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Nandini vallathvienna final

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Striving for equity in the treatment of pain Nandini Vallath WHO CC for Training and Policy on Access to Pain Relief, India Side Event - International Doctors for Healthier Drug Policies Commission on Narcotics Drugs, UN, Vienna
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Page 1: Nandini vallathvienna final

Striving for equity in the treatment of

pain Nandini Vallath

WHO CC for Training and Policy on Access to Pain Relief, IndiaSide Event - International Doctors for Healthier Drug Policies

Commission on Narcotics Drugs, UN, Vienna

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Opioids in Acute

& Chronic Pain

Cancer

Non-Cancer

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120 countries with grossly inadequate access and availability

HRW Survey

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• 96% adults and 99% children who require opioids DO

NOT have access to it

Unbearable Pain ….Human Rights Watch report – 2010Duthey B, Scholten W: J of Pain and Symptom management 2013

http://www.nacoonline.org/QuickLinks/HIVData

UNMET NEED FOR PAIN RELIEF1/6th of world’s population

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Inequity in the treatment of pain

Does drug policy have a role?

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Inequity in the treatment of pain

• India a major producer

• Regulatory obstacles became obvious in the 1990s

• Doctors Taxation department

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Central Bureau of Narcotics Ministry of Finance

National Competent Authority

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18th -19th centuryOpium as trade crop

• Need for monopoly dictated the policy language

19th -20th centuryOpioids as drug for abuse

• Need to eradicate drug abuse dictated the policy language

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Medical use NOT within

policy language

Poor stockingUnder-treatment FearPoor demand

Prohibitory orientation of policies

impacted Knowledge, Attitudes,

Priorities and AVAILABILITYLack of Job mandate for NCAfor ensuring availability

Complex procurement, procedures,prescriptions

Doctors No Training, Experience in using Opioids

Misconceptions about opioid benefits / risks

Threat of Harsh punishments

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International Narcotics Control Board

Central Bureau of Narcotics Ministry of Finance

Production at Govt. Factories

Quotas to Manufacturers

Opioid Consumption

Mandate for Regulations

Pain Relief Providers

Narcotics Control Bureau Ministry of Home Affairs

Enforcement of drug laws

Distribution System in India

1203/05/2023

Availability of essential narcotics is NOT a

mandate at any of NCA office!!

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Post NDPS Act 1985, Morphine consumption in india ↓ by 97% [716 Kg 18 Kgs]

Dr Nandini Vallath 13

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J Cleary et al Annals of Oncology - Vol 24 (11) Dec 2013

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Basis for National Drug Policies

• Ensure availability of drugs for medical and scientific

use

• “the medical use of narcotic drugs continues to be

indispensable for the relief of pain and suffering… adequate

provision must be made to ensure the availability of narcotic

drugs for such purposes.” Preamble, p. 13

• Prevent against diversion and abuse

• “addiction to narcotic drugs constitutes a serious evil for the

individual and is fraught with social and economic danger to

mankind…” Preamble, p. 13

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18th -19th centuryOpium as trade crop

• Need for monopoly dictated the policy language

19th -20th centuryOpioids as drug for abuse

• Need to eradicate drug abuse dictated the policy language

20th -21st centuryOpioids as medicine

• Need to improve access for medical use to dictate policy language

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AMENDED

Step1 Supportive Policy

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Supportive policies

Ensured and SAFE access and availability of essential drugs

Poor access and availability of essential drugs

We are here..

Many other countries

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What did it take for policy reform in India?

• Acknowledging Untreated pain as a major public health issue

• Awareness of the contribution of policy language to availability

• 25 years of efforts

• Support ……lots and lots of it

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Teachers

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Policy Analysis

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GovernmentCivil Society Alliance

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Litigation

Draft Proposalof

National Program for Palliative Care

for12th plan (2012-17)

Directorate General of Health ServicesMinistry of Health & Family Welfare

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2014 Amendment of NDPS Act

Transformation of mindset of key policy makers - the notion that

ensuring opioid availability is an essential objective of the national

narcotic control policy

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March 2016 - India

• The Revised Rules following the 2014 Act amendment not released

• Old barriers with New look

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Unmet need for pain relief ContinuesStudy at Cancer Centres: Kolkata, Hyderabad, Ahmedabad, Cuttack

79.7% of the patients who came in with pain received inadequate or NO pain management

30%

Authors: M R Rajagopal, Gayatri Palat, Joseph Amon, Diederik Lohman

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Quality of Death Index

Wide availability of opioid analgesics-

was a constant element in countries

with high Indices

India

Ref: Economist Intelligence Report

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Reoriented drug policy for all member-states

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What if all member states have policies with appropriate language ……??

Ensured and SAFE access and availability of essential drugs

Poor access and availability of essential drugs

?

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Striving for equity in the treatment of pain •Yes, we should have supportive drug policy

•What more should we do to overcome the

inequity?

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Perceptions far more powerful …than substance of the law

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Process towards equity

• Changing the perception of the purpose of drug policy

• Culture and mandates of competent authorities

• Reflect the spirit of policy reform in the functioning units

• Interagency collaboration, Participatory, inclusive consultative

processes

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Perception of Purpose at the Highest level

Illicit use medical use

In the 5 UN Drug reports……Out of the total 256 times of mentioning “opioids”

"opioids for medical use” is mentioned 9 times

HRW

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Expression of Purpose at the Highest level

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Perception Purpose at the NCA

Revenue, Finance, Police, Crime, Home,

Foreign affairs, Economic development,

Drug enforcement, internal affairs

DEPARTMENT OF HEALTH

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Reorientation of Policy Mandate The Convention to articulate specific

provisions to ensure availability

Reorient National Drug Policy Identify negative language, themes Add

Specific strategies, action plansNational Competent AuthorityShould have Opioid Availability as their job mandate

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Process towards equity

• Changing the perception of purpose of drug policy

• Culture and mandates of competent authorities

• Reflect the spirit of policy reform in the functions

• Interagency collaboration, Participatory, inclusive consultative

processes

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Review of Policy Tools

Intent, priorities, language of the National Drug Control Strategy

With Specific Provisions and plans towards balance

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MODEL POLICY??

The Participatory and inclusive

consultative process

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Process towards equity

• Changing the perception of purpose of drug policy

• Culture and mandates of competent authorities

• Reflect the spirit of policy reform in the functions of the competent

authorities

• Interagency cooperation and collaborative action

• Participatory Inclusive consultative processes

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Resources

• WHO guidelines for Ensuring balance in national policies

• WHO, UNODC and UNAIDS Technical Guides

• WHO/INCB Guidance for estimates

• World Health Assembly Resolution on Palliative Care

• International Community as Regional consultative Bodies?

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Strong Licit Drug Distribution System

Level 6. PATIENTS

Level 2: National Competent Authority

Level 3. Importer/Manufacturers/Distributors

Level 1: International Narcotics Control Board

Level 4. Hospitals/Pharmacies/Hospice/PC programs

Level 5. Physicians/Pharmacists/Other

X

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Supportive policies

Interagency collaborationParticipatory, inclusive consultative processes

Enlightened implementation, monitoring

Ensured and SAFE access and availability of essential drugs

Poor access and availability of essential drugs

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Agencies of the UN uniteConventions

Clear Purpose of drug policy

Medical Availability a Job Mandate of NCA

Functioning supply and distribution

systems

Simple procedures for

access

Knowledge in SAFE medical

usage of opioids

Penalties proportionate

to offence

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More and more of Justice …..less and less of Rules

International Community

NCA

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05/03/2023 47

UNGASS 2016 For Freedom from Pain

Thank [email protected]


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