Cancer Pain Relief

Despite substantial effort and expenditure, at least one-third of patients diagnosed with cancer in high-income countries (HICs) die of their disease within a few years of diagnosis (National Cancer Institute 2009). In low- and middle-income countries (LMICs), two-thirds succumb, because the cancer types prevalent in LMICs tend to have poor prognoses, most cancers are advanced when diagnosed, and even for curable cancers few people have access to effective cancer treatment. For rich and poor everywhere, cancer can cause pain and severe distress, especially during the last few months of life. Cancer-related pain is not the exclusive domain of those who die of cancer. Even many who are cured of their disease live with the long-term effects of the disease and its treatment; many of them live with pain, as do people with a range of chronic conditions other than cancer. For the majority of cancer patients in LMICs, the most effective and feasible intervention for pain control is medication. For mild pain, over-the-counter, inexpensive analgesic medicines can provide adequate relief. When these nonopioids no longer relieve pain, then weak opioids, such as codeine, may work. Cancer patients most often experience worsening pain as their cancer progresses; 70–80 percent progress to severe pain, which only strong opioid medicines can relieve. Other approaches are effective for specific pain indications; the most widely applicable are palliative radiotherapy and surgery. Chemotherapy, neurologic, psychological, and other approaches also can be effective (see Foley and others 2006 for a comprehensive listing). All but analgesic medications and psychological approaches require access to well-developed health care facilities; these are usually available in large urban areas of middle-income countries (MICs), although not necessarily in sufficient numbers, but they may not exist at all in low-income countries (LICs). For example, many countries have no radiotherapy centers, and many have only one center (International Atomic Energy Agency Directory of Radiotherapy Centres, http://www-naweb.iaea.org/nahu/dirac/default.asp). Palliative surgery and palliative radiotherapy are discussed further in chapters 13 and 14, respectively. The focus of this chapter is pain control medication, which can relieve most cancer pain and can be delivered at home, even in remote areas. Since 1990, the World Health Organization (WHO) and other bodies have offered definitions of palliative care. These definitions differ in specifics but share a common vision of care that emphasizes effective pain relief and a team approach to care throughout the course of the illness (Cleary and Carbone 1997; Foley and Gelband 2001; Morrison and Meier 2011; WHO 1990). The primary goal of palliative care is improving the quality of life of patients and those around them; it is not the prolongation of life or the hastening of death. Access to pain relief has been declared a human right (Brennan, Carr, and Cousins 2007; Gwyther, Brennan, and Harding 2009; International Pain Summit of the International Association for the Study of Pain 2011; Lohman, Schleifer, and Amon 2010). From a global perspective, the growth of palliative care has been largely limited to HICs, which also rank high on the Human Development Index (HDI). The availability of palliative care—using the availability of opioid medicines as a surrogate—is correlated with a country’s HDI. At the low end, the availability is almost nil, and repeated surveys have shown that this availability changed only marginally between 2006 and 2011 (Gilson and others 2013). In the previous edition of Disease Control Priorities in Developing Countries, Foley and others (2006) documented the global problem of low access to adequate pain relief in LMICs. Since then, a few countries have improved access, but these accomplishments are sporadic; in many countries, the change is negligible. Now, there is both cause for optimism and the view of a long road ahead. Efforts to support leaders in reforming policy and clinical practice in LMICs have grown and provide a basis for improvements (Cherny and others 2013; Cleary, Radbruch, and others 2013). This chapter describes the current state of pain relief in LMICs, consistent with WHO’s use of opioid consumption as a surrogate for access to palliative care in the Global Monitoring Framework for Noncommunicable Diseases (WHO 2013a). We describe the gaps in pain control access across countries, analyze the barriers to improving its delivery, and describe the costs and benefits that might accrue from removing the barriers. Evidence summarized in this chapter focuses on the modest costs and substantial benefits of providing pain control, and it supports increased efforts in the short term. Pain control medication and other aspects of palliative care can lead, rather than follow, increased efforts in cancer treatment, relying on interventions that are part of a more advanced cancer control and treatment infrastructure.