO/PAHO, Global Cancer Care newsletter to be distributed throughout the world, and a computer-based telecommunication system giving professionals the opportunity to access and share information.
5. Establish a comprehensive database of resources available to educate cancer patients about pain control and palliative care and configure the information so that it can be easily retrievable.

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We are committed to policy and communication efforts that are relevant to the needs of policy makers, drug regulators, medical administrators and health professionals in different parts of the world, with the ultimate aim of improving the quality of life for as many cancer patients as possible.

The Center has been an active partner with the WHO Cancer and Palliative Care Unit (CPL), Programme on Substance Abuse (PSA), other cancer-related WHO Collaborating Centers and Demonstration Projects, including the Wisconsin Cancer Pain Initiative. The Center has also developed cooperation with other agencies of the United Nations, including the U.N. International Drug Control Programme, and the International Narcotics Control Board (INCB). We have begun developing relationships with national governments, as well as with national and international non-governmental organizations (NGOs) in pain and palliative care, for example the International Association for the Study of Pain and other national and regional palliative care NGOs.

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David E. Joranson, MSSW, Director
Sophie M. Colleau, PhD, Editor, Cancer Pain Release
Aaron M. Gilson, MS, MSSW, Researcher in Policy Studies
Carolyn Williams, BS, MBA, Research Program Administrator
Kate Edwards, BA, Research Specialist
June Jacobs, MA, Program Assistant
Erin Stenson, Office Assistant
Gia Weier, Editorial Assistant

Special Advisors:
Ms. Liliana De Lima, Fellow in Policy Studies
Mr. Kailash Sethi, Former Narcotics Commissioner of India

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Policy Activities

The Collaborating Center has focused its policy-related efforts primarily, although not exclusively, in developing countries. The following summarizes these activities.

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• In 1993, with permission from the WHO, we pre-printed an English version of "WHO Guidelines for Opioid Availability;"(6) these were ultimately published by the WHO. (3) Colleagues in Colombia translated the report into Spanish, and it was printed by the Colombian Ministry of Health. The report was distributed widely in Latin America so that health professionals and national drug regulators could use it to begin evaluating the need for regulatory reform to increase patient access to opioid analgesics for cancer pain relief.
• To begin addressing the worldwide myth that a pain patient's physical dependence on an opioid is "addiction," we developed a monograph on the subject requesting the WHO to clarify WHO terminology.(7) In response, the WHO Expert Committee on Drug Dependence issued a statement, clarifying that according to official WHO nomenclature, a cancer patient who is using opioid analgesics for pain relief and who would exhibit withdrawal symptoms upon cessation of opioid therapy is not considered to be "drug dependent" (the term that WHO used to replace "addiction").(8)
• In 1995, we assisted the INCB to survey all national governments about opioid availability. The purpose of the survey was to determine whether governments have implemented the Board's 1989 recommendations which requested them to examine the adequacy of opioid availability and to identify and address barriers. Based on the 1995 findings, the Board published a report, recommending more specific steps that should be taken by governments, the WHO, the United Nations International Drug Control Program, the Commission on Narcotic Drugs and NGOs, including the International Association for the Study of Pain (IASP).(9) In 1996, we produced a special issue of the WHO newsletter Cancer Pain Release to communicate widely the findings and recommendations of the Board,(10) as well as an article in the Journal of Pain and Symptom Management.(11)
• The Center participated in WHO meetings to update participants from around the world on the progress and issues regarding opioid availability. These meetings occurred during conferences of the IASP in 1990 (Adelaide), 1993 (Paris) and 1996 (Vancouver), and also at the European Association for the Study of Palliative Care in 1996 (Barcelona).(12)

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The Region

• The Center assists with efforts to improve opioid availability for cancer pain relief in Latin America, in cooperation with the WHO, PAHO, health professionals, NGOs and national governments. To date, our work has been primarily in Colombia and Mexico, which will be reviewed below.
• The Center has cooperated with WHO to plan two regional conferences to address methods to improve opioid availability, in Florianopolis, Brazil (1994) and in Santo Domingo, Dominican Republic (1996). These conferences served an important function of education and networking, as well as evaluating progress, defining issues and forming consensus about the next steps needed to develop palliative care, opioid availability and communications in the region. The Center prepared monographs for the all participants, to summarize relevant literature and provide information about trends in opioid use for each country. (13) Findings, conclusions and recommendations for action, including opioid availability, were developed and published in international journals.(14,15,16,17) The Center's efforts to include national narcotic regulators in these meetings were partially successful. A theatrical drama about the difficulty of obtaining opioids for cancer pain in Latin America was prepared, and was performed in Santo Domingo.(18)
• The Center has the assistance of Liliana De Lima with policy projects in Latin America. She has been appointed as an off-site Fellow in Policy Studies. Ms. DeLima is a psychologist from Cali, Colombia, whose extensive experience in palliative care and opioid availability are well-recognized in the region. She assists the Center with analysis of national narcotic laws and opioid prescribing requirements; develops plans for meetings in the region; provides liaison with health professionals and regulators in Mexico and Colombia who are working on opioid policy matters; provides advice on effective regional distribution of the special INCB issue of Cancer Pain Release to health and regulatory professionals. The Center supported her attendance at the American Pain Society (APS) meeting in Washington, DC in 1996 to meet with Center staff, begin planning for future projects, and to review recent developments in pain management.
• The Center participated in a 1996 PAHO meeting on "Control y Cuidado Paliativo de Cancer," in Washington, D.C. to explore issues and opportunities, and to coordinate efforts in the region, with Dr. Eduardo Bruera and Dr. Charles Cleeland. In November 1996, we met with PAHO again, as well as with the InterAmerican Drug Abuse Control Commission (CICAD), to explore methods of cooperation.(19)
• Ms. DeLima represented the Center in 1996 at a regional Organization of American States meeting of drug regulators in Caracas, Venezuela. She presented information on the need to address regulatory barriers to the availability of opioid analgesics for the relief of cancer pain.
  Colombia
  
  • The Center has assisted with identification of barriers to opioid availability, in cooperation with the National Cancer Institute, the Ministry of Health and health professionals. We have developed a survey to evaluate health professionals' perception of the barriers to opioid availability.(20) Ms. De Lima administered this survey to 190 health professionals who attended a palliative care conference; the results were used to focus attention on the barriers to opioid availability in Colombia.
  • Colombian health professionals and members of the Ministry of Health cooperated with the Center to translate, print and distribute the WHO Guide to Opioid Availability. The Ministry of Health has arranged to acquire a broader range of opioid analgesics needed by health professionals for the effective management of cancer pain. Efforts have been made to ensure that opioids are sufficiently available to satisfy prescription demand.
  • The Center was invited to give a presentation to the 60th anniversary meeting of the National Cancer Institute, Bogota (1996) on the importance of evaluating barriers to opioid availability, as well as comparative opioid consumption trends among Latin American countries.
  • The Center prepared a preliminary analysis of Colombia's national narcotics laws to identify provisions which should be modified to improve opioid availability. (21) This analysis was used during the consideration of the changes needed in national narcotics control policy to improve patient access to opioids for pain relief.

  
  Mexico
  

  • The Center assists with identifying barriers to opioid availability for cancer pain relief, in cooperation with the Ministry of Health, the Mexico National Cancer Institute (INCAN) and the Mexican Association for the Study and Treatment of Pain (AMETD).
  • Dra. Silvia Allende, Director of the Pain Clinic of the INCAN, administered the Center's barriers survey to 352 health professionals in Mexico in order to gather data on health professionals' perception of the range and severity of barriers to opioid availability. The results were published in the Journal of Pain and Symptom Management.(22)
  • The Center prepared a preliminary analysis of Mexico's public health law to identify provisions that could be modified in order to improve the availability of opioids for the treatment of pain. (23) The analysis has been used by the AMETD to propose changes to the government. Ms. De Lima represented the Center at a meeting of the AMETD and government representatives in Chihuahua to assist with these discussions.
  • The AMETD invited Mr. Joranson to present a lecture on international principles governing opioid regulation at the 1996 annual meeting of the AMETD, 1996 (Mexico City).
  • In preparation for the announcement of major revisions to the narcotic regulations, the Ministry of Health, the INCAN and the AMETD are collaborating with the Center to plan effective training of physicians and implementation of the new system for opioid prescription.

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The Region

• Since 1993, the Center provides opioid policy-related lectures for an annual international seminar for overseas experts in narcotics control. The participants are drug regulators from Asian and Latin American governments who come to Tokyo for several weeks to learn about drug control policy and administration, including ensuring the availability of opioids for medical and scientific purposes.(24) The seminar is sponsored by the Japanese International Corporation for Welfare Services (JICWELS), and is supported by the INCB and the WHO Programme on Substance Abuse. Mr. Joranson participates as a Temporary Advisor for the WHO PSA. We have also provided monographs, summarizing the pertinent literature and reviewing national opioid consumption trends in the region.(11,12,17,25)
• The Center participated in the Hospice in Asia conference in Singapore in 1996; Mr. Joranson provided a monograph entitled "Fear of Addiction Blocks Cancer Pain Relief and Palliative Care," a lecture on steps to ensure availability of opioids for cancer pain relief, and a proposed curriculum for hospice education on hospice policy to ensure opioid availability.
• The Center has cooperated with the Collaborating Center at Saitama Cancer Center, which has produced Japanese publications on fear of addiction when opioids are used to manage cancer pain (26) and on the methods to ensure opioid availability for patient care.(27)
• The Center has appointed Mr. Kailash Sethi, former Narcotics Commissioner of India, as special advisor for narcotics policy. Mr. Sethi has extensive knowledge and experience with narcotic control policy in India as well as internationally. Mr. Sethi has provided valuable guidance on narcotics policy in India.
  
  India
  
  
  • The Center is working with WHO regional and country office in New Delhi, Ministry of Health and Family Welfare (National Cancer Control Program, NCCP), Regional Cancer Centers, the Indian Association for Palliative Care Committee on Opioid Availability and Control, and pain and palliative care professionals to evaluate and improve the availability of opioid analgesics for cancer pain relief. India has a very low and declining consumption of morphine for medical purposes, even though it produces narcotic raw materials for the rest of the world.
  • We have participated in a series of meetings, workshops and visits to hospitals to understand how the health care system, the cancer treatment system, the narcotic regulatory system and the tax collection system interact to make opioids practically unavailable in many medical settings where cancer patients are cared for.
  • We have studied the central and state narcotics laws in detail, and collaborated with the Narcotics Commissioner of India and other central and state government officials to begin developing national guidelines which medical institutions can follow to obtain morphine. Opioids are being manufactured, but distribution is difficult and there is a low demand. Significant barriers exist in the health care system and narcotic regulations. The removal of regulatory barriers by itself would help, but must also be accompanied by sufficient education and training of professionals and the public in order to create an effective demand for opioid analgesics for patient care.
  • The Center has also been working with the WHO Demonstration Project in the state of Madhya Pradesh (Gwalior) to improve the use of oral morphine in the regional cancer center and also to explore whether availability of morphine in District Hospitals (Morena, Bhind) could increase cancer patients' access to pain relief. Preliminary findings suggested that District Hospitals could provide opioids such as morphine at the community level, but only if (a) a program for cancer pain relief and palliative care becomes a responsibility of state operated Primary Health Centers, and if (b) there is sufficient training, institutional leadership and resources for health professionals to deliver pain and palliative care. It is doubtful whether only making morphine available will contribute significantly to pain relief.

  
  
  China
  
  

  • In 1995, PAHO and the Center, then directed by Dr. Charles Cleeland, sponsored an on-site fellowship for Mr. Zhang Hong, a pharmacist in charge of narcotic regulation in China. Mr. Zhang was assigned to the Policy Studies Division. He was a productive and valuable member of the Center, and has since become an employee of the INCB.
  • The Center remains a consultant on opioid policy matters in the bilateral cancer pain relief program between the PRG, now at M.D.Anderson Cancer Center, and the Ministry of Health of the Peoples' Republic of China. We have studied the opioid distribution system and the narcotic control regulations in the PRC. We have provided lectures on methods to ensure opioid availability for national seminars in Beijing, Guangzhou and Shanghai. We were invited to present our work at the Fifth Anniversary meeting of the Chinese National Institute on Drug Dependence. We have reported on the program (28) and on the results of our survey of the barriers to opioid availability in China. (29)

  
  
  Indonesia
  
  

  • The Center is cooperating with the Ministry of Health, NCCP, the narcotics regulators, regional cancer centers and palliative care professionals to improve patient access to opioid analgesics. The Center works with Dr. Soetomo Cancer Hospital in Surabaya, a WHO demonstration project, and its community-based home care project. The Center has participated in several meetings, workshops and hospital visits to better understand the situation and to identify opportunities to improve the system for opioid availability. We recommended changing national policy to permit the use of opioids outside hospitals; the goverment has approved a change in national policy and developed guidelines for use of opioids in home care.

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The Region

• The Center cooperated with Dr. Robert Twycross, Director of the WHO Collaborating Center for Palliative Cancer Care in the United Kingdom, to produce a review of the WHO guidelines for cancer pain relief and palliative care.30
  
  France
  
  
  • Collaboration between the Center and French health professionals has led to changes in national policy and the increased visibility of cancer pain management. In 1990, Center staff participated in a meeting of health professionals and government drug regulators in Paris to discuss impediments to using opioids for the treatment of cancer pain.(31) As a result, international collaboration was set up between the PRG and a group of French health professionals (Action Douleur) to improve cancer pain management in France through a program of research and education. This collaborative relationship continues with the Center. Over the course of the last six years, this collaboration has facilitated and supported several important developments:
    • Restrictive prescribing regulations were modified in 1992; (32)
    • A national study of cancer pain prevalence and severity was completed; (33)
    • A study of physicians' attitudes towards cancer pain management and morphine prescribing was completed; (34)
    • French Ministry of Health (Direction Générale de la Santé) endorsed making cancer pain management part of continuing medical education (Unaformec);
    • French clinical guidelines for the management of cancer pain were published, modeled after US guidelines; (35)
    • The first national multicenter study of pain prevalence and severity in AIDS patients was completed. (36)

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  Communications Activities

  Publication of Cancer Pain Release

  • The WHO newsletter Cancer Pain Release was started in 1988 to fulfill an original and continuing mandate to establish a global communications network. Beginning as a 4-page tabloid to provide information on the status of cancer pain relief programs in different countries, Cancer Pain Release has grown to an 8-page, quarterly publication with a worldwide circulation of over 150,000 in several languages.

  
  
  Objectives
  
  

  • Cancer Pain Release is designed to support the goals of WHO's Cancer and Palliative Care Program: to change attitudes towards cancer pain; to dispel fears about medications; to help make analgesics available; to encourage the rational use of drugs and to increase awareness that pain can be managed and treated.
  • The communications objectives of Cancer Pain Release are to:
    • inform about relevant new developments and guidelines about cancer control and palliative care issued by WHO, the INCB and other key government and non-government organizations;
    • give visibility to programs with teaching value in both developed and developing regions of the world;
    • recognize achievements of countries and programs according to WHO's outcome measures;
    • provide access to current research in cancer pain and palliative care.

  
  
  Content
  
  

  • Cancer Pain Release provides information on the progress of individual national or regional programs to improve cancer pain management and palliative care, including activities of WHO Collaborating Centers; it provides information on guidelines prepared by WHO Expert Committees regarding pain relief, supportive care, palliative care and end-of-life care; information about technical aspects of the pharmacology of pain management, as well as information about health policy, regulatory issues, and the availability of opioid analgesics. (Appendix A: Index to Cancer Pain Release)
  • In 1994, a new professional education section called "Recent Research in Cancer Pain and Palliative Care" was started. This section presents abstracts, reviews and comments on articles from the literature on topics of interest to the field of palliative care, such as nausea and vomiting, respiratory depression, opioid analgesic availability, and professional education.

  
  
  Editorial Advisory Board
  
  The Board includes the directors of WHO Collaborating Centers with a specialty in cancer pain relief and palliative care. Current advisors include: Eduardo Bruera, MD (Edmonton, Canada); Charles S. Cleeland, PhD (Houston, Texas); Kathleen M. Foley, MD (New York City, NY, USA); David Joranson, MSSW (Madison, WI, USA); Neil MacDonald, MD (Montreal, Canada); Fumikazu Takeda, MD (Saitama, Japan); Robert Twycross, FRCP (Oxford, UK); Frits Van Dam, PhD (Amsterdam, Netherlands); and Vittorio Ventafridda, MD (Milan, Italy).
  
  Foreign language editions
  
  In 1989, a one-time edition of Cancer Pain Release was published in Italian, with the support of Dr. Francesco Nicosia of the National Cancer Institute in Genova, Italy.
  
  In 1990, publication of a Spanish-edition of Cancer Pain Release was initiated. To-date, approximately three-fourths of all editions are regularly translated into Spanish in order to respond to a growing demand from health professionals in 25 Spanish-speaking countries of Central and South America.
  
  In 1992, a one-time edition of Cancer Pain Release was published in Chinese with the assistance of Dr. Gao ShouZeng, of the Beijing International Medical Exchange Center. It was inserted in the Beijing Medical Journal for distribution to health care professionals in China.
  
  In 1996, translation of Cancer Pain Release into French was initiated and continues to-date. 20,000 copies are presently disseminated to health professionals in countries where French is spoken, including Algeria, Belgium, Cameroon, Ivory Coast, France, Laos, Lebanon, Luxembourg, Mali, Morocco, Switzerland, and Vietnam.
  
  Worldwide circulation
  
  Cancer Pain Release is disseminated either by subscription or bulk shipment to physicians, nurses, pharmacists, researchers, governments officials, and industry representatives in 120 countries. (Appendix B: Worldwide Circulation)
  
  Insertion in medical journals
  
  In an effort to increase communication about cancer pain relief and palliative care, Cancer Pain Release is inserted in widely-read medical journals. In December 1991, Cancer Pain Release started being inserted in the pages of Primary Care and Cancer, a US journal distributed to 80,000 primary care physicians. Since 1991, Cancer Pain Release is inserted in the Journal of Pain and Symptom Management, which reaches approximately 3,000 health professionals in the US and abroad. Issues of special interest to the membership of the International Association for the Study of Pain have been reproduced in the IASP Newsletter. The Center has recently received requests for insertion of the Spanish-language edition in two medical journals (Mexico and Spain).
  
  Distribution at professional meetings
  
  Part of the Center's international outreach effort consists of contacting professional organizations and speakers to arrange for distribution of Cancer Pain Release at professional meetings on cancer pain and palliative care. Many thousands of complimentary issues have been disseminated in this manner.

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  Creation of a Worldwide Web Site

  In keeping with the Center's term of reference to "maintain a computer-based telecommunication system giving professionals the opportunity to access and share information," the Center started an electronic version of Cancer Pain Release on the Worldwide Web in Fall 1995. The Internet address is: http://www.medsch.wisc.edu/WHOcancerpain.
  
  A complete index of past issues is available in English, as well as complete versions of selected editions and excerpts of others. The site allows users to request subscription information, as well as print copies of back issues.

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  Evaluation of the Communication Network

  Survey of Latin American Health professionals
  
  In order to assess the usefulness of Cancer Pain Release to health professionals in Spanish-speaking countries, we administered a readership survey at a professional meeting of cancer pain and palliative care professionals in Latin America. Results indicated that 94% of respondents use Cancer Pain Release for their own education, while 58% use it in discussions with colleagues. Respondents expressed the most interest in information about WHO priorities, followed by abstracts of current research in cancer pain and palliative care.
  
  Web page statistics
  
  Preliminary data from our site on the Internet indicate that the Cancer Pain Release site is accessed approximately 4,000 times per month from users worldwide.

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  Future Directions

  The following future directions are contemplated, depending on the availability of resources.
  
  International
  U.N. Organizations
  
  The Center will be available to support the WHO Programme on Cancer Control, the Programme on Substance Abuse and the INCB with their efforts aimed at improving policy and communications about opioid availability and palliative care. The Center looks forward to supporting the efforts of the PAHO to improve palliative care, opioid availability and communications in Latin America.
  
  International Association for the Study of Pain
  The Center will support the development of national opioid availability initiatives and will participate in the IASP Congress in Vienna in 1999, with a view to providing additional information about progress and needs in the area of opioid availability when the INCB re-evaluates the global situation in 2000.
  
  Cancer Pain Release
  The Center will continue to publish Cancer Pain Release, with the goal of further increasing circulation and having each issue available in English, French and Spanish. The Center will establish a new Pain policy website which will make available key resource information about opioid availability policy. We will explore methods to improve national and international communication networks to promote the mission of WHO Cancer and Palliative Care Program.
  
  The Center will continue to update and increase the amount and type of information available on the Worldwide Web, including resources available to educate cancer patients about pain control and palliative care.
  
  The Center will develop English, Spanish and French-language editions of its WHO cancer pain website depending on the availability of financial support.
  
  Advisors
  From time to time, the Center will ask individuals with specialized expertise provide advice and guidance for the Center's activities.
  
  Fellows
  
  The Center will consider sponsoring Fellowships or Internships for the purpose of improving national opioid policy expertise.
  
  Europe
  The Region
  
  The Center will assist European cancer and palliative care organizations with the development of national task forces to study and improve opioid availability at the national level, especially in eastern, central and southern Europe, through collaborations during international palliative care meetings in Cyprus and London during 1997.
  
  France
  
  The Center will continue its collaborations with French colleagues and the France-USA Pain Association (Association Douleur France Amérique) to measure the short and long-term impact of policy and educational changes in specific health professionals and patient groups.
  
  Latin America
  
  The Region
  
  The Center will assist in planning and implementation of the Latin American Palliative Care Association Conference scheduled for March, 1998 in Concepcion, Chile. Our goals will be to promote national studies of barriers to opioid availability, showcase the efforts in Colombia, Mexico, and other countries, expand the communications network, review progress and help to plan the steps for the next two years.
  
  Colombia
  
  The Center will continue its support of the Ministry of Health and health professionals who are working to improve patient access to opioids, and will monitor changes in the barriers and in opioid consumption as measures of progress.
  
  Mexico
  
  Our plans are to study the implementation of regulatory changes in opioid prescription, monitor changes in the barriers, evaluate consumption of opioids as a measure of progress, and consider development of a physician handbook on opioid prescription regulations, training materials, and a basic list of opioid policy reference materials.
  
  Asia
  
  India
  
  The Center will continue its development of guidelines for opioid availability for medical institutions, support modification of national policy to allow for more flexible availability, support the development of national expertise in opioid policy, monitor indicators of progress, and continue collaboration with key government and non-government organizations.
  
  China
  
  The Center will pursue several opioid-related policy issues, in cooperation with the PRG and the PRC, including development of model hospital policy for the outpatient use and control of opioids, and monitoring of changes in the barriers and in opioid consumption as measures of progress.
  
  Indonesia
  
  The Center will support the efforts of the NCCP, and of the cancer hospitals and the Demonstration Project at Dr. Soetomo Cancer Hospital, Surabaya, to improve the availability of opioids in hospital and community, and will monitor consumption of opioids as a measure of progress.

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  Needs of the Center

  The Terms of Reference are presently adequate to direct the Center's activities; they complement the center's areas of expertise. Financial support from the WHO or other governmental or nongovernmental sources will be necessary if the Center is to continue or expand the work described in this report.

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  References

  1. World Health Organization. Cancer pain relief. Geneva, Switzerland: 1986.
  2. World Health Organization. Cancer pain relief and palliative care. Geneva, Switzerland: 1990.
  3. World Health Organization. Cancer pain relief, second edition. With a guide to opioid availability. Geneva, Switzerland: 1996.
  4. Stjernsward J, Joranson DE. Opioid availability and cancer pain-an unnecessary tragedy. Supportive Care in Cancer (Europe) 1995; 3:157-158.
  5. Stjernsward J, Colleau SM, Ventafridda V. The World Health Organization Cancer Pain and Palliative Care Program: Past, Present and Future. Journal of pain and Symptom Management 1996; 12: 65-72.
  6. World Health Organization. Cancer pain relief.- A Guide to Opioid Availability. Pre-printed with permission of the World Health Organization by the WHO Collaborating Center for Symptom Evaluation in Cancer Care, Madison, WI, 1992.
  7. Joranson DE. "Fear of addiction is an impediment to cancer pain relief. a proposal to the World Health Organization Programme on Substance Abuse." Unpublished monograph.
  8. World Health Organization. WHO Expert Committee on Drug Dependence: twenty-eighth report. (WHO Technical Report Series, No. 850). Geneva, Switzerland: 1995.
  9. International Narcotics Control Board. Availability of Opiates for Medical Needs. Report of the International Narcotics Control Board for 1995. United Nations, New York: 1996.
  10. Joranson DE, Colleau SM. "Highlights of the INCB Report." Cancer Pain Release 1996; 9 (summer): 2-3.
  11. Joranson, DE. New international efforts to ensure availability of opioids for medical purposes. Journal of pain and Symptom Management, 1996; 12(2):85-86.
  12. Joranson DE, Smokowski PR. Pain management and opioid regulation: Resources for progress. University of Wisconsin Pain Research Group, WHO Collaborating Center for Symptom Evaluation; Madison, WI, USA, 1995 (Monograph)
  13. Joranson DE, Gilson AM, Krchnavek K. Opioid analgesics for Cancer pain relief.- A review of consumption trends and the literature. The University of Wisconsin Pain Group, WHO Collaborating Center for Symptom Evaluation; Madison, WI, USA, 1994. (Monograph)
  14. Stjernsward J, et. al. "Opioid Availability in Latin America: the Declaration of Florianopolis," Progress in Palliative Care, 1994; 2(4):163-166.
  15. Bruera E. "Palliative care Delivery in Latin America: Obstacles and Solutions." Cancer Pain Release 1996; 9(l),l.
  16. De Lima L, Bruera E, Joranson DE. "Opioid availability in Latin America: The Santo Domingo Report-Progress since the Declaration of Florianopolis." Journal of Pain and Symptom Management, 1995; 10(3):233-236.
  17. Colleau SM. "Barriers to Cancer Pain Control in Latin America and Their Impact on Patent Care." Cancer Pain Release 1996; 9(l): 2-3.
  18. Joranson DE. Tiene usted dolor? A play about the difficulties encountered by a cancer patient along the road to pain relief. (Spanish). First performed in Santo Domingo, March, 1996.
  19. Joranson DE, Smokowski PR, De Lima L. Tendencias en el Consumo de Opioids en Sur America. Division of Policy Studies; Univ. of Wisconsin Pain Research Group, WHO Collaborating Center, Madison, Wisconsin. March, 1996. (Monograph)
  20. Joranson DE. "Availability of opioids for cancer pain: recent trends, assessment of system barriers, new WHO guidelines, and the risk of diversion." Journal of pain and Symptom Management 1993;8:353-360.
  21. Joranson DE, De Lima L. "Analisis preliminar de la legislacion Colombiana en relacion a los principios intemacionales de disponibilidad de opioides. March, 1996 (Monograph).
  22. Allende S, "Mexico: Status of cancer pain and palliative care." Journal of pain and Symptom Management 1996; 12(2): 121-123.
  23. Joranson De, De Lima L. "Analisis preliminar de la legislacion Mexicana en relacion a los principios internacionales de disponibilidad de opioides. March, 1996 (Monograph).
  24. Outline of the 11th Study Programme for Overseas Experts on Drug Abuse and Narcotics Control, Japan International Corporation of Welfare Services, 19th June-17 July, 1996.
  25. Joranson DE, Smokowski PR. Selected Trends in Opioid Consumption for Medical Purposes. Division of Policy Studies; University of Wisconsin Pain Research Group, WHO Collaborating Center, Madison, Wisconsin. March, 1996. (Monograph)
  26. Joranson DE. "Current thoughts on opioid analgesics and addiction." Symptom Control in Cancer Patients (Japan) 1995 6(l):105-1 1 0.
  27. Joranson DE. "Fears of dependence of morphine: the background. In: Takeda, F. Morphine: Its indication and limitation in Cancer pain management. Tokyo: Shinko-Koeki, Ltd. 1995: 134-141.
  28. Zhang H, Gu W, Joranson DE, Cleeland CS. "People's Republic of China: Status of cancer pain and palliative care." Journal of pain and Symptom Management 1996; 12(2):124-126.
  29. Joranson DE, Cai ZJ, Gilson AG. "Barriers to opioid availability in China." Bulletin on Drug Dependence (China) 1995; 4(2).
  30. International Consensus on the Management of Cancer Pain. Looking forward to cancer pain relief for all. Oxford: CBC Oxford, 1997.
  31. Colleau SM. "France: Physicians, pharmacists, government officials discuss medical, legal aspects of morphine prescribing." Cancer Pain Release 1990; 4 (2-3): 1-2.
  32. Colleau SM. "Developing International Collaboration in Cancer Pain Research and Education: A Case Study Between France and the USA," Seventh World Congress on Pain, International Association for the Study of Pain, Paris, France, August 22-27, 1993.
  33. Larue F, Colleau SM, Brasseur L, Cleeland CS. "Multicentre Study of Cancer Pain and Its Treatment in France" The British Medical Journal 1995; 310: 1034-103 7.
  34. Larue F, Colleau SM, Fontaine A, Brasseur L. "Oncologists and Primary Care Physicians' Attitudes toward Pain control and Morphine Prescribing in France." Cancer 1995; 76(l 1): 2375-2382.
  35. ANDEM. Recommendations pour la prise en charge de la douleur du cancer chez l'adulte en medecine ambulatoire, Paris: ANDEM, 1995.
  36. Larue F, Fontaine A, Colleau SM. "Underestimation and undertreatment of pain in HIV disease: A multicentre study." The British Medical Journal 1997; 314:23-28.

Back to Table of Contents

Appendix A: Index to Cancer Pain Release

Vol, No 2,1 1988

• "Reaching Around the World: The WHO Cancer Pain Relief Program" -- Jan Stjernsward, MD
• "Vietnam: Making Cancer Pain Relief a Reality"
• "Why Morphine Dosages Require Titration Part 1" -- Robert Kaiko, PhD
• "Legal Barriers to Pain Management" -- Robert Angarola, Esq
• "Availability of Opioid Analgesics in Argentina" -- Roberto Wenk, MD

2, 2 1988

• "Canada: Support for WHO Cancer Pain Program" -- Neil MacDonald, MD
• "Japan: Implementing the WHO Cancer Pain Relief Program" -- Fumikazu Takeda, MD
• "WHO Surveys Cancer Pain Relief Program Globally" -- Jan Stjernsward, MD
• "Why Morphine Dosages Require Titration Part 2" -- Roberto Kaiko, PhD
• "World Narcotics Consumption" -- Roberto Angarola, Esq
• "Availability and Use of Opioids For Cancer Pain Patients in Italy" -- Augusto Caraceni, MD

2, 3-4 1988

• "Vietnam: A Small Country Showcase"
• "Oral Morphine Solution Field-Tested in Bangalore"
• "Achieving Optimum Pain Control Through Titration" -- Robert F. Kaiko, PhD
• "U.S. Narcotic Imports" -- Robert T. Angarola, Esq
• "Unavailability of Narcotic Analgesics for Ambulatory Cancer Patients in New York City" -- Ronald M. Kanner and Russell K. Portenoy
• "Many Programs, One Commitment": Vietnam, Dominican Republic, Mexico, India
• "Pain Expert Teaches Palliative Care in Ahmedabad": Profile of Pamela Sutton, MD

3, 1 March 1989

• "Mexican NCI Receives Morphine Sulfate, Starts Training Program in Cancer Pain Relief" -- Sophie M. Colleau, PhD
• "Responding to Prescription Drug Abuse" -- David E. Joranson, MSSW
• "Cooperation With Industry" -- Robert F. Kaiko, PhD
• "U.S. War on Drugs Follows Historic Cycles" -- Robert T. Angarola, Esq
• "Oral Administration of Morphine and Methadone in the Treatment of Cancer Pain: A Randomized Study" -- Vittorio Ventafridda, MD
• "Second International Congress on Cancer Pain Targets Current Controversies": Report on the Rye, NY Congress -- Sophie M. Colleau, PhD

3, 2 May 1989

• "Dedication, Volunteers: Key Ingredients to Initiate Cancer Pain Relief Program in Argentina" -- Sophie M. Colleau, PhD
• "Dominican Cancer Institute Starts Pain Relief Program in Santo Domingo"
• "Foundation Dolores Almansa de Hackenberg' Helps Cancer Pain Research"
• "The Management of Cancer Pain in Children" -- Neil L. Schechter, MD
• "Cancer Patients: Innocent Victims of the War on Drugs" -- Robert T. Angarola, Esq
• "Evaluation of WHO Analgesic Guidelines for Cancer Pain in a Hospital-Based Palliative Care Unit" -- VA Walker, MD
• "Pharmaceuticals Contribute Funds, Donate Drugs for Cancer Pain Management"

3, 3 September 1989

• "International Experts Call for WHO Support of Palliative Care": A Report on the Expert Committee Meeting on Cancer Pain Relief and Active Supportive Care
• "Psychotropic Adjuvant Analgesic Drugs for Cancer Pain" -- William Breitbart, MD
• "Victories and Losses on the Cancer Pain Front" -- Robert T. Angarola, Esq
• "Use of Methylphenidate as an Adjuvant to Narcotic Analgesics in Patients with Advanced Cancer" -- Eduardo Bruera, MD
• "Satellite Teleconference Relays Cancer Pain Information to Multi-Site Network in Europe"
• "Working Together to Relieve Cancer Pain": Report on the First National Meeting for State Cancer Pain Initiatives -- Sophie M. Colleau, PhD
• "New Study Section Focuses on Children's Pain"

4, 1 March 1990

• "United Nations Drug Agency Targets Underuse of Opiates"
• "The Premature Use of Intravenous Opioids" -- Ada G. Rogers, RN
• "A Quiet Revolution in Pain Control" -- Robert T. Angarola, Esq
• "Experience with Oral Morphine for Cancer Pain Relief" -- S. Vijayaram, MD
• "WHO: INCB Action Key to Cancer Pain Relief Programs" -- Jan Stjernsward, MD
• "What is the INCB?"
• "INCB Sets Policy Guidelines"
• "Estimating Medical Needs for Opiates"
• "Are Physicians Restricted in Pain Management Efforts?" -- Sophie M. Colleau, PhD

4, 2-3 Fall 1990

• "Pain and Cancer in the Pacific Basin"
• "Mexico Adopts National Cancer Pain Policy"
• "France: Physicians, Pharmacists, Government Officials Discuss Medical, Legal Aspects of Morphine Prescribing" -- Sophie M. Colleau, PhD
• "Intravenous Opioid Therapy in a Toddler with Advanced Cancer" -- Ada G. Rogers, RN
• "1990: A Year of Gains and Losses" -- Robert T. Angarola, Esq
• "Cancer Pain Management in Germany According to WHO Analgesic Guidelines" -- Stephan Schug, MD
• "Oral Morphine Available in India" -- MT Bhatia, MD
• "Latin Americans Share Information on Cancer Pain and Palliative Medicine": Report on the First International Course in Cancer Pain and Palliative Medicine
• "Drug Controllers Consider Pain Issues in Beijing"
• "Pharmaceutical Donates Morphine Tablets to Vietnam"
• "USA: New Drug Law Affirms Opioids for Cancer Pain" -- David E. Joranson, MSSW

5, 1 Special Issue on State Cancer Pain Initiatives February 1991

• Editorial: "Networking to Relieve Cancer Pain" -- Sophie M. Colleau, PhD
• Updates on: Washington, Colorado, Indiana, New Hampshire, Minnesota, Vermont, Pennsylvania, Wisconsin, New Mexico, Ohio, Florida, Illinois, Texas, Michigan, Massachusetts, New York, and Iowa

5, 2 June 1991

• "WHO Publishes New Report on Cancer and Palliative Care"
• "Opioids and the Fear of Addiction in Germany" -- Jurgen Jage, MD
• "Non Steroidal Anti Inflammatory Drugs for Cancer Pain" -- June L. Dahl, PhD
• "International Drug Regulators Emphasize Medical Use of Opiates" -- Robert T. Angarola, Esq
• "Hypodermoclysis for the Administration of Fluids and Narcotic Analgesics in Patients with Advanced Cancer" -- Eduardo Bruera, MD
• "Creating a Cancer Pain Program in a Developing Country" -- Charles S. Cleeland, PhD

5, 3-4 Fall 1991

• "WHO and its Collaborating Centers" -- Jan Stjernsward, MD and Noreen Teoh, Rph
• "Winnipeg, Manitoba, Canada: Quality of Life in Cancer Care"
• "Amsterdam, The Netherlands: Quality of Life in Relation to Health Care"
• "Madison, Wisconsin, USA: Symptom Evaluation in Cancer Care"
• "Milan, Italy: Palliative Care and Cancer Pain Relief"
• "Oxford, United Kingdom: Palliative Cancer Care"
• "Saitama, Japan: Cancer Pain Relief and Quality of Life"
• "New York City, NY, USA: Cancer Pain Research and Education"

6, 1 Spring 1992

• "US Cancer Pain Initiatives: Active in Over 25 States"
• "US Groups Mobilize for Cancer Pain Relief: Building Bridges Across Disciplines" -- Sophie M. Colleau, PhD
• "National Cancer Institute Targets Pain Control"
• "Initiative Updates": Professional Education, Regulatory Issues, Patient Education, Research, Pharmacy Education, Public Education
• Updates on: "Hawaii," "California," "Oregon," "Utah," "Missouri," "North Carolina,"
• "Virginia," "Connecticut," and "Rhode Island"
• "State Cancer Pain Initiatives": List of state contacts.

6, 2-3 Winter 1992- Spring 1993

• "Cancer Pain Relief in Central and South America: A Progress Report"
• Editorial: Sophie M. Colleau, PhD
• Editorial: Eduardo Bruera, MD
• "Argentina" -- Roberto Wenk, MD
• "Brazil" -- Maria Teresa Evangelista Schoeller, MD and Eduardo Bruera, MD
• "Colombia" -- Liliana De Lima, PhD and Nessa Coyle, RN
• "Costa Rica" -- Lisbeth Quesada Tristan, MD and Isaias Salas Herrera, MD
• "Dominican Republic" -- Gloria Castillo, MD and Richard Patt, MD and Eduardo Bruera, MD
• "Mexico" -- Ricardo Plancarte, MD and Eduardo Bruera, MD
• "Uruguay" -- Eduardo Mendez, MD
• "Ecuador" -- Federico Santos Oehlert, MD

7,1 Spring 1994

• "Cancer Pain Initiative Movement Grows in the US"
• "US Health Professionals Attitudes Toward Cancer Pain Control: Trends in Recent Research" -- Sophie M. Colleau, PhD
• "Robert Wood Johnson Foundation Supports Cancer Pain Resource Center" -- Jacqueline Wineke
• "United States Joins Canada, Mexico in Issuing Guidelines on Cancer Pain Control"
• "RESEARCH IN CANCER PAIN AND PALLIATIVE CARE: WHO Guidelines For Cancer Pain Relief: Validation Studies"
• Commentary -- Russell K. Portenoy, MD
• Commentary -- Neil MacDonald, MD

7, 2-3 Fall 1994 "Making Opioids Available To Treat Cancer Pain: The International System" "Managing Cancer Pain with Opioids: Addiction, Tolerance and Physical Dependence Defined" "The International Narcotics Control Board" "Opioid Availability and the Role of National Governments" "What Can Health Professionals Do About Opioid Availability?" -- Sophie M. Colleau, PhD "RESEARCH IN CANCER PAIN AND PALLIATIVE CARE: Noninvasive Routes of Administration of Opioids" Commentary -- Kirk V. Shepard, MD 8, 1 Spring 1995

• "Cancer Pain, Palliative Care and the World Health Organization: 1995-99 Priorities"
• "WHO Program on Cancer Pain and Palliative Care: Mandates of Collaborating Centers and Focal Points Linkages with Other Organizations"
• "Collaborating Centers, Focal Points, Demonstration Projects: Definitions"
• "Measuring Progress in Cancer Pain and Palliative Care Programs"
• "RESEARCH IN CANCER PAIN AND PALLIATIVE CARE: Recent Contributions From WHO Collaborating Centers"
• Commentary -- Professor Vittorio Ventafridda

8, 2 Summer 1995

• "Governmental Policy, Drug Availability and Education: Building Blocks of National Cancer Control Programs" -- Jan Stjernsward, MD, PhD
• "Cancer Care, Pain Control Ignored in Economically Strained Tanzania" -- Patrick Coyne, RN, and Thomas Smith, MD
• "Colombia: Palliative Care Program Grows National in Scope" -- Liliana De Lima, PhD and Guillermo Vanegas, RN
• "Palliative Care in Catalonia: A Model WHO Demonstration Project" -- Sophie M. Colleau, PhD
• "RESEARCH IN CANCER PAIN AND PALLIATIVE CARE: Nausea and Vomiting in Advanced Cancer"
• Commentary -- Eduardo Bruera, MD

8, 3 Fall 1995

• "Cancer Pain Relief: A Primary Health Care Issue in the Philippines" -- Adriano V. Laudico, MD
• "Development of Cancer Pain and Palliative Care in the Philippines": A chronology
• "Chinese Government Engages in Long-Range Collaborative Program to Control Cancer Pain": An interview of Hong (John) Zhang, Beijing Bureau of Drug Administration and Policy
• "RESEARCH IN CANCER PAIN AND PALLIATIVE CARE: Fatigue in Patients With Cancer"
• Commentary -- Barbara Piper, DNSc

9, 1 Spring 1996

• "Palliative Care Delivery in Latin America: Obstacles and Solutions" Spring 1996 -- Eduardo Bruera, MD
• "Barriers to Cancer Pain Control in Latin America and their Impact on Patient Care" -- Sophie M. Colleau, PhD
• "From Florianopolis (1994) to Santo Domingo (1996): A Progress Report on Opioid Availability"
• "Latin American Resources for Professional Education" - Educational Resources: print - Educational Resources: audiovisual
• "Volunteers: Keys to the Success of Palliative Care Programs in Latin America"
• "New WHO Guidelines": Cancer Pain Relief With a Guide to Opioid Availability, Second Edition, 1996.

9, 2 Summer 1996 (Supplement)

• "Medical Need for Opioids Far From Being Met" -- Sophie M. Colleau, PhD and David E. Joranson, MSSW
• "Highlights of the INCB Report" -- David E. Joranson, MSSW and Sophie M. Colleau, PhD
• "Conclusions and Recommendations of the 1996 INCB Report"

9, 3 1996

• "Physician education in palliative medicine: a vehicle to change the culture of pain Fall management" -- Sophie M. Colleau, PhD
• "Advanced Training in Palliative Medicine: Some Fellowship Opportunities"
• "RESEARCH IN CANCER PAIN AND PALLIATIVE CARE: Can Education Improve Physicians' Cancer Pain Practice?: Findings From North American Research"
• Commentary -- David E. Weissman, MD

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