Clark Joseph, Salins Naveen, Daniel Sunitha, Currow David C, Jones Lesley, Pearson Mark, Bunton Robin, Mankel Joseph, Braithwaite Christopher, Gilchrist Marianne M, Johnson Miriam J
Wolfson Palliative Care Research Centre, Allam Medical Building, University of Hull, Hull, United Kingdom.
Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, India.
PLOS Glob Public Health. 2023 Sep 21;3(9):e0002401. doi: 10.1371/journal.pgph.0002401. eCollection 2023.
Opioids (e.g. morphine) are affordable, effective interventions for cancer-related pain. However, equity of access to this key medication remains a global challenge, particularly in low- and middle-income countries. We aimed to explore views of palliative care providers and public-representatives about opioid analgesia access in two States in India. We conducted a qualitative study using semi-structured interviews. Transcribed audio-recordings were subjected to thematic analysis using a Framework Approach. Palliative care providers and public-representatives were purposively sampled from services reporting consistent opioid availability and prescribing (≥4kg per annum) from Karnataka and Kerala. Twenty participants (doctors (10), nurses (4), pharmacists (2), service managers (2) and public-representatives (2) were interviewed. Three themes were identified: 1) Attitudes and awareness: opioid treatments are perceived as end-of-life (last days/weeks) interventions; fears of addiction and misunderstanding of pain management goals limit access. 2) Expected and unexpected inequities: patients/carers from lower socioeconomic strata accept doctor recommendations if opioids are affordable, more educated patients/families have reservations about opioids, delay access and perceive expensive medicines as better. Non-palliative care specialist doctors have negative entrenched views and require specialist training. 3) Experiential learning-positive experiences can positively alter attitudes (e.g., participants in Kerala report improved attitudes, awareness and understanding influenced by exposure and community awareness, but experience can also reinforce perceptions as end-of-life care. Entrenched negative views are reinforced by poor experiences while positive experiences improve attitudes. To promote access, opioid prescribing must be needs-based rather than prognosis-based. Addressing the lack of training for non-palliative care workforce would help overcome a major barrier.
阿片类药物（如吗啡）是治疗癌症相关疼痛的经济有效干预措施。然而，获取这种关键药物的公平性仍是一项全球性挑战，在低收入和中等收入国家尤为如此。我们旨在探讨印度两个邦的姑息治疗提供者和公众代表对阿片类镇痛药物可及性的看法。我们采用半结构式访谈进行了一项定性研究。对转录的录音使用框架分析法进行主题分析。从卡纳塔克邦和喀拉拉邦报告阿片类药物持续供应和处方量（每年≥4公斤）的服务机构中，有目的地抽取了姑息治疗提供者和公众代表。采访了20名参与者（医生（10名）、护士（4名）、药剂师（2名）、服务经理（2名）和公众代表（2名））。确定了三个主题：1）态度和认知：阿片类药物治疗被视为临终（最后几天/几周）干预措施；对成瘾的恐惧和对疼痛管理目标的误解限制了可及性。2）预期和意外的不公平：如果阿片类药物价格可承受，社会经济地位较低阶层的患者/护理人员会接受医生的建议，受教育程度较高的患者/家庭对阿片类药物有所保留，延迟获取并认为昂贵的药物更好。非姑息治疗专科医生有根深蒂固的负面看法，需要接受专科培训。3）经验性学习——积极的经历可以积极改变态度（例如，喀拉拉邦的参与者报告称，受接触和社区认知的影响，态度、认知和理解有所改善，但经验也可能强化临终关怀的观念。糟糕的经历会强化根深蒂固的负面看法，而积极的经历则会改善态度。为促进可及性，阿片类药物的处方必须基于需求而非预后。解决非姑息治疗工作人员缺乏培训的问题将有助于克服一个主要障碍。
