Cohort III International Pain Policy Fellows

University of Wisconsin Pain & Policy Studies GroupWorld Health Organization Collaborating Center forPain Policy and Palliative Care

Cohort IIIInternational Pain Policy Fellows

Opioid Availability Action Planning Worksheet

Madison, Wisconsin, USA

6 – 10 August 2012


Action Plan - Sri Lanka

Dr.Suraj Perera

Dr. N. Jeyakumaran

10 August 2012


Provinces (9) & Districts(25) of Sri Lanka

Sri LankaSri Lanka

Nine Provinces.Nine Provinces.

Nine Cancer UnitsNine Cancer Units

Types of HospitalsTypes of Hospitals

• Teaching Hospitals • Provincial General Hospitals• District General hospitals • Base Hospitals • Divisional Hospitals.• Central Dispensaries.

National Cancer Control Programme, Sri Lanka

Minister of Health

Secretary of Health

Director General of Health Services (DGHS)

Deputy Director General (DDG/ PHS 1)

Director / National Cancer Control Programme

* Consultant Community Physician

National Advisory National Advisory Committee on Committee on

Cancer ControlCancer Control

National Advisory Committee on Cancer Control

Ministry of Health

National Health Council

National Cancer National Cancer Control Control Programme Programme (NCCP )(NCCP )

National Cancer Institute (Maharagama)

Provincial Cancer Provincial Cancer Treatment Centres Treatment Centres ( Kandy, Galle, ( Kandy, Galle, Jaffna, Jaffna, Anuradhapura, Badulla, Anuradhapura, Badulla, Batticaloa Ratnapura, Batticaloa Ratnapura, KurunegalaKurunegala

Other National level institutions ( FHB , Epidemiology Unit , D/NCD)

Provincial Ministries of Health

Provincial Committees of Cancer Prevention & Control( PDHS, RDHS,Line Ministry Health Institutions of the district., Consultant Oncologist at provincial cancer treatment centres , Curative & Preventive health sectors )

District Committees of Cancer Prevention & Control

Technical working GroupsTechnical working Groups1. Cervical / Breast Cancer 1. Cervical / Breast Cancer PreventionPrevention2. Oral Cancer prevention2. Oral Cancer prevention2. Diagnosis & Cancer Therapy2. Diagnosis & Cancer Therapy

3. 3. Palliative carePalliative care4. Cancer surveillance4. Cancer surveillance5. Cancer research5. Cancer research

Issue

Inadequate Patient access to Opioid

Analgesics

Problems • Less Priority given to Palliative Care • Limitations of existing law related to Opioids

prescription • Inconsistencies on Distribution & Availability

of Opioids at the point of delivery • Gaps in knowledge, attitudes and practices of

health care professionals on pain management in palliative setting

Problem 1: Less Priority given to Palliative Care

• Underlying reasons for the problem .– Multiple health issues with communicable & non

communicable diseases.– About 15,000 to 20, 000 new cancer cases / year.– Most of the cancers are detected in late stages.– Palliative care is given a less priority.– Some aspects of palliative care.

• In Cancer treatment centres.• In four hospices.

– With few facilities.– minimum human resources.

Problem 1 :

Less Priority given to Palliative CareObjective (What) To consider palliative care as a priority in the Cancer

Policy of Sri Lanka

Action steps (How) To include the component of palliative care in the National Cancer control Policy.

Authority and/or Responsibility (Who)

• Secretary/Health• National Advisory Committee on Cancer Control• National Cancer Control Programme .

Timeline (When) September 2012

Assistance (How Much)

Expert participation Reviewing the Draft Policy Document.

Expected outputs Palliative Care is an essential component in the National Cancer Control policy.

Output measurement Relevant palliative care Policy statement.

Problem 1 : (Cont…)

Less priority given to Palliative CareObjective(s) (What) To coordinate planning, implementation and evaluation of

palliative care initiatives nationally

Action steps (How) To establish a National Working Group on Palliative Care for Cancer Patients


National Advisory Committee on Cancer Control National Cancer Control Programme

Timeline (When) September 2012 onwards At least two meetings in each year


Technical advice on initiatives

Expected outputs Palliative care initiatives are conducted in coordinated manner

Output measurement Functional National Working Group on Palliative Care for Cancer Patients established.No. of meetings held per year, No. of Meeting Reports

Problem 1 : (Cont…)

Less priority given to Palliative CareObjective(s) (What) To conduct advocacy leading to acceptance of palliative care

as a priority

Action steps (How) To conduct an advocacy meeting to obtain support from all stakeholders


National Advisory Committee on Cancer Control, National Cancer Control Programme ‘ Sri Lanka Medical Association, Sri Lanka College of Oncologists/ Anethesiologists/ Family Medicine WHO Country Office - Sri Lanka Sri Lanka Cancer Society

Timeline (When) Every year in the month of October, commencing from year 2012


Logistic support for an International expert

Expected outputs Participation of stakeholders to the advocacy meeting Ability to get support from stakeholders

Output measurement Report of advocacy meeting

Guest Lecture : Palliative Care

Symposium on Palliative Care – 2010

Symposium on Palliative Care – 2010

Problem 2 :Limitations of existing law related to Opioids prescription

Underlying reasons for the problem Deficiencies of POISONS,OPIUM, AND DANGEROUS DRUGS ordinance & its

Amendments Under section 56 (1)• “A medical practitioner may administer, prescribe or supply any dangerous drug for the

treatment of his patients, but shall not supply to any patient more than the amount to be taken by him during three days.”

Under section 59 (2c)• “The total amount of the drug prescribed shall not exceed the amount to be taken by

the patient during three days: Provided that the prescription may direct that the amount prescribed may be supplied on more than one but not more than three occasions at intervals to be specified in the prescription”

Problem 2 : Limitations of existing law related to Opioids prescription

Objective (What) To amend the existing law that restrict duration of opioid prescription to the patients

Action steps (How) Detailed review of existing legal documents (amendments, regulations, administrative orders)Identify the necessary amendments & submit to Legal Draftsmen Department for further action Cabinet Approval, Public Opinion, Parliamentary approval


Ministry of Health National Advisory Committee on Cancer ControlLegal Draftsmant Department

Timeline (When) 2012-2014


Technical Assistance – Information related to similar amendments in other countries

Expected outputs Relevant law is amended

Output measurement Availability of amended legal document

Problem 3: Inconsistencies related to the distribution & availability of opioids at the point of delivery• Reasons for the problem..

– In Sri Lanka, palliative care and pain management is mainly offered at cancer units.

– There is a varying level of availability of drugs and practice of dispensing analgesics including opioids.

– Supply of Morphine: from one week to a month.

– An availability of minimal pain management without access to Oral Morphine in the District General and Base Hospital.

Problem 3: Inconsistencies on Distribution & Availability of Opioids at the point of deliveryObjective ( What) To Identify the Reasons for the Inconsistencies

Action steps (How) Reviewing the current problem at the Institutional level including Health System Research in each Cancer Hospital. (BOAT Survey)


National Advisory committeeNational Cancer Control Programme.Director, MSDDirectors of each Hospitals.Oncologists.Pharmacists.IPP Fellows.

Timeline (When) Till February 2013.


1. Technical assistance for Research activities eg. Research papers / Questionnaires / advise on methodology.

2. Study Materials / Books on Health System Research.3. Support on Statistics

Expected outputs Better understanding of the reasons for the problem.

Output measurement Reports.

Problem 3: (Cont…)Inconsistencies on Distribution & Availability of Opioids at the point of deliveryObjective(s) (What) To ensure the availability of the opioids at the Teaching

Hospitals and Provincial General Hospital (9) level.

Action steps (How) Conducting pilot studies to forecast the amount of opioids in two cancer centres


Director, MSDDirectors of each Hospitals.Oncologists.Pharmacists.

Timeline (When) September 2013


Technical assistance.

Expected outputs To see the estimates.

Output measurement The reports of estimates.

Problem 3: (Cont…)Inconsistencies on Distribution & Availability of Opioids at the point of deliveryObjective(s) (What) To make availability of opioids at the District General

Hospital(16) level.

Action steps (How) Conducting pilot programmes in two District General Hospital.


National Cancer Control Programme.Directors of each Hospitals.Oncologists. Pharmacists.IPP Fellows.

Timeline (When) December 2013


Technical and financial assistance to do the pilot study

Expected outputs Achieving Cancer Pain Management. Model at District General hospital.

Output measurement Patient satisfaction.

Problem 3: (Cont…)Inconsistencies on Distribution & Availability of Opioids at the point of deliveryObjective(s) (What) To conduct pilot projects on achieving community based

palliative care

Action steps (How) conducting pilot studies in two districts to provide pain management.


National Cancer Control Programme. Provincial Directors of Health servicesDirectors of each Hospitals..Oncologists. Pharmacists.IPP Fellows.

Timeline (When) February 2014


Technical and financial support.

Expected outputs Two models in two cultures.

Output measurement Project Reports.

Problem 3: (Cont…)Inconsistencies on Distribution & Availability of Opioids at the point of deliveryObjective(s) (What) Include Oral liquid morphine available.

Action steps (How) Ensuring purchase of oral liquid Morphine through MSD,


National Cancer Control Programme. MSD.

Timeline (When) June 2013


Donation initially from available countries for 2013,

Expected outputs Availability of Oral Solution of Morphine for Cancer pain Mx.

Output measurement Report from Director / Hospitals

Problem 4: Gaps in knowledge, attitudes and practices of health care professionals on pain management in palliative setting.

• Reasons for the problem..• In Sri Lanka Health Care Professionals have

varying levels of Knowledge, Attitudes and Practice towards Pain Management in general and opioid prescription in particular. – Imposes barriers to receive opioids for pain

management.

Problem 4: (Cont…)Gaps in knowledge, attitudes and practices of health care professionals on pain management in palliative settingObjective(s) (What) To have Continuing Medical Education (CME) on Palliative care and pain

management in each District at least one per year.

Action steps (How) Discussing this idea with the National Cancer Control Programme to arrange this programme Developing guidelines / Desktops / Power point Slides.


Secretary, Ministry of Health.

Director Genearal of Health

Director / National Cancer Control Programme

Sri Lanka Medical Association.

Professional Colleges.

Timeline (When) 2013 -2014 ( Year 2)


Technical and financial assiaatance .

Expected outputs Programmes are conducted.

Output measurement No. of Programmes conducted and reports of them

Problem 4: (Cont…)Gaps in knowledge, attitudes and practices of health care professionals on pain management in palliative setting

Objective(s) (What) To have detailed component of palliative care module in postgraduate streams such as Oncology, anaesthesiology and Family Medicine .

Action steps (How) To initiate this matter with Director Postgraduate Institute of Medicine and Boards of study in Clinical Oncology and Family Medicine.


Director PGIM.

Chairman BOS in Oncology and Family Medicine

Timeline (When) 2013 - 2014


International Experts (PPSG) and Local experts

Expected outputs Inclusion of Palliative care components in the curricula.

Output measurement Prospectus of Board of Study


Objective(s) (What) To commence Postgraduate Diploma course on palliative care for Medical Officers

Action steps (How) To discuss this matters with Director, PGIM involving members from specialties concerned.


Secretary of Health,Director Genearal of Health Services Director PGIM.National Cancer Control Programme.

Timeline (When) 2013-2014


Technical support of International Experts (PPSG) to Post Graduate Institute to develop curricula.

Expected outputs Acceptance establishment of Curriculum Development Committee.

Output measurement Study Prospectus.


Objective(s) (What) To include training modules on palliative care nursing to the basic nursing training curricula

Action steps (How) Conducting a Training programme for tutors of Nursing Training Schools


Director Genearal of Health Director / Nursing (Training)

Timeline (When) 2014


Technical support of international experts

Expected outputs Availability of trained palliative care nursing tutors

Output measurement No. of programmes conducted.


Objective(s) (What) To strengthen the knowledge of Nurses in Palliative Care Services.

Action steps (How) Conduct Certificate course in Palliative Care for Nurses


Secretary of Health.Director General Health Services.Director / Nursing (Training)

Timeline (When) 2014


Technical support of international experts

Expected outputs Availability of trained palliative care nurses.

Output measurement No. of trained palliative care nurses

To include palliative care as a priority in the Cancer Policy of Sri Lanka

September 2012

To establish a National Working Group on Palliative Care for Cancer Patients

September 2012

To conduct an advocacy meeting to obtain support from all stakeholders

October 2012

To amend the existing law that restrict duration of opioid prescription

2012 - 2014

Reviewing the current problem at the Institutional level including Health System Research in each Cancer Hospital. (BOAT Survey)

February 2013

Conducting pilot studies to forecast the amount of opioids in two cancer centres

September 2013

conducting pilot studies in two districts to provide pain management.

December 2013

Ensuring purchase of oral liquid Morphine through MSD. June 2013

Time Line of Activities

To have Continuing Medical Education (CME) on Palliative care and pain management in each District.

2013 - 2014

Inclusion of Palliative care components in the curricula of Oncology & Family Medicine.

2013 - 2014

Acceptance establishment of Curriculum Development Committee.

2013 - 2014

Conducting a Training programme for tutors of Nursing Training Schools

2013 - 2014

Conduct Certificate course in Palliative Care for Nurses

2014

Time Line of Activities (cont..)

Goal :

Opioid analgesics are available to the patients who need them.

Quality of life of patients and families are improved.

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Thank You

Documents

Cohort III International Pain Policy Fellows