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.
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.