Latin American Region

Regional meeting: San Juan, Puerto Rico (December 1997):

The Center participated in a regional drug control meeting sponsored by the Interamerican Commission on Drug Abuse (CICAD) and made a presentation on "The availability of narcotic drugs for medical use." A monograph was also distributed.¹⁴

Regional meeting: Concepción, Chile (March 1998):

Since 1994, the Center has been an active participant in the Latin American conferences on palliative care which are held every other year in a different Latin American country (Florianopolis, Brazil 1994; Santo Domingo, Dominican Republic, 1996; Concepción, Chile, 1998).

Situation:
In most Latin American countries, opioid analgesics such as morphine are not readily available for cancer pain relief. The reasons have been discussed in a number of publications (referenced on the Pain & Policy Studies Group website), and include low prescription demand, cost, lack of palliative care infrastructure, exaggerated fears of opioids, lack of training in pain relief, and excessive drug regulation.

Method:
To study and address the situation, the Center has participated since 1994 in a number of meetings and conferences, provided presentations for health care providers and drug regulators, promoted the development of cooperation between health care professionals and drug regulators, used surveys to collect information about the barriers to opioid availability and has begun to evaluate regulatory barriers as well as national policies. The Center cooperated with Dr. Eduardo Bruera, WHO Focal Point for Latin America, and with Ms. Liliana De Lima, a Fellow and then Consultant with the Center and subsequently liaison to Collaborating Centers for the Pan American Health Organization (PAHO), to prepare for the regional meeting in Concepción. The Center assisted in the assessment of progress and future directions to improve palliative care education and opioid availability in the region according to WHO guidelines. The Center developed links with Latin American clinicians and drug regulators to identify participants for a panel discussion on opioid availability. The Center designed and administered a survey of Latin American health professionals to assess educational needs in terms of knowledge/attitudes toward cancer pain management.

Outcomes:
In March 1998, the Center participated in the 5^th Latin American Congress of Palliative Care in Concepción, Chile with approximately 200 physicians, nurses, psychologists, regulators and others from 16 Latin American countries. The Center produced two posters in Spanish: "Opioid analgesics in Latin America: trends, legal requirements, recommendations;" ¹⁵ and "Panorama del cuidado paliativo en Latinoamérica: datos de 1994, 1996 y 1998." ¹⁶ The Center also produced a monograph in Spanish about opioid consumption trends in the region, and the status of regulatory requirements in selected countries.¹⁷ A report from the previous Latin American congress in the Dominican Republic was published in the Journal of Pain and Symptom Management in 1997.¹⁸

Evaluation:
Regional meetings in Latin America are an opportunity to assist participants to identify and remove regulatory barriers to opioid availability, to provide information about differing regulatory requirements in the region, to promote communication between key palliative care professionals and their governments, and to gather data on the clinical practice of palliative care in the region.

There is a need for additional resources to make it possible to 1) carefully evaluate progress to improve availability of opioids in the region, on a country by country basis, 2) convene interested parties and develop action plans, 3) monitor progress and 4) provide technical assistance.

The potential for progress in pain relief and palliative care in Latin America improved when the PAHO announced in 1998 an initiative to improve palliative care in the region, including opioid availability. In the same year, the Center proposed that PAHO sponsor, in cooperation with the Center, one or more workshops to convene representatives from countries (representing drug regulation, cancer control, and palliative care) to assess opioid availability in each country, review the expectations of international treaties and government bodies to ensure not only control but also availability of opioids, identify barriers and develop action plans.

In 1999, the Center asked the US Cancer Pain Relief Committee to arrange funding for PAHO to organize a workshop on opioid availability for the Andean countries. The new WHO Guidelines for Assessment or National Narcotic Control Policy for Balance prepared by the Center for WHO will provide a valuable framework for the workshop discussions.

Mexico:

Objective:
To collaborate with health professionals and the national government to assist in identifying barriers to, and improving the availability of, opioid analgesics to cancer patients in Mexico.

Situation:
Opioid analgesics such as morphine are limited to a few institutions due to lack of demand and also due to regulatory impediments such as limited availability of the special government prescription form, as well as regulatory limitations on the amount and duration of opioids such as morphine that can be prescribed.

Method:
The Center approached the situation in several ways in order to develop cooperation and to systematically identify the barriers as well as the need for changes in national opioid policies.

Cooperation:
The Center was pleased to participate in several professional conferences of the National Cancer Institute (NCI) and the Mexican Association for the Study of Pain in 1997. The Center was invited to present "Papel del gobierno: asegurar la disponibilidad de opiáceos y prevención de abuse." ¹⁹ The purpose was to present information about the principles of international opioid regulation and to become acquainted with the situation and the key people and organizations.

Exchange of information:
The Center sponsored a week-long meeting in Madison to which was invited Dra. Araceli Garcia, in charge of narcotic control for the government of Mexico; Dra. Silvia Allende, Chief of Pain and Palliative Care from the NCI in Mexico City; and her nursing colleague, Mrs. Helen Carvell. The purpose was to study the regulatory issues in providing opioids, the international requirements for doing so, to better understand the Mexico policies, and to develop a basis for future communication and collaboration.

Data Collection and Policy Analysis:
The Center, with the assistance of Ms. De Lima, had earlier prepared a monograph, "Preliminary analysis of the Mexican legislation in relation to the international principles of opioid availability." ²⁰ This policy analysis identified a number of barriers to availability of opioids in Mexico. The preliminary analysis was provided to our colleagues in Mexico. In 1997, Ms. De Lima visited Mexico City to give a presentation on opioid availability in Latin America and Mexico and worked with health care professionals and government representatives on ways to improve opioid availability. In addition, the Center's "Barriers to opioid availability" (BOAT) questionnaire was used by Dra. Silvia Allende to survey health professionals about their perceptions of what factors contribute to inadequate use of opioids in relieving cancer pain.

Outcomes:
The Center's efforts to develop cooperation with the government were accepted and several meetings were held with the chief regulator as well as the director of the NCI. These meetings, the week of information exchange in Madison, and the preliminary analysis of Mexican narcotics laws subsequently contributed to meetings of health professionals and government representatives that were organized in Mexico to formulate revisions to the regulatory requirements for opioid prescriptions. In addition, Dra. Silvia Allende published an article about barriers to pain management in Mexico, including the results of the BOAT survey.¹

Evaluation:
The Center's efforts were well received and served as one important contribution to the establishment of a more positive regulatory environment for medical use of opioids: the government adopted significant changes to the narcotic prescribing requirements, including replacement of the triplicate prescription form with a bar-coded single copy prescription form. The prescription form is to be available to physicians at the capitals of each state rather than only the federal capital, and the restrictions on amount and duration of prescribing were changed. These changes in policy are historic and should be seen as an important development for pain relief in Mexico.

The Center also became aware of strong interests to expand information and training about pain relief and palliative care in Mexico. We explored the possibility of assisting in the establishment of a cooperative newsletter venture with the Autonomous University of Mexico (UNAM), a "role model" training program adapted to Mexican needs and also providing a basic library ("biblioteca básica") of resource materials to selected libraries of medical, nursing and pharmacy schools. However, resources were not available, and these ideas will have to wait until financial support is available.

Argentina:

Objective:
To work with health professionals in Argentina to bring greater visibility to pain control and palliative care and enlist support of policy makers in government.

Method:
The Center has a 10-year history of supporting Argentinian clinicians in cancer pain control and palliative care through articles in Cancer Pain Release, technical assistance with publications, assistance with educational initiatives, participation in conferences, and encouragement of changes in national policy regarding cancer pain relief and palliative care.

Outcomes:
The Center provided information about the goals of Programa Argentino to the readership of Cancer Pain Release in May 1989, October 1990, December 1992, March 1996 and 1999. In 1991, the Center assisted the Programa Argentino in the publication of the Manual de San Nicolas, a monograph describing how to select and train volunteers to assist terminally ill patients in hospital and at home, using minimal resources.

In October 1997, the Center participated as faculty in the first Jornadas del Programa Argentino de Cuidados Paliativos in Buenos Aires, and observed the status of pain control and palliative care programs in three cities: Rosario (province of Santa Fe), Cordoba (province of Cordoba) and Buenos Aires. Dr. Colleau gave two lectures in Spanish on "WHO strategies to implement cancer pain control and palliative care," and "Can professional education change professional practice?"

In May 1999, the Center participated as faculty in the 6^th International Course on Pain Control, Fundación Dolor, Buenos Aires. Dr. Colleau gave three lectures in Spanish 1) "Strategies to overcome obstacles to cancer pain relief" ("Estrategias para superar los obstaculos al alivio del dolor en cáncer"); 2) "Availability of opioids for pain relief: relevant points for Latin America" ("Disponibilidad de opioides para el alivio del dolor: puntos relevantes a Latinoamérica"); 3) "Education about the control of cancer pain and palliative care: courses for professionals, patients and families" ("La educación sobre el control del dolor de cáncer y el cuidado paliativo: recursos para profesionales, pacientes y familiares").

The Center produced two monographs in Spanish for dissemination. One dealt with issues in opioid availability relevant to Latin America;²¹ the other presented the resources available for professional education in pain control and palliative care.²² In addition relevant Spanish editions of Cancer Pain Release were distributed to participants.

Evaluation:
WHO has recommended adoption of national policies to support development of cancer pain relief and palliative care. To achieve this goal, the Center recommended that Argentinian clinicians develop a consensus about and broad support for a national policy. However, the cost of analgesics prevents access to care for many cancer patients and remains a major barrier to adequate pain relief.

The Center encouraged clinicians in the Provinces of Cordoba, Santa Fe and Buenos Aires to work with drug regulators and health authorities to change the regulations to be consistent with modern medical practice and the needs of patients so that the duration of prescription of morphine as well as the amount of dosage allowed are not limited. The establishment of a national commission to harmonize and modernize opioid prescribing policy should be considered.

The Center should continue to provide coverage in Cancer Pain Release of Argentinian and other Latin American initiatives in national policy, drug availability and education; however, additional resources will be necessary to produce and disseminate Cancer Pain Release in Spanish.

In Buenos Aires, Rosario and Cordoba, the experienced program leaders who are already in place should consider developing distance learning courses in pain control and palliative care as a cost-effective method to reach health professionals in remote, rural areas of the country.

Colombia:

Previously, Ms. De Lima had assisted the Center in preparation of a "Preliminary analysis of Colombian legislation in relation to the international principles of opioid availability." ²³ In 1997, Ms. De Lima gave a presentation on opioid availability in Colombia and participated in discussions with representatives of the national chapter of the International Association for the Study of Pain and government representatives on how to improve ways to make opioids more available in the country.

On October 10, 1997, Ms. De Lima attended the 2^nd International Forum on Palliative Care in Bogota, where she presented a talk on the "Status of opioid availability in Latin America" ("Disponibilidad de opioides en Latinoamérica: definiendo estrategias").

The Center also gave ongoing technical support to the chief narcotic regulator to assist the government in providing opioids for those suffering from cancer pain in Colombia.

Costa Rica:

On September 25, 1997, Ms. De Lima visited Costa Rica upon the invitation of the Ministry of Health to aid in the evaluation of the opioid distribution system and the identification of barriers within that system.

Venezuela:

The Center worked with the chief narcotics regulator for Venezuela, to assist in making opioids available and the identification of impediments.

In July 1996, Ms. De Lima visited Caracas at the invitation of the PAHO to attend a meeting on the Andean Medications Program. Ms. De Lima gave a presentation on the WHO recommendations for the use of opioids in cancer pain treatment ("Uso de medicamentos opioides en el manejo del dolor por cáncer: recomendaciónes de la organización mundial de la salud").

An article resulting from the meeting was published in the PAHO Journal, "El empleo de analgesicos opiáceos para el alivio del dolor por cáncer." ²⁴

In November 1998, Ms. De Lima presented a talk in Caracas entitled, "Barriers to opioid utilization in Latin America" ("Barreras en la utilización de opioides en Latinoamérica").

European Region

Asian Region

African Region

North American Region

PPSG Home     Table of Contents    Top   Next section