Opioid consumption and palliative care indicators

Per Sjøgren, Vice-president, European Association for Palliative Care (EAPC) and Professor in Palliative Medicine, University of Copenhagen, Denmark

It was encouraging to read Willem Scholten’s post on the indicator “opioid analgesic consumption per cancer death”, which has been proposed as a global indicator for palliative care. I would like to add some thoughts and data. We have, in collaboration with the National Institute of Public Health, monitored opioid consumption in Denmark, which is among the top-10 developed countries regarding high legal opioid consumption 1,2.

In Denmark and in other high income countries, > 2/3 of the legal opioid consumption is generated by individuals with chronic non-malignant pain conditions (>50% musculoskeletal pain), and the prevalence of regular opioid users in western populations is now exceeding 4% 1,3. An epidemic of opioid over-use in primarily individuals with non-malignant pain conditions in high-income countries has given rise to concern, which is addressed in a recent article in the New York Times.  The consequences of the long-term opioid use include cognitive dysfunction, addiction, opioid-induced hyperalgesia, tolerance, deficiency of the immune and reproductive systems and premature death.

In low/middle income countries the situation is quite different and numerous countries around the world can be placed between the extreme ends of the scale of legal opioid consumption. Adding this information to the figures given by Willem Scholten the validity of the proposed indicator seems to be highly questionable. Furthermore, as Willem Scholten rightly points out, the indicator is focussed on pain management rather than palliative care. Taking the lack of focus into account, the indicator will not even grasp the quality of pain management as multimodal and differentiated therapies should be the remedy.

Uncritical advocacy for increased use of opioids has in high-income western countries most of all pleased the pharmaceutical industry and left a lot of patients with chronic non-malignant pain conditions with additional problems 1. The EAPC should strongly support and demand access to opioids in low/middle-income countries. However, a global indicator for palliative care must be related to its capacity.

References
1. Eriksen J, Sjøgren P, Bruera E, Ekholm E, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain. An epidemiological study. Pain 125; 172-179, 2006.
2. Sjøgren P, Grønbæk M, Peuckmann V, Ekholm O. A population-based cohort study on chronic pain: The role of opioids. Clin J Pain 26; 763-769, 2010.
3. Toblin RL, Mack KA, Perveen G, Paulozzi LJ. A population-based survey of chronic pain and its treatment with prescription drugs. Pain 2011; 152:1249-1255.

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2 Responses to Opioid consumption and palliative care indicators

  1. Diederik Lohman says:

    I fully agree that a global indicator for palliative care should ideally measure not just pain control but palliative care more broadly. The problem is that we do not have an indicator for palliative care broadly that has been tested, validated and for which the data can realistically be gathered in a standardized manner across the world. So the choice is stark: 1. We go with an indicator linked to opioid consumption, for which data does exist from around the world; or 2. We end up with nothing related to palliative care in the global monitoring framework for non-communicable diseases.

    There are real concerns about the opioid consumption indicator. But better an indicator with limitations than the alternative: The world adopts a monitoring framework that will set the agenda for discussions on non-communicable diseases for the next decade that doesn’t include any reference to palliative care. That would mean that palliative care would be marginalized in NCD discussions for a decade to come. The risk that palliative care would be left without an indicator is not imaginary. Had it not been for persistent advocacy for a palliative care indicator, the WHO discussion paper would likely not have included one.

    With an indicator–even one that isn’t ideal–palliative care has a seat at the table. It will be on the agenda, giving palliative care advocates an opportunity to push for integration of comprehensive palliative care–not just pain control–into national and international NCD strategies. In my opinion, the number one priority of the palliative care community should be to make sure that the currently proposed indicator is not removed because I think the only alternative is ending up with no indicator. Secondly, the palliative care community needs to develop, test, and validate a more comprehensive indicator that can be measured in a standardized fashion worldwide in a cost-effective manner so that next time a global monitoring framework is agreed we can propose something better.

    Diederik Lohman

  2. Xavier Gómez-Batiste says:

    About the morphine consumption as indicator
    1. I agree that the morphine consumption is not the only parameter to monitorise, and has limits in its relation to palliative care implementation (only for cancer patients). But it is also true that, in the initial phases, it can be very useful to monitorise the progress of a Public Healht program.
    2. If so, I think that there are combined methods (not only consumption, but also legislation, access, etc) to consider

    – About general indicators:

    We propose to use a set of different indicators (structure, process, results) and to combine quantitative (morphine, services, coverage, etc) and qualitative (to identify strengths and weaknessess).

    – The question of the coverage for noncancer is one of the best indicators of the quality and adjust of a public health program, because this is the best inditactor of the extension of palliative care.
    Xavier Gómez-Batiste, MD, PhD

    Director,
    Observatori Qualy / Centre Col•laborador de l’OMS per a Programes Públics de Cures Pal•liatives
    Observatorio Qualy / Centro Colaborador de la OMS para Programas Públicos de Cuidados Paliativos
    The “Qualy” Observatory / WHO Collaborating Centre for Public Health Palliative Care Programmes

    Director,
    Càtedra de Cures Pal.liatives / Cátedra de Cuidados Paliativos / Chair of Palliative Care. Facultat de Ciències de la Salut i Benestar. Universitat de Vic.

    Our references are:

    Gómez-Batiste X, Caja C, Espinosa J, Bullich I, Martínez-Muñoz, M et al. The Catalonia World Health Organization Demonstration Project for Palliative Care Implementation: Quantitative & Qualitative Results at 20 Years. J Pain Symptom Manage 2012;43(4):783-794. doi:10.1016/j.jpainsymman.2011.05.006

    Gómez-Batiste X, Ferris F, Paz S, Espinosa J, Porta-Sales J, Stjernswärd J. Ensure quality public health programmes: a Spanish model. Eur J Palliat Care 2008; 15(4): 195-9

    http://www.iconcologia.net/catala/qualy/centre_recerca.htm

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