Willem Scholten, Team Leader, Access to Controlled Medicines, World Health Organization
Palliative care is an essential element in WHO’s integrated cancer care strategy, but in many countries it is not yet available. We need policies to promote palliative care. A good starting point for policies is to measure the state of palliative care. At least, we need indicators to measure palliative care and pain measurement. They will help us to monitor if we are globally on the right track.
Some NGOs propose to use “opioid analgesic consumption per cancer death” as the indicator. This indicator says nothing about the development or availability of palliative care around the world. I agree with Carlo Leget’s post (16 April) that this is not a good idea.
We know that in the top-20 developed countries approximately 4.5% of all opioid analgesics is used for end-stage cancer, end-stage HIV and patients who had severe accidents (counted by the number of lethal accidents).1 To work out the proportion of cancer in pain management, we need to subtract around 20% for HIV and accidents. This leaves 3.7% as the proportion for cancer. In addition, we need to incorporate that even in countries where palliative care is well integrated in health care, it reaches rarely over 10% of the cancer patients. Thus, only about 0.4% of all the strong opioid consumption in developed countries is used in palliative care.
The calculation reveals that there is no correlation between the proposed indicator of “opioid analgesic consumption per cancer death” and palliative care. It is undoubtedly better to develop a meaningful indicator that provides real information about the availability of palliative care. For example, palliative care capacity in a country can be measured by the total of available hospice beds and the number of places in home care per 100,000 inhabitants.
The development of an indicator to measure pain management is a different challenge. The proposed indicator “opioid analgesic consumption per cancer death” will be a disaster for pain patients. In several countries the law allows only strong opioids for use in (terminal) cancer pain. These countries may consider the proposed indicator a confirmation of their policies. By adopting “opioid analgesic consumption per cancer death” as indicator, we are ignoring, even discriminating against patients with other diseases, like end-stage HIV patients or children with congenital disease. They too deserve that their pain is addressed.
We need a methodologically strong indicator that does not produce too high figures – this is what will happen if we divide by ‘cancer deaths’ instead of by total population (‘per capita’). The proposed indicator can easily serve as an excuse to governments and hospital managers to sit idle, because the indicator blew up the performance.
Cancer patients are not the only people who have a right to be treated for their pain. It is cruel not to treat other patients with moderate and severe pain. Integrating palliative care in health care will be an aid for this. Let’s start by getting the indicators right: “total of strong opioid consumption per capita” for pain management and “palliative care capacity (hospice beds and places in home care) per 100,000 inhabitants” for palliative care services.
1. Seya MJ, Gelders SFAM, Achara UA, Milani B, Scholten WK. A First Comparison between the Consumption of and the Need for Opioid Analgesics at Country, Regional and Global Level. J Pain and Palliative Care Pharmacotherapy, 2011; 25: 6-18. Accessible at: http://informahealthcare.com/doi/pdf/10.3109/15360288.2010.536307