Availability and Accessibility of an Essential Medicine. Key Issues Around Opioid Pain Relief for Palliative Care in Georgia

Abstract

Background. Opioids are a mainstay for the alleviation of medium-strong pain. Nevertheless, if opioids are taken inappropriately, they have the ability to induce dependence on them. Their manufacture, import, distribution, prescription, stocking, dispensing and administering are therefore subject to (international) control mechanisms. Unfortunately, opioid control often impedes its access for medical purposes. This study explored barriers to opioid access in Georgia, an Eastern-European country that to some extent introduced opioid-related legislative changes. The study’s aim was to identify issues around impediments to accessing opioid pain relief and recommend ways to overcome these barriers. The specific objectives were fourfold:

 1) get an overview of the existing knowledge base around barriers to opioid access;

 2) critically review the present legislation/policies in the field of medical opioid control/use;

3) seek expert opinion of relevant stakeholders;

4) provide recommendations. Methodology. A mixed methods approach with data triangulation was selected: literature review, background documentary analysis and a subsequent focus-group discussion (FGD). Data analysis took place through categorizing/indexing and subsequent coding/charting. Ethical approval was obtained from both LSHTM and the National Center for Disease Control and Public Health in Georgia. Results.

- Thirty-six publications were identified for data extraction. A common concern is that despite advanced medical knowledge on pain, access to safe and rational use of opioid analgesics remains problematic.

- The administrative frame in which opioid access in Georgia is regulated showed certain ambiguities/inconsistencies.

-- FDG main insights per barrier type:

1. I) lack of knowledge: myths and misconcep tions, e.g. morphine mostly administered at final stage of life establishing an apparent causal relationship between inception of morphine and death;
2. II) issue of side-effects: prudence leading to underdosage, NSAID pharma-lobby;

III) fear of dependence and tolerance: opiophobia delaying inception of opioid treatment;

1. IV) healthcare system barriers: police stations’ role in dispensing opioids, limited opioid formularies, lack of palliative care specialists, governmental reluctance to promote medical use, difference urban-rural service provision;
2. V) legislation: issue of prescribers, legislative inconsistencies. Issues to be addressed based on key findings:

• Access to opioids as it remains problematic and the barriers are interrelated, occur often simultaneously;
• Implementation of the reformed legislation, which is weak;
• Pharma-lobby for NSAIDs which hinders medical use of opioids; • Knowledge base needs to be strengthened;
• Lack of time (physicians);
• Opioid formulary availability should be expanded;
• Governmental support to integrate palliative care in Universal Health Coverage (UHC) needs strengthening.

Conclusions, Significance of work. From the EECA-related literature and the FGD it became clear that the ‘war on drugs’ is still waging in Georgia, Armenia, Ukraine and Russian Federation, despite the fact that certain legislative changes have been pursued and partly implemented. The FGD yielded new insights on barriers: increasing NSAID pharma-lobby, lack of time for physicians to keep abreast of legislative changes and progress in pain management. The study also clearly showed that barriers to opioid access occur concurrently and are often synergizing. The recommendations of this research are relevant and timely as Georgia has taken the road towards UHC. In 2014, the World Health Assembly adopted a resolution on ‘Strengthening of palliative care as a component of comprehensive care throughout the life course’, seen as the ethical responsibility of health systems.