Elsevier

The Lancet Oncology

Volume 14, Issue 4, April 2013, Pages e176-e182
The Lancet Oncology

Series
Improving access to analgesic drugs for patients with cancer in sub-Saharan Africa

https://doi.org/10.1016/S1470-2045(12)70343-1Get rights and content

Summary

WHO expects the burden of cancer in sub-Saharan Africa to grow rapidly in coming years and for incidence to exceed 1 million per year by 2030. As a result of late presentation to health facilities and little access to diagnostic technology, roughly 80% of cases are in terminal stages at the time of diagnosis, and a large proportion of patients have moderate to severe pain that needs treatment with opioid analgesics. However, consumption of opioid analgesics in the region is low and data suggest that at least 88% of cancer deaths with moderate to severe pain are untreated. Access to essential drugs for pain relief is limited by legal and regulatory restrictions, cultural misperceptions about pain, inadequate training of health-care providers, procurement difficulties, weak health systems, and concerns about diversion, addiction, and misuse. However, recent initiatives characterised by cooperation between national governments and local and international non-governmental organisations are improving access to pain relief. Efforts underway in Uganda, Kenya, and Nigeria provide examples of challenges faced and innovative approaches adopted and form the basis of a proposed framework to improve access to pain relief for patients with cancer across the region.

Introduction

WHO has estimated that worldwide cancer incidence will increase from 12 million new cases in 2008 to 26 million per year by 2030.1 Cancer burden in developing countries is growing rapidly2 and incidence in sub-Saharan Africa is expected to exceed 1 million by 2030.1 Roughly 80% of cancer cases in developing countries are in advanced stages at the time of diagnosis because of late presentation to health facilities and poor access to diagnostic technology.2 Despite documented successes in cancer treatment and control programmes globally,3, 4 large differences in mortality persist, with survival rates in developing countries often less than half those of developed countries.5 The need for improved access to effective cancer pain treatment will become increasingly acute in coming years.

WHO recommends opioid analgesics for the treatment of moderate to severe pain,6 such as that of patients with advanced cancer, and regards morphine as an essential drug (figure 1).7 According to WHO data,8, 9 about 552 100 people died of cancer in sub-Saharan Africa in 2009 and studies have shown that roughly 80% of deaths from cancer need pain treatment.10 Opioid analgesics are also used for pain in AIDS patients: 1·84 million people died from HIV/AIDS in the region in 20098, 9 and pain treatment is needed for roughly 50% of deaths from HIV/AIDS.10 Based on these numbers, in sub-Saharan Africa in 2009 pain treatment was needed by about 441 682 people who died of cancer and about 921 800 people who died of HIV/AIDS.

Governments in sub-Saharan Africa reported an overall annual consumption of 720 kg of opioids per year across the whole region for the years from 2007 to 2009 (with consumption of different opioids standardised, by potency, to morphine-equivalent volumes for summation).11 Based on the estimation that, on average, patients who need pain treatment at the end of life consume 67·5 mg of morphine daily for 3 months,10 720 kg is enough to provide treatment for about 116 600 people (ie, about 8·6% of the total number of painful deaths from cancer or HIV/AIDS). However, South Africa (an upper-middle-income country) consumed 71% of the opioids in the region.11 Therefore, only 205 kg of opioids were consumed per year by the remaining countries—enough to treat about 33 000 people (ie, about 2·8% of the estimated 1·17 million annual painful deaths from cancer or HIV/AIDS).

Since opioids are also used to treat pain in patients with other indications for which data are not routinely collected across countries (eg, diseases other than HIV/AIDS or cancer, traumatic injuries, addiction disorders, surgeries, and non-fatal cancer or HIV/AIDS), estimation of how many cancer patients in pain were treated is difficult. However, if all opioids in each country were used to treat only painful cancer deaths (excluding the relative excess consumed in South Africa and Mauritius for patients with other indications), 54 768 people would have been treated, leaving 386 914 (88%) patients with untreated cancer pain. In view of the conservative nature of these calculations, the true proportion of cancer patients with untreated pain is probably much higher.

Section snippets

Access to pain relief

Several initiatives have been created across Africa for the provision of palliative care, but scale-up has been limited by lack of access to affordable, effective, pain-relieving drugs. In countries where palliative care initiatives have become established, providers have noted that the most affordable opioid is oral morphine that is reconstituted locally with imported morphine powder, water, preservative, and a food dye to show the strength of the formulation.12

Before 1990 there were only two

Framework for improvement of access to pain relief

The past 8 years have seen an expansion throughout Africa of efforts to improve access to pain relief for cancer patients. These efforts have been led by ministries of health and health-care workers and supported by national palliative care associations, regional networks such as Hospice Africa and the African Palliative Care Association, and international supporters such as the Worldwide Palliative Care Alliance, the Foundation for Hospices in Sub-Saharan Africa, and the Open Society

Uganda

Uganda has a population of 33 million,8 with 87% living in rural areas.21 It has one physician for every 8547 people and the per head gross national annual income is US$420.18, 21 About 16 200 deaths from cancer and 109 700 from HIV/AIDS occurred in 2009.8, 9 The average annual morphine-equivalent opioid analgesic consumption from 2007 to 2009 was 27·8 kg,11 which is enough to treat about 7% of the roughly 68 000 deaths in pain from cancer or HIV/AIDS.

Morphine is controlled under the National

Conclusions

Millions of people in low-income and middle-income countries do not benefit from the advances in cancer treatment achieved in high-income countries over the past few decades. The substantial disparity in cancer outcomes between high-income and lower-income countries has been called the cancer divide.35 Improving timely diagnoses and increasing the availability of expensive radiotherapy machines and chemotherapy drugs in sub-Saharan Africa will need substantial external funding and a long time

Search strategy and selection criteria

We searched PubMed using the terms “pain”, “cancer”, and “Africa”. We included relevant articles published in English from 1980 to July, 2012.

References (35)

  • Global Health Observatory data repository

  • The global burden of disease: 2004 update

    (2008)
  • KM Foley et al.

    Pain control for people with cancer and AIDS

  • Narcotic drugs: estimated world requirements for 2011—statistics for 2009 (E/INCB/2010/2)

    (2011)
  • A Merriman et al.

    Palliative medicine: pain and symptom control in the cancer and/or AIDS patient in Uganda and other African countries, 5th edn

    (2012)
  • Ensuring balance in national policies on controlled substances: guidance for availability and accessibility of controlled medicines

    (2011)
  • Report of the International Narcotics Control Board for 1995: availability of opiates for medical needs

    (1996)
  • Cited by (0)

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