Evaluation of the Effectiveness of Workshops on the Availability and Rational Use of Opioids in Latin America

Abstract

Background:

Many patients around the globe do not have access to pain treatment. A series of workshops on the availability and rational use of opioids in Latin America (LA) were implemented.

Aim:

To evaluate the effectiveness of action plans (APs) resulting from workshops to eliminate barriers to the availability and accessibility of opioids in 13 Latin American countries (Bolivia, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Peru, and Venezuela). Effectiveness was measured qualitatively and quantitatively.

Methods:

A cross-sectional study was conducted from September to October 2015. Outcome variables were qualitative: the country coordinators (CCs) perceived workshop benefit and effectiveness and ability to implement the resulting AP and quantitative: (1) 2013 opioid consumption; (2) opioid consumption change from 2010 to 2013; (3) formulations available. For analysis we used nonparametric tests [Wilcoxon, Mann-Whitney, Spearman correlation (Rs)] and content analysis.

Results:

Qualitative: 10 CCs rated the workshop very useful or useful and the resulting AP helpful in eliminating barriers. Communication/collaboration with regulators improved in 11 countries. Content, organization, and methodology were rated positively. Quantitative: no significant difference was found between countries that had one, two, or no workshops and the outcome variables. A positive significant correlation was found between Human Development Index and consumption (Rs [Spearman's rank correlation coefficient] = 0.688; p = 0.009) and in consumption changes: (Rs = 0.445; p = 0.128), but not in number of formulations available.

Discussion:

The APs were rated useful in eliminating barriers but only four countries were able to implement >75% of their APs, which may suggest that the barriers were overwhelming and beyond their means to eliminate.

Conclusion:

Limited access to pain treatment is multifactorial, including restrictive laws and regulations. Strategies to eliminate barriers need to be broad and include clinical and government representatives to be effective. It may take several years before results are observed.

Introduction

Latin America (LA) consists of 19 countries and a total population of approximately 570 million inhabitants. Countries differ greatly in size (Brazil being the largest with over 8 million km² and almost 200 million inhabitants or 34% of the regional population) compared with countries like El Salvador, which is the smallest (over 21,000 km²) and Uruguay where only over 3 million people live.¹ Thirteen countries in LA and the Caribbean fall in the middle- to high-income levels, whereas six fall within the low- to middle-income levels.²

Currently, noncommunicable diseases (NCDs) are the main cause of death and disability in LA. In 2002, they were responsible for 44% of deaths of men and women less than 70 years old and were the main cause of death in one out of two in the total population. NCDs contributed to almost 50% of the lost disability adjusted life years in the region.³ Palliative care, which could relieve pain and suffering of individuals with such needs, is very limited in LA. According to the atlas of palliative care of the Latin American Association for Palliative Care, there are 1.6 palliative care/hospice services per million inhabitants in the region.¹

Pain is one of the most feared and prevalent symptoms in patients with life-limiting conditions.⁴ According to the World Health Organization (WHO), 80% of patients with AIDS or cancer and 67% of patients with cardiovascular disease or chronic obstructive pulmonary disease will experience pain at the end of their lives.^5–7 Opioid analgesics are included in the WHO model list of essential medicines.^8,9

The International Narcotics Control Board (INCB) collects the consumption data of internationally controlled medications from member states and, along with other UN organizations, has called on governments to improve availability and access to opioids for medical treatment.¹⁰ Over 5 billion people (83% of the world's population) live in countries with low to no access, 250 million (4%) have moderate access, and only 460 million (7%) have adequate access. High-income countries (HICs) account for more than 90% of the global consumption of opioids.^11,12 Latin American and the Caribbean countries consume less than 2% of the global consumption of opioids,¹³ mostly due to unduly restrictive laws and regulations that interfere with legitimate prescription and dispensing and lack of knowledge and skills on how to appropriately assess and treat pain with opioids.¹

The challenges to access pain treatment have been reported and described in the literature, including unnecessary restrictions in national policies^14,15; limited knowledge and attitudes¹⁶; socioeconomic conditions, and cost of medications.¹⁷

The International Association for Hospice and Palliative Care (IAHPC), adapted a strategy developed several years ago by the Pain and Policy Studies Group (PPSG) at the University of Wisconsin,^18,19 and implemented a series of workshops on the availability and rational use of opioids in LA to improve access to pain treatment for patients in need. This strategy is one of the components of the IAHPC agreement as an NGO in formal relations with the WHO and is based on the concept of balance: governments should take the necessary steps to ensure availability and access to controlled medications for legitimate medical use while also preventing diversion and illicit use.²⁰ Other organizations have also implemented national or regional workshops in other regions to reduce these barriers.^21,22 There are no previous studies published in the literature measuring their effectiveness.

This article presents a summary of the strategy and evaluation of the effectiveness of the workshops in improving availability and eliminating barriers to opioids in 13 Spanish-speaking countries in LA: Bolivia, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Peru, and Venezuela.

Methods

A pilot workshop (Colombia) was implemented in October 2007 to test the methodology and the materials used. Minor modifications were made based on feedback from the participants.

After funding was secured, additional workshops were conducted with the participation of 12 additional countries. Criteria for the selection of countries were as follows:

Designated office and official responsible for the controlled medications in place (National Competent Authority [NCA]).

Existence of a reporting system to the INCB in place.

Critical mass of prescribers interested in improving the availability and access to opioid medications.

Opioids are authorized in the country: the mechanisms for their importation, manufacture, distribution, and dispensation are in place.

Interest on the part of the government to improve access to essential medicines for pain treatment.

Low consumption of opioids as compared with the global average reported by the INCB.

For the implementation of the workshops, the following steps were then taken:

1. A country coordinator (CC) (physician, with the ability to prescribe opioids) was identified for each country. They were selected based on their demonstrated interest and leadership in advancing palliative care and pain treatment, measured by their publications, participation in the congresses of the Latin American Association for Palliative Care, and their role as presidents or past presidents of the national palliative care association and/or of the national chapter of the International Association for the Study of Pain. Table 1 lists the assigned coordinators in each country.

2. Additional key individuals were identified and invited. Box 1 includes a list of the invitees.

3. Before the workshops, background and working material were shared with the invitees (Box 2).

4. The workshops were conducted in the following sequence:

a. Presentations on the global situation on access to opioids, the international legal framework and the countries' obligations, the role of the INCB, the WHO Model Lists of Essential Medicines (EMLs), and explanation of the methodology for the group discussions.

b. Participants were distributed in working groups for the identification of barriers using self-assessment check list from the WHO guidelines²⁰ and their country's respective laws and regulations.

c. Participants, with the help of workshop facilitators, developed an action plan (AP) to eliminate the unnecessary barriers. The AP included proposed solutions, named the individuals responsible for each task, and set the timeline for the completion of each.

5. The participants agreed to implement the AP and report on its progress.

Table 1.

Countries and Coordinators

Country	World bank socioeconomic classification	Country coordinator	Was the country coordinator an international fellow PPSG
Bolivia	LMIC	Martin Vargas	No
Chile	HIC	Marisol Ahumada	No
Colombia	UMIC	Marta Ximena Leon	Yes
Costa Rica	UMIC	Carlos Acuña	No
Ecuador	UMIC	Maria Cristina Chirola	No
El Salvador	LMIC	Rolando Larin Lovo	No
Guatemala	LMIC	Eva Duarte	Yes
Honduras	LMIC	Tulio Velasquez	No
Mexico	UMIC	Paola Diaz	No
Nicaragua	LMIC	Elizabeth Mercado	No
Panama	UMIC	Rosa Buitrago	Yes
Peru	UMIC	Maria del Rosario Berenguel-Cook	No
Venezuela	HIC	Patricia Bonilla	No

HIC, high-income country; LMIC, lower middle-income country; PPSG, pain and policy studies group; UMIC, upper middle-income country.

Box 1.

Invited Individuals to the Workshop

The respective National Competent Authority (NCA) in each country.

Participants from Latin American countries who completed the International Pain and Policy Fellowship at the PPSG were invited to participate as advisers and facilitators and present topics relevant to the discussions.

The president of the national palliative care association and/or of the national pain association (whenever he/she was not the same individual as the country coordinator in step 1). The association was invited to cosponsor the workshop.

The corresponding focal point working on Access to Essential Medicines, at the local office of the Pan American Health Organization (PAHO–WHO Regional office for the Americas).

Representatives of the national programs for the control of Non-Communicable Diseases in the Ministries of Health.

Pain and palliative care physicians (prescribers) working in the main treatment centers and teaching hospitals in the country.

Pharmacists in academic and teaching hospitals and procurement officers.

For regional workshops, a member of the INCB and a representative of the

PPSG/WHO Collaborating Center were invited.

In addition to the pilot workshop in Colombia in 2007, seven workshops were implemented between February 2010 and March 2015. Of these, three were regional or multicountry. In total, 13 countries participated, of which 4 had two workshops (regional and national): Bolivia, Chile, Nicaragua, and Peru. The decision to implement a national workshop following a regional or multicountry one was based on the grade of difficulty in accessing opioids for patients as evidenced in the initial analysis. Table 2 includes the list of the countries and the types of workshops implemented. In all the workshops, the corresponding NCA participated, with the exception of Nicaragua.

Table 2.

Workshops Conducted

Date	Type	Countries
October 2007	National (pilot)	Colombia
February 2010	Multicountry	Chile, Mexico, Peru
July 2010	National	Peru
April 2011	Regional–Central America	Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama
May 2011	National	Chile
February 2012	Regional: Andean	Bolivia, Ecuador, Venezuela
November 2013	National	Nicaragua
March 2015	National	Bolivia

Box 2.

Working Material

UN Single Convention on Narcotic Drugs³²

UN Convention on Psychotropic Substances³³

WHO Ensuring balance on national policies on controlled substances: Guidance for Availability and Accessibility of Controlled Medicines¹³

INCB Guide on Estimating Requirements for Substances under International Control³⁴

Corresponding national laws and regulations on the distribution, prescription, dispensation, administration, and use of controlled medicines

Qualitative outcomes

A cross-sectional study was conducted in September–October 2015. The data were obtained through a structured online survey with the CC. The survey included questions related to their perception of the usefulness of the workshop, the appropriateness of the resulting AP for eliminating barriers, improving the availability of opioids, their ability to implement the AP, and their general opinion on the workshop methodology and the quality of the information and materials used. The survey also included questions on the availability of strong opioids in oral immediate release (IR) and sustained release (SR) formulations as well as transdermal and injectable formulations (Table 3). The opioids were those included in the IAHPC List of Essential Medicines in Palliative Care²³ and those for which the INCB reports consumption by member states.

Table 3.

Availability of Five Opioids in Different Formulations in Each Country

Country	Morphine (oral liquid)	Morphine (oral solid, IR)	Morphine (oral solid, SR)	Methadone (oral liquid)	Methadone (oral solid)	Oxycodone (oral solid IR)	Oxycodone (oral solid SR)	Fentanyl (transdermal)	Hydromorphone (injectable amp)	Total medications available	Total formulations available
Bolivia	− −	− −	++	− −	+	− −	+	+	− −	4/5	4/9
Chile	++	− −	++	− −	++	− −	++	+	− −	4/5	5/9
Colombia	+	− −	− −	− −	+	− −	+	+	+	5/5	5/9
Costa Rica	− −	++	++	− −	++	− −	++	++	− −	4/5	5/9
Ecuador	− −	− −	− −	− −	− −	− −	+	− −	− −	1/5	1/9
El Salvador	− −	− −	++	− −	++	++	++	++	− −	4/5	5/9
Guatemala	−	+	+	−	+	+	+	+	−	5/5	6/9
Honduras	− −	− −	− −	− −	− −	− −	++	++	− −	2/5	2/9
Mexico	− −	++	− −	− −	+	− −	+	++	− −	4/5	4/9
Nicaragua	−	−	−	− −	− −	− −	− −	− −	− −	0/5	0/9
Panama	− −	+	− −	− −	− −	− −	+	+	− −	3/5	3/9
Peru	− −	++	+	− −	− −	++	++	++	− −	3/5	5/9
Venezuela	− −	+	++	− −	+	− −	++	−	− −	3/5	4/9

++, available, included in the list of essentials medicines; +, available, not included in the list of essentials medicines; −, not available, included in the list of essentials medicines; − −, not available, not included in the list of essentials medicines.

IR, immediate release; SR, sustained release.

Quantitative outcomes

Analyses were carried out to determine whether there was statistical association between the following three outcome variables: (1) opioid consumption for 2013 as reported by the INCB,²⁴ (2) the increase in opioid consumption from 2010 to 2013,²⁴ and (3) the number of formulations available, with the following independent variables: (a) having had one versus two workshops (regional and national or only one national), (b) having had a workshop versus none. Spanish-speaking Latin American countries that report to the INCB and that had never had a workshop were selected to do this comparison (Argentina, Dominican Republic, and Uruguay), (c) the socioeconomic level as per the World Bank classification,² and (4) the country's Human Development Index (HDI).²⁵ (The HDI is a composite statistic of average achievement in key dimensions of human development: life expectancy, education, and income per capita indicators. The HDI is the geometric mean of normalized indices for each of the three dimensions. A country scores higher HDI when the life expectancy at birth is longer, the education period is longer, and the income per capita is higher.)²⁶

Table 4 includes the trend in consumption of opioids in morphine equivalence (ME) per capita in each country.²⁴ The total ME includes the following opioids: hydromorphone, fentanyl, methadone, morphine, oxycodone, and pethidine. We included methadone, as in LA it is used more frequently for pain treatment than for substitution therapy.²⁷

Table 4.

Countries' Opioid Consumption Trends–Morphine Equivalent per Capita (Source: PPSG ²⁴ )

Country	2007	2008	2009	2010	2011	2012	2013
Bolivia	NA	0.9437	0.2399	0.1701	0.6864	NA^b	0.8506
Chile	7.7585	8.9548	9.9238	11.2756^b	13.1470^b	20.6040	16.1985
Colombia	6.5971^a	6.5733	5.9235	6.7416	7.6072	7.2203	8.7437
Costa Rica	NA	7.1473	8.7354	9.6493	9.7338^b	9.2841	10.3565
Ecuador	1.0910	1.5689	1.2953	1.5082	1.6947	1.5130^b	1.5893
El Salvador	3.1289	3.4023	3.0304	3.5109	3.0081^b	1.4600	2.0765
Guatemala	0.8056	1.1776	NA	1.1933	1.6901^b	1.3250	1.3953
Honduras	NA	NA	NA	0.6336	NA^b	0.9427	1.2520
Mexico	4.3978	4.5111	4.3600	4.0101^b	5.5353	3.8924	3.9214
Nicaragua	0.5924	1.3709	0.6120	1.1846	1.0319^b	0.7669	0.7037^b
Panama	2.7708	2.7674	2.7651	3.2102	6.0983^b	8.0049	3.8809
Peru	1.4189	1.8649	1.6131	1.7777^b	1.4452	2.2519	4.0435
Venezuela	1.9177	1.7672	1.7146	2.8837	2.4917	5.4700^b	1.1554

Peru had two workshops (regional and national), both implemented in 2010. Bolivia had an additional workshop (national) that took place in 2015.

Pilot.

Year when workshop(s) was/were implemented.

NA, country did not report consumption to the International Narcotics Control Board.

Additional analyses were carried out to determine whether there was a significant difference among the three countries where the CCs were International Fellows at the PPSG (Colombia, Guatemala, and Panama) and where the CCs were not.

Given the small number of cases, we used nonparametric test (Wilcoxon test, Mann–Whitney test, and Spearman correlation [Rs]). The descriptive statistical analysis was conducted using an IBM SPSS, Inc., for Windows (v 21). Free text was analyzed using content analysis.

Results

Thirteen CCs were invited and all voluntarily participated in the survey (response rate [RR] = 100%).

Qualitative analysis

In a Likert scale, where 1 was very limited and 5 very useful, the CC rated the content of the workshops (median 5.0; IQR = 0.50) very useful as well as the organization (median = 5.0; IQR = 1.0). The methodology of the workshop and the materials were rated very appropriate (median 5.0; IQR = 0. 50). In general, the workshop was considered very useful or useful in 10 countries (median 4.0; IQR = 1.0) with the exception of Ecuador and Venezuela where the usefulness was rated moderate and limited, respectively. No significant difference was found in the perceived usefulness among the three countries where the coordinator was an International Fellow PPSG versus those who were not.

In 10 (77%) of the countries, the AP developed during the workshop was considered helpful in eliminating barriers in the availability and rational use of opioids.

Some of the reported improvements were as follows:

Increased availability of medicines and different formulations (Chile, Colombia, Costa Rica, and Peru)

Improvements in the registration process for pharmaceutical products in Costa Rica.

Opioid medications were included in the national health plan (Colombia), and programs to subsidize opioid medications for poor patients were implemented (Peru).

Extension of prescription privileges to General Practioners (GPs) and other medical specialties in Panama.

Extension of the prescription validity (10–30 days in Colombia and Bolivia)

Elimination of maximum dosage per prescription (Bolivia and Colombia) and extended number of days for the provision of the special prescription pad (from one to five days in Chile).

Improvements in education for medical doctors (Costa Rica and Peru) and pain courses added in undergraduate and postgraduate curricula (Chile).

Improvements in relationships between prescribers and NCAs in Colombia, Panama, El Salvador, and Peru.

As one CC reported: In my opinion [the workshop] changed the reality of the country: Opioids were included in the list of essential medicines, six new units for pain and palliative care were opened, and a national cancer control program is in development which includes palliative care. We are working on a strategy to ensure adequate availability of opioids 24/7 for the whole country.

The most significant barriers reported for the implementation of the AP were as follows:

Difficulty and resistance to modify outdated laws and regulations.

Red tape and bureaucratic processes.

High turnover of personnel in key government positions.

NCAs have limited budgets and limited human resources.

Four participants reported having able to implement more than 75% of their corresponding APs (Chile, Colombia, Costa Rica, and Peru).

Before the workshop, the communication among the NCAs and prescribers was considered moderate (median 3.0; IQR = 1.5) with a range between 1 (very bad) in Honduras and 5 (good) in Colombia, Costa Rica, Chile, El Salvador, and Panama. After the workshop, there was improvement in the communication for all the countries, with the exception of El Salvador and Venezuela, where no changes were reported.

The quality of collaboration with the NCAs before the workshop was described as moderate (median 3.0; IQR=1.00).The workshop had a positive effect in the collaboration with the NCAs in all countries, exception in Ecuador and El Salvador.

Eleven countries have a list of essential medicines with exception of Colombia and Panama. The workshop was helpful for the inclusion of opioids in the list of essential medicines in four countries (Costa Rica, El Salvador, Nicaragua, and Peru).

Only Colombia and Guatemala reported having availability of the five medications included in the survey (hydromorphone, fentanyl, methadone, morphine, and oxycodone). However, Ecuador reported having only one (oxycodone) and Nicaragua none (although morphine is included in the list of essential medicines). Oxycodone is available in 12 countries (92%), whereas morphine and fentanyl are available in 10 of them (77%). Eight (54%) countries have methadone oral solid (the oral liquid was not available in any country), whereas hydromorphone was available only in one country (Colombia) (Table 4).

The formulations available varied from six of nine formulations in Guatemala to none in Nicaragua. Of the immediate release (IR) formulations, morphine solid IR was available in six countries and oxycodone solid IR was available in three countries. The prolonged release formulation of morphine was available in 7 countries and of oxycodone in 12 countries.

Some of the suggestions provided by the coordinators to achieve better results in future workshops are the following:

Include a training session on estimating opioid needs.

Include presentations of simulated painful situations or real cases.

Develop a set of indicators to assess the outcomes and results of the APs.

Quantitative analysis

No statistically significant difference was found in opioid consumption between 2010 and 2013 (Wilcoxon test). Opioid consumption in 2013 was higher than in 2010 in nine countries, although it was lower in El Salvador, Mexico, Nicaragua, and Venezuela.

No statistically significant difference was found between countries included in the study (which had at least one workshop) compared with countries not included in the study (Argentina, Dominican Republic, and Uruguay) and the three outcomes: (1) opioid consumption for 2013; (2) the increase in opioid consumption from 2010 to 2013; and (3) the number of formulations available (Mann–Whitney test). Similarly, there was no statistically significant difference among countries that had one workshop and countries that had two workshops (Mann–Whitney test).

HICs and upper middle-income countries (UMICs) had statistically significant more opioid consumption than lower middle-income countries (LMICs) (Mann–Whitney test; p = 0.019). The number of formulations available and the increase in the consumption from 2010 to 2013 were also higher in HICs and UMICs than in LMICs but not statistically significant. A positive strong statistically significant correlation was found between consumption in 2013 and HDI (RS = 0.688; p = 0.009), a moderate positive (RS = 0.445; p = 0.128) with the change in opioid consumption from 2010 to 2013. The HDI was not statistically significant in the number of formulations available (RS = 0.185; p = 0.545).

No statistically significant difference was found in the three outcomes: (1) opioid consumption for 2013, (2) increase in consumption from 2010 to 2013, and (3) the number of formulations available among the three countries (Colombia, Guatemala, and Panama) where the coordinators were PPSG fellows and in the countries where they were not.

Discussion

This article describes the effectiveness and perceived usefulness of workshops on the availability and rational use of opioids in 13 selected countries in LA. The participants rated the workshops positively as related to the organization, the content, and the methodology. Workshops implemented in other regions have also been considered useful in identifying the barriers in the laws and regulations interfering with legitimate access to controlled medicines.²⁸

The APs were rated useful in eliminating barriers in the availability and medical use of opioids. However, only four countries were able to implement >75% of their APs, which may suggest that the barriers in the remaining countries were overwhelming and beyond their means to eliminate. The four countries where the AP was implemented (Chile, Colombia, Costa Rica, and Peru) have better (lower) scores in the Ease of Doing Business Index from the World Bank than the rest (except Mexico),²⁹ probably reflecting a more flexible regulatory environment and culture. However, the country with the best (lowest) score index is Mexico where the plan was implemented only partially. The reasons provided by the CC were lack of political will and limited education of health professionals.

In all the countries included in the study, the NCAs worked in offices that were understaffed, having several responsibilities as part of their job (not only monitoring controlled medications). Although in theory, they were aware that ensuring access to patients in need was also part of their responsibility, in practice they were concerned that eliminating barriers could lead to diversion, abuse, and misuse. This could reflect that the global drug control treaties are focused mostly on the illicit use and prevention of abuse of controlled medicines, rather than on a balanced approach.^30,31

Communication and collaboration between NCAs and prescribers improved in most of the countries. The NCAs of El Salvador and Venezuela who participated in the workshops left their positions shortly after their return. This may explain why the CC reported no improvement in the level of communication and collaboration with the NCA. It can be assumed that when an NCA leaves the job, whoever replaces him/her goes through a learning process during which things may slow down. In addition, prescribers have to dedicate time to build the relationship with the new NCA, which also takes time and dedication.

Nicaragua had the most challenges: the NCA did not participate in any workshop (regional or national) and there are no opioids available (although included in the list of essential medicines). Ecuador reported having only oxycodone available. The other countries have more than one opioid available, which allows for opioid rotation. The availability of only complex expensive delivery mechanisms such as prolonged release or transdermal formulations results in difficulties for titration and treatment maintenance.

The AP developed for Bolivia was successfully implemented after the workshop in 2011, when the Ministry of Health eliminated several barriers, including limits to the number of dosages per prescription and the number of days for which opioids could be prescribed. However, these changes were not socialized or announced by the government at the time, so the palliative care, pain physicians, and pharmacists were unaware they had been implemented and kept operating under the old rules. Not until four years later, during the second (national) workshop in 2015, they learned that these barriers were no longer in place. This example underscores the importance of building collaborative relationships between prescribers and the NCAs to keep the communication flowing. So even if the initial AP was implemented, the negative response by the participant may reflect the frustration of limited communication and collaboration.

We did not find a statistically significant increase in opioid consumption between 2010 and 2013. Availability and consumption are complex phenomena that depend on a wide spectrum of factors (limited education, limited resources, limited political will, political instability, etc.), hindering the evaluation of the effectiveness of the workshops. In addition, there is a time lapse between actual consumption and when the reports are published: Every June, NCAs are required to report consumption of controlled medications for the previous year to the INCB and the data get published in February of the following year (14 months after). Changes in laws and regulations take a few years and, thus, it may take longer for these changes to be reflected in consumption.

The analysis showed that the HDI is a strong predictive factor on absolute consumption and on trend.

Limitations

The qualitative responses to the survey were provided by a single person from each country (the CC) and, therefore, their views may not be shared by other participants in the workshops.

The quantitative outcomes used in this study (opioid consumption and changes in consumption and availability) have been used previously as indicators of palliative care development. We did not evaluate the effects of the workshops in other areas.

We did not consider regional differences on opioid availability within each country. The study did not evaluate the affordability and prices of opioids, which have been identified as factors impacting access.¹⁷

We are unable to predict whether the workshops will reflect changes in the future in the three outcomes included in this study. There are no studies assessing the time elapsed between a policy change and observed outcomes. The first workshop (Colombia) took place over seven years ago, whereas the last one (Bolivia) took place a year ago. Workshops do not happen in vacuum and it is not possible to evaluate the impact of all the variables in the outcomes.

Conclusions

Lack of access to pain treatment is a global crisis. There are many reasons behind this, including restrictive laws and regulations. The study described a method to identify and eliminate such barriers by developing an AP for the country by the relevant stakeholders. Strategies to eliminate such barriers need to be broad in scope and include clinical and government representatives to be effective, and it may take several years before results are observed. This underscores the importance of fluid communication and collaborative work between prescribers and government authorities. Additional studies are required to evaluate the specific barriers and limitations in the implementation of the countries' APs.

Footnotes

Acknowledgments

The workshops were funded by grants from the US Cancer Pain Relief Committee and Open Society Foundations. The authors thank the CCs for responding to the survey and all the participants and facilitators in the workshops.

Author Disclosure Statement

No competing financial interests exist.

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