Purposes for cancer treatment in Latin America
There are many challenges for the treatment of cancer pain in Latin America; effective application of opioid use is an example. (1)Joranson DE. Improving availability of opioid pain medications: testing the principle of balance in Latin America. J Palliat Med 2004; 7: 105–14. Morphine and other opioids are necessary to control severe pain, and WHO it has included them in the list of essential medicines. (2)WHO. Health topics. Essential medicines. http://www.who.int/selection_medicines/list/en/ (accessed Jul 1, 2012). Apart from the indications Defined medical drugs, these drugs have potential for abuse and have been classified as controlled substances by the 1961 Single Convention on Narcotic Drugs. (3)International Narcotics Control Board. Single convention on narcotic drugs. http://www.incb.org/incb/en/narcotic-drugs/1961_Convention.html (accessed Feb 13, 2013).
Most Latin American countries are signatories to this agreement, which stipulates that governments have a double obligation to guarantee the availability of these drugs for medical use, and to control and prevent diversion and abuse (The International Board of Control Narcotic Drugs is the independent body in charge of monitoring, executing and supervising the distribution of narcotics).
The WHO Pain and Policy Study Group reports on the use of opiates worldwide and has shown that not all countries have the same availability of opioid medications. (4)International Narcotics Control Board. World Health Organization population data by Pain and Policy Studies Group. Madison, WI, USA: University of Wisconsin / WHO Collaborating Center, 2012. Argentina and Brazil have the highest medical use of opioids, while that Honduras and Bolivia have a very low consumption (figure 5). Other data reported by doctors in Brazil, Argentina, Mexico, Cuba and Peru suggest a good availability of fast-acting morphine and mild pain relievers at the institutional level. (5)Torres I. Determinants of quality of advanced cancer care in Latin America — a look at five countries: Argentina, Brazil, Cuba, Mexico and Peru. Houston, TX, USA: University of Texas Health Science Center at Houston, School of Public Health, 2004. However, the limited availability of long-acting opioids and other step 3 pain relievers (according to the WHO pain ladder) is of particular concern, as they are critical to the proper management of pain in patients with advanced diseases. (6)Torres I. Determinants of quality of advanced cancer care in Latin America — a look at five countries: Argentina, Brazil, Cuba, Mexico and Peru. Houston, TX, USA: University of Texas Health Science Center at Houston, School of Public Health, 2004. Despite some recent advances in the use of opioids to control pain in Latin America, average consumption remains well below world levels, which translates into inadequate pain control. (7)Callaway M, Foley KM, De Lima L, et al. Funding for palliative care programs in developing countries. J Pain Symptom Manage 2007; 33: 509–13.
Entities such as the Pain and Policy Studies Group (PPSG) and the International Association of Hospices and Palliative Care (IAHPC) have worked to identify obstacles to adequate supply of opioids in different countries. Factors identified include restrictive legislation, inadequate health systems, poor knowledge among health professionals about the use of these drugs, fear of addiction, the adverse effects of the drug, and excessive regulatory bureaucracy. The PPSG and the IAHPC have organized workshops in Colombia, Peru and Chile with the aim of bringing doctors, Ministers of Health, insurers and patients together to start a dialogue on the challenges they face, and to create solutions applicable to each country. (8)Florez S, Leon MX, Rubiano L, et al. Availability and barriers to access opioids in Colombia: experience of a university institution. Univ Méd Bogotá (Colombia) 2011; 52: 140–48. (9)León MX , De Lima L, Flórez S, et al. Improving availability of and access to opioids in Colombia: description and preliminary results of an action plan for the country. J Pain Symptom Manage 2009; 33: 759–66. La forma de Health professionals in pharmacology and in the administration of opioids and other analgesics and the management of prescriptions are important actions that are needed to achieve optimal use of these medications.
Access to palliative radiotherapy varies in Latin American countries. Guyana, Belize, Suriname and Haiti do not have radiotherapy services. A survey by the IAEA on radiotherapy resources in Latin America showed that 75% of radiotherapy centers are in the largest cities and that postgraduate training in palliative care and the role of palliative radiotherapy is insufficient, as Despite the fact that the vast majority of physicians care for patients with palliative care needs. (10)Wenk R, Bertolino M, De Lima L. Opioid analgesics in Latin America: the barrier of accessibility overcomes availability. Palliative Medicine 2004; 11: 148–51
Conclusion
Palliative care services have progressed in recent years in Latin America; however, limited access to care and medications continues to exist for patients with advanced cancer. Palliative care must be a priority for health authorities. Palliative care education and training should be supported. Countries need to improve access to pain relievers to alleviate end-of-life suffering, and to do this they must overcome persistent fears that opioids will be diverted to illegal use. (11)Torres Vigil I, Aday LA, De Lima L, Cleeland CS. What predicts the quality of advanced cancer care in Latin America? A look at five countries: Argentina, Brazil, Cuba, Mexico, and Peru. J Pain Symptom Manage 2007 ; 34: 315–27 To break these barriers, it is necessary to strengthen the training of health providers, promote research, build capacity, and give communities the right to achieve these goals. Health service managers must be pressured to ensure the safe delivery and distribution of opioid pain relievers. Ongoing efforts to promote healthcare models that include palliative care in conjunction with oncology services are essential.