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People's Republic of China: Status of cancer pain and palliative care
People’s Republic of China: Status of Cancer Pain and Palliative Care
The Bureau of Drug Administlalion and Policy, Minisrry of Health. People’s Repchlic of China, together with nongovernmental organizations, has begun an unprecedemed effort to improve pain relief for the millions of cancer patients in China. The centerpiece 01 the new Chinese program is a national cancer pain relief poliry, adopted in 1392. To address a major obstacle to cancer pain lrcatment in China, namely, the restricted xailability of morphix and other opioids due LO tight r-q+lation and limited supply, the government has adjusted national narcotics control policy: approved new opioid analg&cs for sale and distribution; increased opioid manufacturing through joint venLures and other means; and streamlined procedures for hospitais to obtain suflicienr opioids. Because increases in analgesic availabilir, need IO be matched by assuring professional competence in the use of opioids, the Ministry of Health has also sponsored the training of a large number of professionals. including physicians. pharmacists, nutxs, and public health oIlkids; published guidelines for cancer pain management: distributed patient educational materials; and joined in a program of climcal research and policy studies. In 1994, as a direct result of this program, the consumption of morphine for mstiical purposes increased significantly for the first time in recent Chinese history.
reprint wquests lo: David E. Joranson. Pain Research Group. 19GO University Madison. WI Ei37OS-4013. iJsIL Addms
MSSW, Avenue,
This new cancer pain relief policy has heen developed in a country ham has a long history of concern with opioid addiction. It is estimated that there were roughly 20 million opium addicts before the founding of the People’s Republic. Although opioid addiction ‘was eradiwtcd within 3 years in the early 195Os, the disastel caused by opium has deep roots in the minds of the Chinese people. One result was the strict control of all opioid analgesik for clinical US. with the .aim of limiting nonmedical use. Howevw this control severely limited access LO opb ids for pain management. In 1993. the morphine consumption per capita in China was only 0.01 mg while the figure in Denmark was 66.53 mg and in the United States, 20.80 mg (United Nations International Narcotics Control Board: Narcotic Drug; Estimated World RequirementsSlatistics for 1993) The stimulus for change began in 1990, when a scientific symposium on cancer treatment was held in Guangzhou. The World Health Organization’s (WHO) three+tep analgesic ladder for cancer ‘pain ws introduced to Chinese medical professionals by Dr. Jan Stjernsward of the World Health Organization, and. in 1991. the Ministry of Health issued a document to spr-ead the summary of the Cuangzhou meeting and the WHO guidelines on cancer pain relief and palliative care. The Ministry of Health promulgated a new policy on pain management in 1992. By the end of 1993. 80,000 copies of the Chinese translation of the WHO monograph on cancer pain relief and palliative care methods, translated by Prof. 0885s9!!4/9G/$15.00 PII so885s924(96)ooo942
&II Yan from the Cancer Hospital of the Chinese Academy of .&icncn, had been distributed to major hospitals throughout the country More opioid analgesics, including the first sustinedrelease oral morphine preparations, became a\ailah!e. With changes in supply and regulation, doctors could ai last prescribe morphine at doses that could relieve pain. In 1992. an international meeting on cancer pain l-clef and palliative care wxs held in Bejjing. qwnsored by rhe Beijing Bureau of’ Public Health with the cooperation of the Pain Research Group and WHO Collaborating Ccnter for Symptom Ewluauon in the CSA The meetinp wds chaired by Dr. Cou ShowZheng and included many inrernadonal participanrs. including Prof. Fumikazu Takeda of the WI10 Collaborating Center in Japan. Distinguished Chinese oncologists and public health officials ah took pan Mr. Chen Y~nQing, of the Bureau of Drug Administration and Policy, unveiled major changes in opioid control policy at that time. This came as the firer of a series of official “red head-d documents” (so called because of their importance) directed at imprcning cancer pain management in the counlr): One of the most important activities in improving cancer pain relief has hecn the coop eralive program between the Pain Research Group of the University of Wisconsin, led by Charles Cleeland. and the Mnislry of Health, Bureau of Drug Administration and P4icy. ihdeetiug in Madison, Wisconsin, USA. in March 1993, Ihe Pain Reseal-& Group and the Ministry of Health signed a documenr ourlining a .%year rollabowti~e progrm. This program specified a strategy 10 implement Lhe Chinese Cancer Pain and Palliative Care Program. During the first phase of this %year program, fiive national training seminars were held hy the Ministry of Health and the Pain Research Group iu geographically disrriba!ed Chinese population centers. including Beijing uune 1993). Shanghai (December 1993), Chengdu (March 1994), Guangzhou (Deccmher 1994), and Xian (April 1995). More than 500 medical professionals, including doctors. nurses. pharmacisb. and administrarors from various provinces, have participaled. Expcru from the Pain Research Group, other U.S. institutions. and China gave presentations on M’HO and U.S. cancer pain guidelines, paiu assessment, opioid pharmacology and eficacy,
case studies of cancer pain managcmcnt, and npioid poliq and regldacions. While China has many professors who undentand pain management, a major concern has heen lo prepare a younger generation of health professionals 10 teach cancer pain relief to orher doctors, pharbnacisu, and nurses throughoul the countrv. To this end. the Pain Research Group and’rhe 3iueau of Drug Administration and Policy organized a s-week intensive training course at the Tianjin Tumor Hospital, hoswd by its direcror. Prof. Hao Xi-Shall. Core reams from I’iaujirr, Guangzhou. and Shanghai attended. Each team comprised a doctor, muse, and pharmacist. Volunteer experts from the Pain ReMarch Group. The University of M’isconsin Cancer Center, Fox Chase Cancer Center, Hawchu5etts C&w-al Hospiral, Johns Hopkins Hospital, Rush-Presbyterian-Saint-Luke’s Medical Center, and Memorial Sloan-Kel~erin;: Gncer Center taught Lhe Chinese core teams about cancer pain assewmenr, tirrakion of drugs, monitoring of paliens. managemenr of side effects. and how 10 teach cancer pain management and palliative care. Each day included the collaboativc exe of cancer patients with pain. a critical aspect of the training. Durmg this same period, the Bureau of Drug Administration and Policy finished the translation of both the abbrc-iated form of the “Cancer Pain Managemeru” booklet and the Managemrnr of Cancer Pain-Patient Guide, published by the U.S. Agency for Health Care Policy and Research (AHCPR). These book& have been dirssminated 10 hospirals as tcaching materials for hrallh xofessionals and cancer padenn. In cooper&on with members of Lhe Pain Resparch Gror.p. Chinese cxperls al Tianjin Tumor Hospital and orhcl- institutions have translated rhe full tern “Cliniral Practice Guideline-Management of Cancer Pain” published by rhe AHCPR. Ir mill be a major reference for Chinese oncologisrs in their clinical practice of canrer pain relief. A Chinesesharactcr version of a pain assessment iool. the Brief Pain Invcn~o~ has bet!n develaped as a ~-a?‘ of imp]-oving cancer pain awx~smerit. clinical research. and program e\ah!zlion. Chinese esperts have condncred dozens ofseminars on cancer pr-in managcmenL, both locals;: and region-ally throughout &hc countrr:
Many health professionals have been taught by Profs. Li Tong Du. Professor of Surgical Oncology, Anhui Tumor Hospital. and Cai Zhi-ji, Director of the Nalional Institute on Drug Dependence. who have provided lcadership for the program among Chinese health care professionals. Major figures in the Chinese oncology community, including Profs. Hao Xi-shan, Sun Yan, and Xu Gtrang-wei, have offered support to the pt-ognm throughout China. During the firs1 national seminar in Beijing (1993). a survey on attitudes of health professionals about the t-se of opioid analgesics. authored hy David Joranson, Director of Policy Studies of the Pain Research Group, was COW ducted. Mo1.e than 100 health professionals participated. Ten major harricts on the use 01‘ opioid analgesics for cancer pain relief were ranked, and published in the Chinese Bulletin on Drug Dependence.’ Concern ahout addiction ranked high. This study has hcrn repeated at other national seminars. In 1995. the Bureau conducted a survey on cancer pain management among 466 medical professionals in 93 hospitals in nine provincrs in China. The survey indicated that 1576 of the medical professional have mccivetl pain r&et” tmining at a national or regional level. The survey indi‘cated that the fear of addicting patier.ts is a major barrier for medical professionals in prescribing opioid analgesics. stressing the need for training in the nature and use of these analgesics.
In July of 1995. the !.4inistry of Health signed an additional 3-yLar agreement for pr* gram progress BI the ?ain Research Group in Madison. This nra agreement stresses the impottanre of ‘r~+lcpth training similar to the Tianjin progtam of core-team training, and recognizes the need for a comprehensive clinical and epidemiological research program to support the cancer pain relief effort. The effect of changes in opioid availability and regulation will also be studied. Cu Peiping and Zhang Hong of the Bureau, along with David Jomnson, have worked out a plan to monitor changes in opioid consumption and diversion, and to develop model hospital policies for handling opioids. .t program to provide pain relief for all Chinese cancer patients has begun, hut many barriers will need LO be overcome. This progress is occurring in a country where the fear of the use of morphine and other opioids has traditionally been very high, and government control of these drugs has been very restrictive. The pl-ogtam is one illustration of how government and health-care professionals can work together in a systematic w-y to relieve pain for those who suffer with cancer.
1. Joranson DE. Cai Zhi-ji. Gilson A. Barriers to opioid availability in Chino. Chin Bull Drug Depend 1995;4:8&91.
The Bureau of Drug Administlalion and Policy, Minisrry of Health. People’s Repchlic of China, together with nongovernmental organizations, has begun an unprecedemed effort to improve pain relief for the millions of cancer patients in China. The centerpiece 01 the new Chinese program is a national cancer pain relief poliry, adopted in 1392. To address a major obstacle to cancer pain lrcatment in China, namely, the restricted xailability of morphix and other opioids due LO tight r-q+lation and limited supply, the government has adjusted national narcotics control policy: approved new opioid analg&cs for sale and distribution; increased opioid manufacturing through joint venLures and other means; and streamlined procedures for hospitais to obtain suflicienr opioids. Because increases in analgesic availabilir, need IO be matched by assuring professional competence in the use of opioids, the Ministry of Health has also sponsored the training of a large number of professionals. including physicians. pharmacists, nutxs, and public health oIlkids; published guidelines for cancer pain management: distributed patient educational materials; and joined in a program of climcal research and policy studies. In 1994, as a direct result of this program, the consumption of morphine for mstiical purposes increased significantly for the first time in recent Chinese history.
reprint wquests lo: David E. Joranson. Pain Research Group. 19GO University Madison. WI Ei37OS-4013. iJsIL Addms
MSSW, Avenue,
This new cancer pain relief policy has heen developed in a country ham has a long history of concern with opioid addiction. It is estimated that there were roughly 20 million opium addicts before the founding of the People’s Republic. Although opioid addiction ‘was eradiwtcd within 3 years in the early 195Os, the disastel caused by opium has deep roots in the minds of the Chinese people. One result was the strict control of all opioid analgesik for clinical US. with the .aim of limiting nonmedical use. Howevw this control severely limited access LO opb ids for pain management. In 1993. the morphine consumption per capita in China was only 0.01 mg while the figure in Denmark was 66.53 mg and in the United States, 20.80 mg (United Nations International Narcotics Control Board: Narcotic Drug; Estimated World RequirementsSlatistics for 1993) The stimulus for change began in 1990, when a scientific symposium on cancer treatment was held in Guangzhou. The World Health Organization’s (WHO) three+tep analgesic ladder for cancer ‘pain ws introduced to Chinese medical professionals by Dr. Jan Stjernsward of the World Health Organization, and. in 1991. the Ministry of Health issued a document to spr-ead the summary of the Cuangzhou meeting and the WHO guidelines on cancer pain relief and palliative care. The Ministry of Health promulgated a new policy on pain management in 1992. By the end of 1993. 80,000 copies of the Chinese translation of the WHO monograph on cancer pain relief and palliative care methods, translated by Prof. 0885s9!!4/9G/$15.00 PII so885s924(96)ooo942
&II Yan from the Cancer Hospital of the Chinese Academy of .&icncn, had been distributed to major hospitals throughout the country More opioid analgesics, including the first sustinedrelease oral morphine preparations, became a\ailah!e. With changes in supply and regulation, doctors could ai last prescribe morphine at doses that could relieve pain. In 1992. an international meeting on cancer pain l-clef and palliative care wxs held in Bejjing. qwnsored by rhe Beijing Bureau of’ Public Health with the cooperation of the Pain Research Group and WHO Collaborating Ccnter for Symptom Ewluauon in the CSA The meetinp wds chaired by Dr. Cou ShowZheng and included many inrernadonal participanrs. including Prof. Fumikazu Takeda of the WI10 Collaborating Center in Japan. Distinguished Chinese oncologists and public health officials ah took pan Mr. Chen Y~nQing, of the Bureau of Drug Administration and Policy, unveiled major changes in opioid control policy at that time. This came as the firer of a series of official “red head-d documents” (so called because of their importance) directed at imprcning cancer pain management in the counlr): One of the most important activities in improving cancer pain relief has hecn the coop eralive program between the Pain Research Group of the University of Wisconsin, led by Charles Cleeland. and the Mnislry of Health, Bureau of Drug Administration and P4icy. ihdeetiug in Madison, Wisconsin, USA. in March 1993, Ihe Pain Reseal-& Group and the Ministry of Health signed a documenr ourlining a .%year rollabowti~e progrm. This program specified a strategy 10 implement Lhe Chinese Cancer Pain and Palliative Care Program. During the first phase of this %year program, fiive national training seminars were held hy the Ministry of Health and the Pain Research Group iu geographically disrriba!ed Chinese population centers. including Beijing uune 1993). Shanghai (December 1993), Chengdu (March 1994), Guangzhou (Deccmher 1994), and Xian (April 1995). More than 500 medical professionals, including doctors. nurses. pharmacisb. and administrarors from various provinces, have participaled. Expcru from the Pain Research Group, other U.S. institutions. and China gave presentations on M’HO and U.S. cancer pain guidelines, paiu assessment, opioid pharmacology and eficacy,
case studies of cancer pain managcmcnt, and npioid poliq and regldacions. While China has many professors who undentand pain management, a major concern has heen lo prepare a younger generation of health professionals 10 teach cancer pain relief to orher doctors, pharbnacisu, and nurses throughoul the countrv. To this end. the Pain Research Group and’rhe 3iueau of Drug Administration and Policy organized a s-week intensive training course at the Tianjin Tumor Hospital, hoswd by its direcror. Prof. Hao Xi-Shall. Core reams from I’iaujirr, Guangzhou. and Shanghai attended. Each team comprised a doctor, muse, and pharmacist. Volunteer experts from the Pain ReMarch Group. The University of M’isconsin Cancer Center, Fox Chase Cancer Center, Hawchu5etts C&w-al Hospiral, Johns Hopkins Hospital, Rush-Presbyterian-Saint-Luke’s Medical Center, and Memorial Sloan-Kel~erin;: Gncer Center taught Lhe Chinese core teams about cancer pain assewmenr, tirrakion of drugs, monitoring of paliens. managemenr of side effects. and how 10 teach cancer pain management and palliative care. Each day included the collaboativc exe of cancer patients with pain. a critical aspect of the training. Durmg this same period, the Bureau of Drug Administration and Policy finished the translation of both the abbrc-iated form of the “Cancer Pain Managemeru” booklet and the Managemrnr of Cancer Pain-Patient Guide, published by the U.S. Agency for Health Care Policy and Research (AHCPR). These book& have been dirssminated 10 hospirals as tcaching materials for hrallh xofessionals and cancer padenn. In cooper&on with members of Lhe Pain Resparch Gror.p. Chinese cxperls al Tianjin Tumor Hospital and orhcl- institutions have translated rhe full tern “Cliniral Practice Guideline-Management of Cancer Pain” published by rhe AHCPR. Ir mill be a major reference for Chinese oncologisrs in their clinical practice of canrer pain relief. A Chinesesharactcr version of a pain assessment iool. the Brief Pain Invcn~o~ has bet!n develaped as a ~-a?‘ of imp]-oving cancer pain awx~smerit. clinical research. and program e\ah!zlion. Chinese esperts have condncred dozens ofseminars on cancer pr-in managcmenL, both locals;: and region-ally throughout &hc countrr:
Many health professionals have been taught by Profs. Li Tong Du. Professor of Surgical Oncology, Anhui Tumor Hospital. and Cai Zhi-ji, Director of the Nalional Institute on Drug Dependence. who have provided lcadership for the program among Chinese health care professionals. Major figures in the Chinese oncology community, including Profs. Hao Xi-shan, Sun Yan, and Xu Gtrang-wei, have offered support to the pt-ognm throughout China. During the firs1 national seminar in Beijing (1993). a survey on attitudes of health professionals about the t-se of opioid analgesics. authored hy David Joranson, Director of Policy Studies of the Pain Research Group, was COW ducted. Mo1.e than 100 health professionals participated. Ten major harricts on the use 01‘ opioid analgesics for cancer pain relief were ranked, and published in the Chinese Bulletin on Drug Dependence.’ Concern ahout addiction ranked high. This study has hcrn repeated at other national seminars. In 1995. the Bureau conducted a survey on cancer pain management among 466 medical professionals in 93 hospitals in nine provincrs in China. The survey indicated that 1576 of the medical professional have mccivetl pain r&et” tmining at a national or regional level. The survey indi‘cated that the fear of addicting patier.ts is a major barrier for medical professionals in prescribing opioid analgesics. stressing the need for training in the nature and use of these analgesics.
In July of 1995. the !.4inistry of Health signed an additional 3-yLar agreement for pr* gram progress BI the ?ain Research Group in Madison. This nra agreement stresses the impottanre of ‘r~+lcpth training similar to the Tianjin progtam of core-team training, and recognizes the need for a comprehensive clinical and epidemiological research program to support the cancer pain relief effort. The effect of changes in opioid availability and regulation will also be studied. Cu Peiping and Zhang Hong of the Bureau, along with David Jomnson, have worked out a plan to monitor changes in opioid consumption and diversion, and to develop model hospital policies for handling opioids. .t program to provide pain relief for all Chinese cancer patients has begun, hut many barriers will need LO be overcome. This progress is occurring in a country where the fear of the use of morphine and other opioids has traditionally been very high, and government control of these drugs has been very restrictive. The pl-ogtam is one illustration of how government and health-care professionals can work together in a systematic w-y to relieve pain for those who suffer with cancer.
1. Joranson DE. Cai Zhi-ji. Gilson A. Barriers to opioid availability in Chino. Chin Bull Drug Depend 1995;4:8&91.