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Israeli oncologist: Palliative care neglected in developing world
By JUDY SIEGEL-ITZKOVICH
11/01/2014
Prof. Nathan Cherny, veteran oncologist and head of palliative medicine at Jerusalem’s Shaare Zedek Medical center says cancer pain should be obsolete.
 
Cancer patients suffering from intolerable pain have a natural right to receive medications to alleviate their suffering. But a the first-ever global survey by the European Society for Medical Oncology – headed by an Israeli palliative medicine specialist – has found that a “pandemic of untreated cancer pain” caused by too strict regulation of pain medication has become a “scandal of global proportions.”

Called “groundbreaking and just published in Annals of Oncology, the international collaborative survey of 22 partners shows that more than half of the world’s population – four billion people – live in developing countries where regulations aimed at stemming drug misuse leave cancer patients without access to opioid medicines for managing cancer pain.

“The GOPI study shows the developing world that it is catastrophically difficult to provide basic medication to relieve strong cancer pain,” says Prof. Nathan Cherny, a veteran oncologist and head of palliative medicine at Jerusalem’s Shaare Zedek Medical center who is chairman of the ESMO Palliative Care Working Group. “Most of the world’s population lacks the necessary access to opioids for cancer pain management and palliative care, as well as acute, post-operative, obstetric and chronic pain. When one considers that effective treatments are cheap and available, untreated cancer pain and its horrendous consequences for patients and their families is a scandal of global proportions,” Cherny says.

The study, conducted in Africa, Asia, Latin America, the Caribbean and the Middle East assessed the availability of the seven opioid medications considered to be essential for the relief of cancer pain by the WHO Model List of Essential Medicines and the International Association for Hospice and Palliative Care.

Those essential medications include codeine, oral oxycodone, transdermal fentanyl, immediate- and slow-release oral and injectable morphine, as well as oral methadone.

While there are problems with the supply of these medicines in many countries, the main problem is over-regulation that makes it difficult for healthcare professionals to prescribe and administer them for legitimate medical use, the authors say.

“This is a tragedy born out of good intentions,” says Cherny. “When opioids are over-regulated, the precautionary measures to prevent abuse and diversion are excessive and impair the ability of healthcare systems to relieve real suffering. The GOPI study has uncovered over-regulation in much of the developing world.”

“The next step is for international and local organisations working alongside governments and regulators to thoughtfully address the problems,” adds study co-author James Cleary, Director of the Pain and Policy Studies Group and Founding Director of the Palliative Medicine at the UW Carbone Cancer Center, Madison, Wisconsin.

“Regulatory reform must be partnered with education of healthcare providers in the safe and responsible use of opioid medication, education of the public to de-stigmatize opioid analgesics and improved infrastructure for supply and distribution,” he says.

“The ongoing initiatives to reform regulations, improve accessibility and promote the education of clinicians and consumers in the effective use of opioid medications for the relief of cancer pain will require vision, determination and the same spirit of cooperation among organizations that made this study successful. The challenges are great, but no greater than our resolution to the task of making pain relief for cancer patients a reality irrespective of geography. Governments should look at the GOPI survey data for their country and take concrete actions to reduce the barriers,” Cherny concludes.

PANAMA ADOPTS UNITED HATZALAH MODEL

Panama has quietly been part of a non-military revolution – one that involves emergency medical services – with help from a voluntary Israeli organization. Frustrated by traffic and road conditions that often lead to ambulance response times of 15 to 30 minutes or more, Panamanians Ramon Gateno and Isaac Serfaty were looking for a better solution. Familiar with Israel’s creative and often audacious solutions to technical problems, they began to do some research in Israel. They were intrigued by the emergency medicine solutions provided by the rescue and firstaid organization United Hatzalah and wondered if it would work in Panama.

After months of planning, training and testing United Hatzalah of Panama was launched.

Soon the orange-vest-clad volunteers, such a common sight here, began to appear on the scene of emergencies in Panama. As the group began to grow and the scope of the emergencies that they were exposed to, began to expand they realized that they needed to “up their game” to the next level. Ramon, Isaac and an elite group of leading medics flew back to Israel to enhance their knowledge base and test their mettle against the most rigorous training scenarios. The crash course was a combination of intense classroom study by the finest UH instructors coupled with real-life exposure through “shotgun” ride-alongs with the organization’s ambucycles and ambulances. The course also provided the team with training and exposure to the broadest and most intense forms of medical response in Israel. They observed the practice of combat medicine at the Israel Defense Forces’ elite medical training base. They entered the hyper-realistic computerized combat simulation center.

The flashes of simulated explosions merged with the ear-splitting sounds of a combat soundtrack. Smoke, cries of the wounded and simulated blood combined to create an unsettlingly intense environment to attempt to save lives. The afterevent briefing was almost as brutal as the simulated combat.

UH’s medical director, the Hadassah University Medical Center level 1 trauma unit head Prof. Avi Rivkind, has spearheaded many advances in trauma treatment. It was here that the team from United Hatzalah of Panama learned about the critical triage system utilized at Hadassah that separates the ambulatory from those going to ER, surgery or the trauma unit.

UH founder and president Eli Beer told the Panamanians: “You must take the lessons learned here back to your country and not only use it to save more lives but use it to teach and inspire others to save more lives.” The UH model is expected to spread further to other South American countries and beyond.
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