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Countries need to be cognizant of the suffering of patients in pain when formulating plans to cut down on prescription drug abuse, according to the new World Health Organization’s (WHO) guidelines on balanced drug control policies.

The guidelines, “Ensuring Balance in National Policies on Controlled Substances,” aim to strike a balance between preventing substance abuse and dependence, and helping people in pain get needed access to controlled medicines, says Willem Scholten, Team Leader, Access to Controlled Medicines at the WHO.

“If you restrict prescriptions for people who need them, you’re not addressing the real problem and you are creating a new problem of untreated pain,” Scholten says. “In many cases there is no good alternative to opioid pain relievers, so you cannot just cut patients off who need them for pain relief.”

WHO estimates that every year 5.5 million terminal cancer patients worldwide suffer moderate to severe pain that is not managed at all. Additionally, tens of millions of people experience unrelieved pain from diseases and conditions other than cancer. These people require access to medicines, many of which are controlled, to relieve pain. The WHO guidelines note that there is a broad consensus that opioid analgesics are indispensable for the treatment of moderate to severe pain.

“While the majority of the world has no good access to pain treatment, even in developed nations many patients say they are not sufficiently treated for their pain. A recent study showed that in the Netherlands, a country considered to be reasonably good at pain management, 79% of patients believed their pain not to be well addressed [1],” Scholten notes.

The guidelines state that while misuse of controlled substances poses a risk to society, governments should not set up a system of control that bars their availability for medical and scientific purposes, or interferes in their legitimate medical use for patient care.

There has been a substantial increase in the use of opioids in developed countries, but the availability of these drugs in developing countries has remained very low and is far from adequate in meeting the medical needs of their populations, according to the WHO.

In some countries, laws and regulations intended to prevent the misuse of controlled substances are overly restrictive and interfere with patient access to medical treatment with such substances. The WHO says that such situations can arise when not enough attention is paid to the impact of regulations on the supply of controlled substances for medical purposes.

One issue that governments should pay closer attention to is insurance coverage for pain medication, according to Scholten. “The cost of medication is an issue that can impact use and abuse of pain medicines. For instance, some doctors might prescribe medication that is less expensive so patients can have access to it, but at the same time harder to find the right dose. If they themselves are not properly trained in the use of that medication, this can lead to overdoses.”

Physician training is very important in a balanced drug policy, Scholten emphasized. “Doctors need to be well trained in how to prescribe and dose pain medications, while keeping in mind that patients might abuse these drugs. They need to evaluate patients for risk factors for abuse, and those who are found to be at risk of abusing prescription drugs can be monitored more closely.”

The WHO recommends that all physicians should be sufficiently trained to assess the levels of pain and to treat pain, and that the ability to prescribe opioids should not be restricted to a small number of medical specialties such as oncology. The guidelines state that the amount of medicine prescribed, appropriate formulation and duration of treatment should be the practitioner’s decision, based on an individual patient’s needs and on sound scientific medical guidance. The report advises against legal restrictions on the maximum daily dosage of strong opioids, or limiting the use of strong opioids only to certain conditions such as cancer pain or terminal cancer pain.

The guidelines include a Country Assessment Checklist designed to help government officials analyze their national drug control policies and the extent to which the WHO guidelines are adhered to in their country.

1. Bekkering GE et al, Epidemiology of chronic pain and its treatment in the Netherlands. The Netherlands J of Med. 2011; 69(3): 141 – 152

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