Systematic Review on Barriers to Access Opioid Analgesics for Cancer Pain Management from the Health Worker Perspective.

The increasing incidence of oncological diseases creates a corresponding need for effective cancer pain management (CPM). The lack of access to and availability of opioid analgesics in most countries leads to avoidable suffering. This systematic review aims to identify barriers to accessing opioids, as described in literature that reflects the perspective of health-care workers. A systematic literature search was performed in May 2018 and updated in December 2022, using search terms related to "cancer pain," "opioid analgesics," "access," and "health-care personnel." Medline, Embase, and PsycInfo were searched. Forty-two studies met the inclusion criteria. Principal barriers that have hindered licit access to medical opioids include regulatory, systemic, educational, patient-related, and societal. These barriers are rooted in a lack of adequate education about the importance and significance of appropriate CPM. Barriers were often mutually reinforcing. A interdisciplinary approach is required to overcome them. This research contributes to the important global health issue of unduly limited access to opioid analgesics. It provides interdisciplinary solutions in terms of guidelines to ensure that governments respect, protect, and fulfill the right to the highest attainable standard of health, which includes the relief of severe pain.

Developing a Screening Tool for Serious Health-related Suffering for Low- and Middle-Income Countries - Phase-1: Domain Identification and Item Generation.

Objectives: The Lancet Commission on Global Access to Palliative Care and Pain Relief reported significant levels of health-related suffering globally, with the highest incidence in the low- and middle-income countries. The report describes suffering as health-related when it is associated with illness or injury of any kind and suffering as serious when it cannot be relieved without professional intervention and when it compromises physical, social, spiritual, and/or emotional functioning. This paper describes the preliminary development phase of a tool for screening Serious Health-related Suffering (SHS) at individual patient level, suitable to the healthcare settings in India. The study was conducted by the National Cancer Grid-India, with support from the Indian Association of Palliative Care. Materials and Methods: Domain identification and item generation were conducted according to the recommendations for tool development by the American Psychological Association and World Health Organisation quality of life instrument. The consensus for domain questions and associated items was achieved using Delphi, nominal group technique, expert review, and polling. Results: The Phase-1 study for developing the screening tool for SHS contextualised to resource-limited settings generated a bilevel questionnaire. The initial level assesses and scores the physical, emotional, social, spiritual, and financial domains of health-related suffering. The next level assesses seriousness, through functional limitation and patient's preference. Conclusion: The generation of domains, items, and screening questions for health-related suffering and its seriousness completes the preliminary phase of developing the SHS screening tool applicable to a resource-limited healthcare setting. Field testing of the tool is being conducted as Phase-2 of this study, to validate it in clinical settings.

Oncology-Based Palliative Care Development: The Approach, Challenges, and Solutions From North-East Region of India, a Model for Low- and Middle-Income Countries.

BACKGROUND: Access to palliative care within healthcare systems of low- and middle-income countries (LMICs) has never been more pronounced than in current times. The Lancet Commission Report (2018) estimates that 80% of global serious health-related suffering (SHS), which demands access to palliative care for its relief, are in LMICs. Cancer is a major contributor to SHS and a rapidly growing burden in LMICs. Similar to many LMICs, cancer is a leading cause of death in India. The North-East Region (NER) of India has a high prevalence of cancer and paucity of services for cancer and palliative care. OBJECTIVES: To describe the strategies used to initiate and strengthen palliative care services integrated with the comprehensive cancer care initiatives in the state of Assam in NER. METHODS: After an initial assessment of the status of palliative care in the NER, a multipronged strategy was adopted that aligned with the WHO framework recommended for initiating palliative care services. A core team working with a government and private collaborative strategized and activated supportive policies, education, and training and improved access and availability to essential drugs, while implementing the components synchronously within the state. SIGNIFICANCE: This project demonstrates an informed regional adaptation of the WHO model. It highlights the strengths of integrating palliative care within cancer care program right from its inception. It emphasizes the sustainability of services activated across public healthcare systems, as compared with the donor- or champion-driven initiatives. The outcome of this project underlines the relevance of this model for LMIC regions with similar health systems and sociocultural and economic contexts.

The Palliative Care-Promoting Access and Improvement of the Cancer Experience (PC-PAICE) Project in India: A Multisite International Quality Improvement Collaborative.

Mentors at seven U.S. and Australian academic institutions initially partnered with seven leading Indian academic palliative care and cancer centers in 2017 to undertake a program combining remote and in-person mentorship, didactic instruction, and project-based learning in quality improvement (QI). From its inception in 2017 to 2020, the Palliative Care-Promoting Accesst and Improvement of the Cancer Experience Program conducted three cohorts for capacity building of 22 Indian palliative care and cancer programs. Indian leadership established a Mumbai QI training hub in 2019 with philanthropic support. In 2020, the project which is now named Enable Quality, Improve Patient care - India (EQuIP-India) focuses on both palliative care and cancer teams. EQuIP-India now leads ongoing Indian national collaboratives and training in QI and is integrated into India's National Cancer Grid. Palliative Care-Promoting Accesst and Improvement of the Cancer Experience demonstrates a feasible model of international collaboration and capacity building in palliative care and cancer QI. It is one of the several networked and blended learning approaches with potential for rapid scaling of evidence-based practices.

Concerns and Coping Strategies of Persons Under Institutional Quarantine During SARS-CoV-2 Pandemic.

INTRODUCTION: The World Health Organization has declared severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as a pandemic. The interventions employed by various health authorities in combating the infection may help in eliminating the threat; however, they have long-term cognitive and mental health effects on the population. AIMS: The primary objective was to assess the prevalent concerns and coping strategies and perspectives in persons suspected of SARS-CoV-2 infection under institutional quarantine in India during the period from April 2020 to May 2020. SETTING AND DESIGN: Its a cross-sectional observational study conducted in the National Cancer Institute, Jhajjar, India. METHODOLOGY: After ethical clearance, convenience sampling was done. Relevant demographic details were obtained. Health-care professionally administered questionnaire to assess psychological concerns and coping mechanisms. All statistics are deemed to be descriptive only. RESULTS: The most common physical concern was fever seen in 37% of respondents, followed by cough in 31% and sore throat in 29%. In terms of emotional concerns, 55.3% of respondents were worried and 43% were anxious and 33% were sad. About 80.6% of participants selected support from family and friends helped them cope during the institutional quarantine. 57% maintained a daily routine, 70% selected praying, and 45% used music as a coping strategy. Only 2% felt that they were unable to cope. CONCLUSION: It highlights that the psychological impact of illness on affected individuals should not be overlooked as it may have the potential to cause major psychiatric morbidity. It also provides a crucial assessment of their coping mechanisms.

Approaches and Best Practices for Managing Cancer Pain within the Constraints of the COVID-19 Pandemic in India.

Novel corona virus disease 2019 (COVID-19) is an ongoing pandemic that has impacted the entire world. The Indian government has responded strongly and very stringently to the crisis, through a nationwide lockdown. The health-care (HC) systems in the country are striving hard to maintain equitable care across illness spectra, while responding the emergencies imposed by the COVID-19 crisis. Under these circumstances, guidelines for managing several diseases including that for cancer care have been modified. As modified guidelines for cancer care have their focus on disease management, cancer pain management and maintaining continuity of care for patients with advanced progressive disease have taken a backseat in the available cancer care guidelines. This article describes the challenges, approaches to solutions with evidence-based practices that can be utilized to ensure competent management of cancer pain during the COVID-19 pandemic in India. It provides an overview of adapting to telehealth consultations for identification, evaluation and management of cancer pain, safe and rational use of analgesics and adjuvant drugs, recognizing and responding to holistic care needs and addressing the total pain, ensuring continuity of pain management, and strategies when complying with narcotic drug regulations, while ensuring safety of patients and HC providers.

Palliative Care in Coronavirus Disease 2019 Pandemic: Position Statement of the Indian Association of Palliative Care.

The global pandemic involving severe acute respiratory syndrome-coronavirus-2 has brought new challenges to clinical practice and care in the provision of palliative care. This position statement of the Indian Association of Palliative Care (IAPC) represents the collective opinion of the experts chosen by the society and reports on the current situation based on recent scientific evidence. It purports to guide all health-care professionals caring for coronavirus disease 2019 (COVID-19) patients and recommends palliative care principles into government decisions and policies. The statement provides recommendations for palliative care for both adults and children with severe COVID-19 illness, cancer, and chronic end-stage organ impairment in the hospital, hospice, and home setting. Holistic care incorporating physical, psychological, social, and spiritual support for patients and their families together with recommendations on the rational use of personal protective equipment has been discussed in brief. Detailed information can be accessed freely from the website of the IAPC http://www.palliativecare.in/. We hope that this position statement will serve as a guiding light in these uncertain times.

Palliative care clinicians and online education in India: a survey.

BACKGROUND: Whether online resources can facilitate spread of palliative care knowledge and skills in India is an urgent question given few providers and a large, ageing population. OBJECTIVES: We surveyed needs and feasibility regarding e-learning. METHODS: Indian, Australian and North American palliative care experts developed an electronic survey using Qualtrics, emailed to all registrants of the 2017 Indian Association of Palliative Care (IAPC) conference and distributed during the conference. RESULTS: Of 60 respondents (66% men, 60% doctors), most worked in hospitals and had oncology backgrounds, and 35% were from Kerala and Tamil Nadu. Most (90.9%) received palliative care training in India or overseas with 41% trained in a Trivandrum Institute of Palliative Sciences residential course (4-6 weeks). 17% completed the IAPC essential certificate and 22% had undertaken various distance learning courses. Interest in online training was substantial for most aspects of palliative care. CONCLUSION: There was a high level of interest and reported feasibility in taking a case-based online course. This pilot survey provides support for online case-based education in India, particularly among physicians.

The PEP Project - Synergistic Community Based Action in Prevention, Early Detection and Palliative Care, to Impact the Cancer Burden in India.

With unprecedented surge in the incidence and prevalence of cancer in India, it has become imperative to strengthen the workforce for all the domains of cancer care. A large proportion of the activity required for prevention as well as for palliation, lie outside of tertiary institutions, in the community. Palliative care (PC) as a field is expanding exponentially across the country and the service providers often engage and work actively within the local community in their region. This article describes the scope for reducing the cancer burden in the community, through capacity building of community based PC healthcare functionaries in the domains of Prevention, and Early detection of common cancers along with Palliative care - the PEP domains. It suggests aligning and enhancing the workforce already active within the community for PC, for screening, and if feasible, for early detection of common cancers. The article describes possibilities of initiating PEP activities and offers a set of screening questionnaire that may be used when engaged with family/ community setting. The aim is to integrate the activities done, to detect the need for palliative care in a family / community, with that required to detect need for evaluation of most common cancers- oral, breast and cervix. The PEP concept may be adapted to different levels, based on the team presence in the communities, degree of engagement, and availability of trainers and healthcare personnel.

When to Use Methadone for pain: A Case-Based Approach.

The case studies are written in this article to illustrate how methadone might be used for pain in the Indian context. These cases might be used for discussion in a multidisciplinary team, or for individual study. It is important to understand that pain requires a multidisciplinary approach as opioids will assist only with physical, i.e. neuropathic and nociceptive pain, but not emotional, spiritual, or relational pain or the pain of immobility. The social determinants of pain were included to demonstrate how emotional, relational, and psychological dimensions of pain amplify the physical aspects of pain. The case studies follow a practical step-wise approach to pain while undergoing cancer treatment, pain toward the end-of-life and needing longer acting opioid. Methadone in children, and methadone in conditions of opioid toxicity or where there is a need for absorption in the proximal intestine cases are included.

Civil Society-Driven Drug Policy Reform for Health and Human Welfare-India.

The lack of adequate access to opioids in India as analgesics and for agonist therapies, forces millions to live with severe unalleviated pain, or languish with suffering associated with drug dependence. Although India is a major opium exporter, the excessively prohibitive 1985 narcotics law formulated to control harmful use of drugs, impeded the availability and access to opioids for medical and scientific purposes. Amendment of this law in 2014 established a new national regulatory framework for improved access to essential opioid analgesics. This article reflects on key elements and processes that led to this landmark achievement. Unlike quick timelines associated with effecting policy reforms for law enforcement, realizing the 2014 drug policy change primarily to mitigate human suffering, was a 22-year-long process. The most exacting challenges included recognizing the multilayered complexities of the prior policy framework and understanding their adverse impact on field practices to chart an appropriate and viable path for reform. The evolution of an informal civil society movement involving health care professionals, lawyers, media, policy analysts, government officials, and the public was pivotal in addressing these challenges and garnering momentum for reform. The success of the effort for improving access to opioid medications was underpinned by a three-pronged strategy of 1) persuading the executive arm of the government to take interim enabling measures; 2) leveraging judicial intervention through public interest litigation; and 3) crafting a viable policy document for legislative approval and implementation. We hope our findings are useful for realizing drug policy reforms, given the current transformed global policy mandates emphasizing humanitarian, healthcare, and quality-of-life considerations.

Integration of Early Specialist Palliative Care in Cancer Care: Survey of Oncologists, Oncology Nurses, and Patients.

INTRODUCTION: Palliative care is usually delivered late in the course of illness trajectory. This precludes patients on active disease modifying treatment from receiving the benefit of palliative care intervention. A survey was conducted to know the opinion of oncologists, oncology nurses, and patients about the role of early specialist palliative care in cancer. METHODS: A nonrandomized descriptive cross-sectional study was conducted at a tertiary cancer care center in India. Thirty oncologists, sixty oncology nurses, and sixty patients were surveyed. RESULTS: Improvement in symptom control was appreciated by oncologists, oncology nurses, and patients with respect to pain (Z = -4.10, P = 0.001), (Z = -5.84, P = 0.001), (Z = -6.20, P = 0.001); nausea and vomiting (Z = -3.75, P = 0.001), (Z = -5.3, P = 0.001), (Z = -5.1, P = 0.001); constipation (Z = -3.29, P = 0.001), (Z = -4.96, P = 0.001), (Z = -4.49, P = 0.001); breathlessness (Z = -3.57, P = 0.001), (Z = -5.03, P = 0.001), (Z = -4.99, P = 0.001); and restlessness (Z = -3.68, P = 0.001), (Z = -5.23, P = 0.001), (Z = -3.22, P = 0.001). Improvement in end-of-life care management was appreciated by oncologists and oncology nurses with respect to communication of prognosis (Z = -4.04, P = 0.001), (Z = -5.20, P = 0.001); discussion on limitation of life-sustaining treatment (Z = -3.68, P = 0.001), (Z = -4.53, P = 0.001); end-of-life symptom management (Z = -4.17, P = 0.001), (Z = -4.59, P = 0.001); perimortem care (Z = -3.86, P = 0.001), (Z = -4.80, P = 0.001); and bereavement support (Z = -3-80, P = 0.001), (Z = -4.95, P = 0.001). Improvement in health-related communication was appreciated by oncologists, oncology nurses, and patients with respect to communicating health related information in a sensitive manner (Z = -3.74, P = 0.001), (Z = -5.47, P = 0.001), (Z = -6.12, P = 0.001); conducting family meeting (Z = -3.12, P = 0.002), (Z = -4.60, P = 0.001), (Z = -5.90, P = 0.001); discussing goals of care (Z = -3.43, P = 0.001), (Z = -5.49, P = 0.001), (Z = -5.61, P = 0.001); maintaining hope (Z = -3.22, P = 0.001), (Z = -4.85, P = 0.001), (Z = -5.61, P = 0.001); and resolution of conflict (Z = -3.56, P = 0.001), (Z = -5.29, P = 0.001), (Z = -5.28, P = 0.001). Patients appreciated improvement in continuity of care with respect to discharge planning (Z = -6.12, P = 0.001), optimal supply of essential symptom control medications on discharge (Z = -6.32, P = 0.001), follow-up plan (Z = -6.40, P = 0.001), after hours telephonic support (Z = -6.31, P = 0.001), and preferred place of care (Z = -6.28, P = 0.001). CONCLUSION: Oncologists, oncology nurses, and patients felt that integration of early specialist palliative care in cancer improves symptom control, end-of-life care, health-related communication, and continuity of care. The perceptions of benefit of the palliative care intervention in the components surveyed, differed among the three groups.

Pseudomonas bronchopulmonary infections in a palliative care setting.

Blood stream infections and pneumonia caused by Pseudomonas aeruginosa is associated with high mortality, especially in an immunocompromised host. A large section of the palliative care patient population has varied forms of compromised immunity due to advanced cancer or cancer treatment, organ failures, chronic autoimmune disorders, degenerative conditions, and acquired immunodeficiency syndrome. The lung is one of the most frequently involved organs in a variety of complications in an immunocompromised host and infection is the most common complication. P. aeruginosa is one of the most common pathogens associated with bronchopulmonary infections in an immunocompromised host. Routine radiological tests like chest X-ray may often be unyielding and an early and a prompt initiation of treatment reduces mortality and morbidity risk.

Clinical audit on "evaluation of special issues in adolescents with cancer treated in an adult cancer setting": an Indian experience.

BACKGROUND: Adolescents with cancer form a distinct group with special care needs. These patients are often cared in an adult supportive care setting where the special needs of adolescents are not met. AIM: To identify special issues in adolescents with cancer and to determine whether special needs of adolescents are met in an adult cancer setting MATERIALS AND METHODS: 10 adolescents with cancer were randomly chosen and retrospectively studied for physical, psychoscocial and emotional issues using an internally validated tool. RESULTS: Pain was the most common physical symptom seen in all 10 patients. 3 out of 10 patients were involved in decision making, 3 out of 10 patients had identity issues and 4 out of 10 patients had peer group isolation issues. Only 3 were aware of diagnosis and none were aware of treatment outcomes and mortality. 4 out of 10 had anxiety and depression and 3 out of 10 had body image issues. Sexuality, spiritual and existential issues were not explored in any of the patients studied. CONCLUSION: The outcomes of the study were in an adult oncology setting there was a poor recognition of key adolescent issues such as sexuality, body image, identity and peer group isolation. The psychosocial supports to these adolescents were minimal and spiritual and existential issues were not explored. The inferences drawn from this study suggested a need for multidisciplinary team approach oriented in handling adolescent care needs and preferably to have a dedicated space that will help the peer group to interact, bond and cope better with the illness.

Disparities in the contribution of low- and middle-income countries to palliative care research.

CONTEXT: Important aspects of the palliative care needs of patients from low- and middle-income countries (LMIC) are largely unexplored. About 44 million of the 56 million annual deaths worldwide occur in developing countries, and it is estimated that more than 33 million of those concerned would benefit from palliative care. In this context, the understanding of specific social and cultural needs is fundamental to the development of appropriate health policy and clinical practice concerning palliative and end-of-life care. OBJECTIVES: This study aims to answer the question: what are the contributions, in terms of generation of knowledge, of LMIC to the published palliative care literature? METHODS: A bibliometric analysis was conducted in Medline and EMBASE (to June 2008). Articles were included when either the first author (institutional affiliation or contact address) or the data collection was derived from LMIC, as defined by criteria of the World Bank. Excluded were articles done in migrant and non-palliative care populations. RESULTS: The literature search resulted in 845 references. In total, 245 articles coming from LMIC were identified, being published by 34 LMIC (27.3% of LMIC). The first publications appeared in 1982. The study shows a rather modest contribution of publications from LMIC. However, the volume of publications within LMIC is distributed unequally: upper-middle-income countries published almost half of the articles (46.9%), whereas only 11% of the publications came from low-income countries. In contrast, 104 LMIC (72.7% of LMIC) do not have any registered publications. Surprisingly, 25% of the articles with data from LMIC have been done and published by high-income countries. Reasons for the underrepresentation, as well a possible correction of this imbalance, are discussed. CONCLUSION: Palliative care research should be a priority in LMIC, where many patients could benefit tremendously from it, and publication of findings in these countries should be encouraged.