Background & Aims
Global inequities in access to morphine remain a tragic reality.(1) Barriers to adequate pain relief for children, adolescents and young adults with cancer include regulatory and legal barriers, attitude and knowledge barriers, and economic and procurement impediments.(2,3)
More than 21 million children need access to palliative care globally, including access to pain relief, yet it is estimated that only 5-10% have access, and more than 98% of them reside in developing regions.(4) Before meaningful change can take place, a deep understanding of the barriers to pain relief for children is needed, to inform policy change and advocacy.
In this pilot, we surveyed an international group of workshop participants regarding access to essential medicines for managing children’s pain in palliative care, as a preliminary phase before engaging in a large-scale international survey of providers caring for children with pain.
Methods
Participants to a workshop on equitable access to medications for pain in the practice of pediatric palliative care, under the umbrella of the St. Jude Children’s Research Hospital Global Alliance Convening in December 2023, were surveyed regarding access to specific medications for pain relief and perceived barriers. Participants were asked to answer yes/no regarding access to each of the following: opioids (morphine, fentanyl, tramadol, methadone, oxycodone, meperidine, hydrocodone, codeine, and combined opioid-nonopioid preparations); non-opioids (acetaminophen, ibuprofen, celecoxib, ketorolac, metamizole, and diclofenac); and adjuvants (gabapentin, pregabalin, amitriptyline, and ketamine). Participants were asked to rank in order of perceived relevance the following categories of barriers: lack of access to opioids, lack of pediatric formulations, stock outs, national laws, institutional regulations, high cost, healthcare providers or parental and community misconceptions.
Results
Participants (n=14) represented 11 countries (Cameroon, Colombia, Ethiopia, Jordan, Mexico, Pakistan, Philippines, South Africa, Ukraine, Uganda, Zambia), from all 5 WHO regions. Available opioids were, in descending order, tramadol (100%), morphine (92.9%), combination opioid-nonopioid (61.5%), fentanyl patch (57.1%), meperidine (54.5%), oxycodone (46.2%), methadone (45.5%), codeine (30.8%), and hydrocodone (9.1%). Non-opioids were available: acetaminophen and ibuprofen (100%), diclofenac and celecoxib (84.6%), metamizole (54.5%), and ketorolac (40%). Adjuvants were available: ketamine (76.9%), gabapentin and pregabalin (66.7%), and amitriptyline (58.3%).
The most relevant, frequently reported barriers to access to adequate pain relief were: lack of access to opioids (including pediatric formulations), national laws (including licensing restrictions), parental and community misconceptions, and healthcare providers misconceptions (educational needs).
Conclusions
In our sample, access to medications for pain was 100% for basic non-opioid analgesics (acetaminophen and ibuprofen) and for a single opioid, tramadol. Nevertheless, the use of acetaminophen and ibuprofen in the context of pediatric pain related to cancer may be limited by concerns of masking fever or bleeding risks, respectively, and the efficacy of tramadol may be limited by its weak opioid effect. Difficulties with obtaining pediatric formulations have been identified and education of pharmacists in local preparation of morphine solution may improve availability. The need for policy change and advocacy to improve opioid access for pediatric cancer may be inferred from the fact that limiting national laws were identified as a substantial barrier to access. Opioid-related misconceptions of healthcare providers and of families/communities remain relevant obstacles to adequate pain relief, in need of educational interventions.
References
1. WHO Report. Left behind in pain: Extent and causes of global variations in access to morphine for medical use and actions to improve safe access. June 15, 2023.
2. WHO guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents. Geneva: World Health Organization. 2018.
3. WHO Report. Integrating palliative care and symptom relief into paediatrics: A WHO guide for health care planners, implementers and managers. 2019
4. Knaul FM, Farmer PE, Krakauer EL, De Lima L, Bhadelia A, Jiang Kwete X et al. Alleviating the access abyss in palliative care and pain relief – an imperative of universal health coverage: the Lancet Commission report. Lancet. 2018;391(10128):1391–454.
Presenting Author
Doralina L. Anghelescu
Poster Authors
Doralina Anghelescu
MD
St Jude Children's Research Hospital
Lead Author
Julia Downing
International Children's Palliative Care Network (ICPCN)
Lead Author
Justin Baker
Stanford Medical School
Lead Author
Ximena Garcia
St. Jude Children's Research Hospital
Lead Author
Marta Salek
St. Jude Children's Research Hospital
Lead Author
Michael McNeil
St. Jude Children's Research Hospital
Lead Author
Topics
- Pain in Special Populations: Infants/Children