Section I. A.

The Center has developed methodologies and procedures in several areas to implement its Terms of Reference. These areas include data collection, education, policy evaluation, collaboration and communications.

Barriers Survey: The Center developed a survey (called the "Barriers to opioid availability test" [BOAT]). It is a 26-item questionnaire that is used to evaluate health-care professionals' beliefs about the use and availability of opioids such as morphine for cancer pain relief and the impediments to the use of such drugs in their country. Two publications have reported results using the BOAT.^1,2 The Center has also developed a one-page survey that is to be completed by participants at pain and palliative care conferences as a first step in identifying unmet needs for opioid analgesics in a country.³

INCB Data: The Center has requested complete data on the medical consumption of morphine and other principal opioids for all countries that report to the International Narcotics Control Board (INCB). These data allow the Center to monitor consumption trends and progress to improve pain relief, to identify problem areas, and to educate health-care professionals and government officials from any country about their past and present use of opioids. The Center's analysis of these data has been reported in numerous publications, monographs, and conference presentations and posters. The Center maintains an international database of opioid consumption data and makes these data available to numerous governmental and non-governmental organizations and individuals who are working to improve pain relief.

The Center has organized or participated in meetings and educational programs that bring together representatives from government, cancer control, palliative care, and education within several countries, including India, Japan, Mexico, Italy, and the United States. Such efforts, and continued networking of professionals representing government and medicine, will help create a national infrastructure that can work to ensure opioid availability and enhance the priority of a country's pain management and palliative care in the health care system. The Center has developed presentations which explain the principles of opioid availability and how they are derived from international sources of authority such as the international narcotics control treaties, WHO and the INCB. These presentations can be helpful in understanding the policy framework for ensuring opioid availability. The Center has produced a number of monographs for distribution at national and international meetings to provide participants with information about trends and key resources (See Bibliography).

The Center evaluates policy at both the national and international levels. This work is based on a Central Principle of "Balance," which states that government policies to prevent misuse of controlled substances should not interfere with their use for the relief of pain.^4,5 From this Central Principle, the Center has developed 1) a set of evaluation criteria against which US federal and state policies have been examined to identify provisions that may enhance or impede pain management,⁵ and 2) WHO Self-Assessment Guidelines to encourage national governments to achieve better pain management by identifying and overcoming regulatory barriers to opioid availability.⁶ The WHO Self-Assessment Guidelines can be used to develop balanced national (including states, provinces or territories) drug control policies. This document, which will be published by WHO in 2000, is intended for those who make national drug control policy, as well as those who implement it. It may also be used by health care professionals and their organizations to encourage cooperation with governments and to facilitate further education about ensuring the availability of pain medications. The Center has also developed a procedure to "diagnose" and "treat" barriers to pain management and opioid availability, applying a medical model to policy problems.

The Center is committed to a collaborative process. The Center's collaborative policy evaluation efforts have been conducted in India, Malaysia, Mexico and Colombia in cooperation with governmental, narcotic regulatory, cancer control and health-care professionals. The aim of this work is to establish the relationships that are necessary to evaluate and improve policies governing opioid availability. Examples of collaborative efforts appear throughout this report.

The Center is improving its capacity to disseminate its work to a wide international audience through publications, conference participation, networking on the Internet, websites and frequent email contact with collaborators.

	1.	Allende S, Carvell HC. Mexico: status of cancer pain and palliative care. J Pain Symptom Manage. 1996;12:121-123.
	2.	Zhang H, Gu W, Joranson DE, Cleeland CS. Peoples Republic of China: status of cancer pain and palliative care. J Pain Symptom Manage. 1996;12(2):124-126.
	3.	Joranson DE. Availability of opioids for cancer pain: recent trends, assessment of system barriers, new World Health Organization guidelines, and the risk of diversion. J Pain Symptom Manage. 1993;8(6):353-360.
	4.	Joranson DE, Gilson AM, Ryan KM, Maurer MA, Nelson JM. Achieving balance in state pain policy: a guide to evaluation. Madison, Wisconsin: University of Wisconsin Pain & Policy Studies Group/WHO Collaborating Center for Policy and Communication in Cancer Care; 1999.
	5.	Joranson DE, Gilson AM. Controlled substances, medical practice, and the law. In: Schwartz HI, ed. Psychiatric practice under fire: the influence of government, the media, and special interests on somatic therapies. Washington DC: American Psychiatric Press, Inc.;1994:173-194.
	6.	World Health Organization. Achieving balance in national drug control policy: guidelines for self-assessment. Geneva, Switzerland: World Health Organization, in press.