Introduction to Treat the Pain

2

The problem of unrelieved pain

Globally,

7.3 million people die of cancer or HIV each year in moderate or severe pain

More than

2.9 million die without pain relief

99.9% of these deaths are in low and

middle-income countriesSource: 2010 WHO cause of death and INCB reports (www.gapri.org)

There are 2.9 million deaths from HIV or cancer in untreated pain each year• Sub-Saharan Africa: 41%• South Asia: 29%• East Asia & Pacific: 16%

• Europe & Central Asia, Latin America & Caribbean, Middle East & North Africa, North America: 14%

Scoping the problem

3Source: 2010 WHO cause of death and INCB reports (www.gapri.org)

Untreated deaths in pain

44

Low and middle-income countries

70% of cancer deaths

99% of HIV deaths

just 7% of medicinal opioids

US, Canada, UK, Australia

11% of cancer deaths

<1% of HIV deaths

67% of medicinal opioids

There is a great disparity in access to pain relief

Untreated deaths in pain

5

INDIA

RUSSIAN FE

DERATIO

N

NIGERIA

CHINA

INDONESIA

ZIMBABWE

ETHIO

PIAKEN

YA

TANZA

NIA

DR CONGO

Rest of th

e world

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

60% of the unmet need is in 10 countries

Source: 2010 WHO cause of death and INCB reports (www.gapri.org)

*

**

* Denotes GAPRI partner countries

2008 2009 20100

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

9%12%

Untreated deaths in pain

Progress against goals

2010: 2.9 million untreated deaths in pain and going down

Global coverage rate is 60%•100%-high income•57%-middle income•8%-low income

6

7

Goal

Objectives

Strategy

1. Strengthen government leadership by providing staff (fellows) and technical assistance directly to health ministries2. Reduce cost and improve availability of medicines by negotiating with suppliers and providing technical assistance to buyers3. Improve clinical and regulatory policies and practice by advocating on international, national, and facility levels4. Improve skills and motivation of individual clinicians by improving access to information and to other clinicians interested in pain treatment

Develop high-profile projects in countries with large unmet need; prompt change in neighboring countries and adoption by other organizations

Universal access to essential pain medicines by 2020

Global Access to Pain Relief Initiative (GAPRI)

8

National Agency for Food and Drug Administration and Control

(NAFDAC), with input from Federal Ministry of Health (FMOH), submits

annual estimate to International Narcotics Control Board (INCB)

INCB approves morphine quantity MOH Pharmacy Dept places order with international supplier and NAFDAC approves importation

Drugs received by Central Medical Stores in Lagos

Registered pharmacist, on behalf of a health facility, gets approval from

Central Medical Stores Lagos

Powder is reconstituted into solution

Clinician asks about pain

Patient reports painClinician writes prescription

Patient fills prescription

Patient receives monitoring and follow-up

Nigeria: 3 kg

What does it take to

get morphine in Nigeria?

Registered pharmacist, on behalf of a health facility, gets approval from

state MOH

Registered pharmacist picks up drugs at Central Medical Stores

Lagos

Mechanism of access

9

National Agency for Food and Drug Administration and Control

(NAFDAC), with input from Federal Ministry of Health (FMOH), submits

annual estimate to International Narcotics Control Board (INCB)

INCB approves morphine quantity MOH Pharmacy Dept places order with international supplier and NAFDAC approves importation

Drugs received by Central Medical Stores in Lagos

Registered pharmacist, on behalf of a health facility, gets approval from

Central Medical Stores Lagos

Powder is reconstituted into solution

Clinician asks about pain

Patient reports painClinician writes prescription

Patient fills prescription

Patient receives monitoring and follow-up

Nigeria: 3 kg

Why isn’t it working?

Registered pharmacist, on behalf of a health facility, gets approval from

state MOH

Registered pharmacist picks up drugs at Central Medical Stores

Lagos

MOH is not ordering; last order expired before use

Users did not know morphine was available

Approvals took a very long time; required several days in Lagos

Difficult for facilities far from Lagos

Limited capacity for reconstitution outside of large facilities; lack of quality control

Lack of awareness from patients; lack of trained clinicians

Patients pay for drugs

10

National Agency for Food and Drug Administration and Control

(NAFDAC), with input from Federal Ministry of Health (FMOH), submits

annual estimate to International Narcotics Control Board (INCB)

INCB approves morphine quantity MOH Pharmacy Dept places order with international supplier and NAFDAC approves importation

Drugs received by Central Medical Stores in Lagos

Registered pharmacist, on behalf of a health facility, gets approval from

Central Medical Stores Lagos

Powder is reconstituted into solution

Clinician asks about pain

Patient reports painClinician writes prescription

Patient fills prescription

Patient receives monitoring and follow-up

Nigeria: 3 kg

What can GAPRI do?

Registered pharmacist, on behalf of a health facility, gets approval from

state MOH

Registered pharmacist picks up drugs at Central Medical Stores

Lagos

MOH is not ordering; last order expired before use

Users did not know morphine was available

Approvals took a very long time; required several days in Lagos

Difficult for facilities far from Lagos

Limited capacity for reconstitution outside of large facilities; lack of quality control

Lack of awareness from patients; lack of trained clinicians

Patients pay for drugs

Drug forecast and stock monitoring

Supplier identification and negotiation

Communication of availability

Streamline approvals

Track and monitor stocks

Integrate pain treatment into HIV and cancer care

Collaborate with NGOs to improve awareness

Improve distribution

11

GAPRI Fellowship Program: Nigeria

Three-year partnership with the Federal Ministry of Health (FMOH)• Placed a consultant in the Department of Food and Drug Services, FMOH as

Special Assistant to the Director for Access to Pain Relief

• Procured first batch of morphine in 4 years, improving distribution, training clinicians

• Working with HIV and cancer communities to integrate pain relief

Population: 155 millionDeaths in pain: 177,000Coverage: <1%

12

Supply Project: Uganda

In 2010 GAPRI negotiated a deal between government and an NGO to create a national morphine production program

• Government certified production facility at Hospice Africa Uganda now producing morphine for the entire country

• Current cost is 2 USD for a week of treatment – reducing the government’s cost by 40%

• Increased stability of supply and expanded patient access

• Morphine is now free for all patients

Population: 33 millionDeaths in pain: 69,000Coverage: 4%

13

Pain Free Hospital Initiative: India

A one-year hospital-wide quality improvement initiative in 3 hospitals

Improve knowledge and skills to assess and treat pain

Raise awareness about untreated pain

Improve availability of essential pain medicines

Measure and document activities and their impact

GAPRI is working with partners in India to implement the Pain-Free Hospital Initiative

Population: 1.2 billionDeaths in pain 694,000Coverage: 11%