Palliative Care and Essential Drug Availability: Thailand National Survey 2012

Abstract

Background:

Palliative care in Thailand was not well established in the past, but it is better supported by many organizations at present. Despite the change in the situation, the availability of essential drugs for palliative care has not been well studied.

Objective:

Our aim was to update the medical community on the current situation of essential drug availability for palliative care in Thai hospitals.

Methods:

The International Association for Hospice and Palliative Care (IAHPC) list of 34 essential drugs for palliative care was used in this survey.

Results:

Five hundred and fifty-five hospitals replied to the questionnaire (response rate 57%). Eleven of the 24 nonopioid drugs were available above 90% in all hospitals. However, nonopioid drugs generally were less available in community hospitals (CH) and general hospitals (GH) than in large hospitals (LH). Tramadol was the most available weak opioid. Injectable morphine was the most available form of strong opioid in Thailand (96.9%). For the overall picture of oral morphine, immediate-release morphine was a less available form than the controlled-release form (32.2% versus 51.0%). Controlled-release oral morphine had a nearly two-fold better availability than immediate-release oral morphine in CH, GH, and LH, that is, cancer centers (CC), medical school hospitals (MH), regional hospitals (RH), and other government hospitals. In contrast, in private hospitals (PH), there was no difference between the availability of the controlled-release form and the immediate-release form. Transdermal fentanyl and methadone were also less available in Thailand (14.6% versus 16.5%, respectively).

Conclusion:

LH and PH have better overall nonopioid and opioid medication availability than CH and GH.

Introduction

Previous reports on palliative care in Thailand mentioned that palliative care service was mainly confined to medical schools and cancer centers (CC).¹ The opioids were insufficient and inaccessible to the patients in the community.¹ The development of palliative care in Thailand was classified as a localized hospice-palliative care provision with limited support, limited morphine availability, and without integration into the mainstream health care system.^2,3

At present, palliative care in Thailand is better supported by many organizations. In 2006, palliative care was implemented into the hospital accreditation standard by the Healthcare Accreditation Institutes.^4,5 The Thai Food and Drug Administration (FDA), Nation Health Security Office (NHSO), and the Government Pharmaceutical Organization (GPO) have made great contributions to palliative care development in terms of opioid availability and price lowering. The NHSO has supported the hospital networks with palliative care services in hospitals and communities since 2009, whereas the GPO is now able to produce immediate oral morphine tablets, and the liquid form that has been endorsed by the Thai FDA since 2010. Despite the change in the situation, the palliative care service facilities and personnel in Thailand are not well studied. The status of essential drug availability and the regulation of opioids for palliative care are unknown as well.

The research collaborative group of the Asia Pacific Hospice Palliative Care Network (APHN) conducted a survey on the current status of palliative care in the Asian Pacific region in 2011. This study is a part of that survey and aims to update the medical establishment concerning the current nationwide situation of essential medications for palliative care in government hospitals.

Methods

Setting/Subjects

The database of hospitals registered to the Bureau of Policy and Strategy, Ministry of Public Health was used. We included all government hospitals and CC. Private hospitals (PH), sanatoriums, and nursing homes in the Bangkok area only were also included. Finally, we identified a sample of 975 hospitals. There were 93 PH in Bangkok and 882 government hospitals, including medical school hospitals (MH), CC, regional hospitals (RH), general hospitals (GH), community hospitals (CH), and other hospitals (OH).

CC, MH, RH, and OH were grouped together and renamed large hospitals (LH). LH had similar patterns of essential drug availability, being localized in urban areas, and with highly technological medical facilities, whereas CH and GH were smaller hospitals that mainly distributed in rural areas and worked closely as a provincial network.

Study design

The questionnaire developed by the research collaborative group of APHN was translated into the Thai language; The Thai questionnaires included five parts: the hospital characteristics, palliative care services and personnel, availability of essential drugs, the regulation of opioids, and the need of a supporting system. In the availability of essential drugs part, the International Association for Hospice and Palliative Care (IAHPC) list of 34 essential medicines for palliative care was used. The answer could be “available,” “partially available” (available in some situations or with regulation), or “unavailable.”

The data were collected from January to April 2012. The questionnaires were sent to the director of each hospital in the study population by post. The palliative care leaders in the hospitals were asked to respond to the survey voluntarily and to send the data back either by post, fax, or online. The respondents' names, telephone numbers, and e-mail addresses were also requested, so the investigators could contact them directly for clarification or more information. There was no further contact for nonresponder hospitals. The hospital's current status on January 1, 2012 was used in this study.

Statistical analysis

SPSS for Windows version 11.5 (SPSS Inc., Chicago, IL) was used for statistical analysis. Results are presented as a frequency and percentage.

The study protocol was approved by the Ethics Committee of the Faculty of Medicine at Prince of Songkla University.

Results

Five hundred and thirty-seven government hospitals replied to the questionnaire, for a response rate of 61%. The questionnaire's response rates of the sample hospitals are shown in Table 1. There are seven types of hospitals, including 438 (78.9%) CH, 49 (8.8 %)GH, 18 (3.2%) RH, 8 (1.4%) CC, 13 (2.3%) MH, 18 (3.2%) PH in Bangkok, and 11 (2.0%) OH.

Table 1.

Questionnaire Response Rates of the Sample Hospitals

Hospital type	Total (n)	Response (n)	Response (%)
Community hospital	741	438	59
General hospital	69	49	71
Regional hospital	25	18	72
Medical school hospital	17	13	76
Cancer center	9	8	89
Other hospital	21	11	52
Private hospitals in Bangkok	93	18	19
Overall	975	555	57

Nonopioid drug availability

In Table 2, we categorized the nonopioid essential drugs list by the drugs' mode of action depending on palliative care formulary 4^th edition.⁶ Twenty-four nonopioid drugs are shown in the table. Levochlorpromazine was not available in Thailand. Eleven nonopioid drugs were available above 90% in all hospitals.

Table 2.

Numbers and Percentage of Nonopioid Drug Availability in Different Types of Hospitals ^a

Drug list	PH	CH	GH	RH	CC	MH	OH	Total
Benzodiazepines
Diazepam	12	393	47	17	7	11	10	497
	100%	100%	100%	100%	100%	100%	100%	100%
Lorazepam	12	381	47	17	7	11	9	484
	100%	98.5%	97.9%	100%	100%	100%	90%	98.4%
Midazolam	11	81	40	17	5	10	9	173
	100%	23.7%	93.0%	100%	71.4%	90.9%	100%	39.3%
Antidepressants
Amitriptyline	11	387	46	17	7	11	9	488
	91.7%	99.5%	100%	100%	100%	100%	100%	99.4%
Citalopram^b	6	26	12	11	1	8	5	69
	54.6%	7.9%	29.2%	68.8%	16.7%	72.7%	62.5%	16.3%
Mirtazapine^c	5	10	3	7	0	7	2	34
	45.5%	24.4%	0.9%	41.2%		70%	22.2%	7.8%
Trazodone	8	59	18	9	0	7	5	106
	72.7%	17.1%	43.9%	53%		63.6%	55.6%	24.1%
Antiemetics
Haloperidol	12	381	47	17	6	11	9	483
	100%	99.2%	100%	100%	85.7%	100%	100%	99.1%
Metoclopramide	11	326	43	17	7	11	10	425
	100%	88.3%	97.7%	100%	100%	100%	100%	90.6%
Diphenhydramine	10	127	25	12	6	11	5	186
	83.3%	35.6%	58.1%	70.6%	85.7%	100%	62.5%	43.1%
Laxatives
Bisacodyl	9	345	43	17	6	11	9	440
	81.8%	(91.3%)	93.5%	(100%)	(85.7%)	(100%)	(100%)	(91.8%)
Senna or Senokot™	12	153	38	14	7	10	9	243
	45.5%	43.1%	88.4%	82.4%	100%	100%	90%	53.3%
Mineral oil enema	7	38	12	6	2	4	4	73
	70%	11.2%	28.6%	35.3%	28.6%	40%	44.4%	16.7%
Antiepileptics
Carbamazepine	9	298	41	17	3	11	8	387
	81.8%	84.4%	95.3%	100%	42.9%	100%	88.9%	85.8%
Gabapentin	11	79	40	17	6	11	9	173
	100%	23.1%	95.3%	100%	85.7%	100%	100%	39.4%
NSAIDs
Ibuprofen	12	387	47	17	7	11	10	491
	100%	100%	100%	100%	100%	100%	100%	100%
Diclofenac	9	376	46	17	6	11	9	474
	81.8%	97.4%	97.8%	100%	(85.7%)	100%	100%	97.1%
Other drugs
Dexamethas one^d	11	367	46	17	7	11	9	463
	100%	96.1%	100%	100%	100%	100%	100%	96.8%
Hyoscine butylbromide	11	370	43	17	6	11	9	467
	100%	98.1%	97.7%	100%	85.7%	100%	100%	98.1%
Loperamide	10	128	34	17	4	10	8	211
	90.9%	36.5%	81.0%	100%	57.1%	90.9%	88.9%	47.2%
Megestrol acetate	8	10	10	13	5	11	5	61
	72.7%	2.7%	24.4%	76.5%	71.4%	100%	55.5%	14.2%
Paracetamol	12	387	46	17	7	11	10	490
	100%	99.3%	100%	100%	100%	100%	100%	99.4%
Octreotide	5	9	31	16	3	10	5	79
	50%	2.7%	73.8%	94.1%	42.9%	90.9%	55.5%	18.2%
Zolpidem	5	0	5	9	0	7	1	27
	45.5%		12.2%	53.9%		63.7%	11.1%	6.2%

There are different missing values in each drug item. Gray background means the drug items have above 90% availability. Drug group was categorized by palliative care formulary.⁶

Citalopram or any other equivalent generic SSRI except paroxetine and fluvoxamine.

Mirtazapine or other generic dual action NassA or SNRI.

Dexamethasone or other equivalent generic corticosteroids.

CC, cancer center; CH, community hospital; GH, general hospital; MH, medical school hospital; NassA, noradrenergic and specific seratonergic antidepressants; NSAID, nonsteroidal anti-inflammatory; OH, other hospital; PH, private hospital; RH, regional hospital; SNRI, serotonin-norepinephrine reuptake inhibitors; SSRI, selective serotonin reuptake inhibitor.

Opioid drug availability

Opioid availability in government hospitals is shown in Table 3.

Table 3.

Number and Percentage of Opioid Availability in Different Types of Government Hospitals

Drug list	PH	CH	GH	RH	CC	MH	OH	Total
Codeine	10	84	24	13	7	11	4	153
	90.9%	24.6%	55.8%	76.5%	100%	100%	50%	35.2%
Tramadol	12	387	48	17	7	11	10	492
	100%	98.7%	100%	100%	100%	100%	100%	99.0%
Methadone (immediate release)	6	36	13	11	1	7	2	76
	54.5%	10.7%	30.2%	64.7%	14.3%	63.6%	22.2%	17.5%
Immediate-release oral morphine	9	85	14	13	7	10	5	143
	81.8%	24.7%	31.1%	76.5%	100%	90.9%	55.6%	32.2%
Controlled-release oral morphine	8	149	35	16	7	10	6	230
	72.7%	42.5%	75.6%	94.1%	100%	90.9%	66.7%	51.0%
Injectable morphine	11	361	47	17	7	11	10	464
	100%	96%	100%	100%	100%	100%	100%	96.9%
Injectable fentanyl	8	102	40	15	5	9	8	187
	72.7%	29.8%	87%	88.2%	71.4%	81.8%	88.9%	42.3%
Transdermal	7	15	11	14	7	9	6	69
fentanyl	63.7%	4.4%	25.6%	82.4%	70%	81.8%	66.7%	15.8%

CC, cancer center; CH, community hospital; GH, general hospital; MH, medical school hospital; OH, other hospital; PH, private hospital; RH, regional hospital.

Tramadol was the most available weak opioid in all hospitals, whereas codeine was mainly available in MH, CC, PH, and RH. Injectable morphine was the most available form of strong opioid (96.9%). Overall, for oral morphine, immediate-release morphine was a less available form than the controlled-release form (32.2% versus 51.0%). Controlled-release oral morphine had a nearly two-fold better availability than immediate-release oral morphine in CH (42.5%versus 24.7%), GH (75.6 versus 31.1%), and LH (88.6%versus 55.1%). Both forms of oral opioids were more available in LH than GH and CH. In contrast, in PH, there was no difference between the availability of the controlled-release form and the immediate-release form (72.7% versus 81.8%, respectively).

Injectable and transdermal fentanyl were mainly available in LH and PH. Methadone was only average 17.5% available in overall picture of the survey. Oxycodone and oral transmucosal fentanyl were not available in Thailand.

Discussion

The results of this national survey showed that essential drugs in Thai government hospitals were mainly available in RH, CC, and MH.

Nonopioid essential drugs were categorized by their mode of action depending on palliative care formulary 4^th edition.⁶ Each group had at least one item that had good availability. This finding implies that the supply of nonopioid essential drugs was sufficient for basic symptom management. However, there were limited drug choices from which doctors could select the proper drugs for palliative care patients in CH. The Thai national list of essential medicines limits the availability and quantity of certain drugs in different types of hospitals. The drugs that were classified as Non-Essential Drugs (NED) were more available in larger medical centers than CH.⁷

Oral morphine availability is still problematic in rural Thailand. Oral morphine, the immediate-release form in particular, was less available in CH and GH. This finding affirms the potential for inadequate pain control in the first referral level of the health care system. It is similar to that of previous studies. Palliative care services were confined to tertiary care, although palliative care patients seldom die in tertiary care hospitals.^1,8 In addition, 60% to 80% of palliative care patients died at home in the first author's palliative home care program.⁹ The supply of oral morphine was limited in CH and GH. CH were the most accessible units for patients, whereas GH were mainly referral centers to support CH. Limited essential drug availability in these centers may impact patients' accessibility to effective symptom management.

The immediate-release morphine form was less available than the controlled-release form because there was no commercial immediate-release morphine in Thailand until 2010. Only some medical schools and regional hospitals produced immediate liquid morphine for their own practice. The Thai FDA, GPO, and NHSO tried to solve the opioids problem by producing immediate-release oral morphine, lowering the price of opioids, and educating medical personnel in palliative care concepts and pain management. The NHSO solved the financial barrier to the access of opioids by subsidizing oral opioids for palliative care outpatients.

However, there are still some obstacles in stocking immediate-release oral morphine and in the complex procedures for the procurement of opioids. The short half-life of liquid morphine and small caseload in CH mean that much of the stored liquid morphine will expire before use. Hospital pharmacists need to send a monthly report and yearly summary of opioids use in the hospital to the Thai FDA.¹⁰ The distribution of opioids from GPO to hospitals might take 3 weeks to one month, which makes it difficult for pharmacists to manage the stock.

Moreover, strict drug legislation and the fear of drug diversion potentially prevent CH from stocking opioids for medical purposes.^11,12 The primary care facilities have a limited availability of opioids in supply.¹³

In the first author's program, the shortage of liquid morphine caused pain to be the second most common readmission symptom (24.3%), although the average pain score was good, with pain controlled after one week of pain management in 2011 (7.2 versus 2.9, p<0.01).¹⁴ When immediate-release morphine was in short supply, the first author managed breakthrough pain by recycling the unused oral morphine from the palliative care patients who no longer required opioids.¹⁴ The first author concomitantly prepared liquid morphine from injectable morphine.¹⁴ In emergency conditions when the liquid morphine was unavailable, the first author advised patients to crush morphine sustained-release tablets for use for breakthrough pain. Some hospitals managed breakthrough pain by using tramadol.

These findings make it clear that there is an inadequate supply of opioids for patients who need them, especially for palliative care. Therefore, palliative care policy should emphasize providing these drugs in CH and GH in particular.

The limitations of this study include a modest response rate (57%) and incomplete questionnaire answers. The response rate from PH in Bangkok was very low (19%). Moreover, data for PH was collected only in Bangkok. Therefore, the results may not represent the overall picture of PH in Thailand.

Incomplete questionnaire answers on the essential drugs list ranged from 9.7% to 23.3%. This paper potentially has a selective bias. The hospitals that have palliative care personnel and palliative services tended to provide more detailed, up-to-date information in their responses on the questionnaire. The real levels of essential drug availability may be lower than our results indicate.

Conclusion

This study demonstrated the essential drugs for palliative care distribution pattern in various types of Thai government hospitals. LH (CC, MH, RH, and OH) and PH had better overall nonopioid medications and oral opioid availability than rural hospitals (CH and GH).

Footnotes

Acknowledgments

The Health Promotion Foundation provided funding to distribute the survey questionnaires.

The authors wish to thank the Health Promotion Foundation and The Consortium of Thai Medical Schools that support Thai Medical Schools Palliative Care Network projects, including this survey. We also would like to thank all questionnaire respondents, and Mr. Trevor Pearson for his English language advice.

Author Disclaimer Statement

No competing financial interests exist.

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