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Skip to 0 minutes and 9 seconds As you can imagine, some patients at the end of life have symptoms that are difficult to deal with. Not surprisingly, pain is one. Indeed, uncontrolled pain has been a major driver in developing palliative care services. The average consumption of morphine in Europe is 80 milligrammes per capita per year. A typical country would be the Netherlands. In the Netherlands, opioids are easily available when there is an indication for using them. GPs, medical specialists, and under a new law, trained nurse practitioners have to subscribe the opioids. And they are always must be delivered by a pharmacist. In the nationwide guideline concerning pain and cancer care published in 2008, opioids are described as one of the pharmaceutical treatment options.

Skip to 1 minute and 0 seconds In this guideline, the WHO analgesic ladder forms the basis of a step wise procedure which has to be used in the treatment of pain. However, the guidelines states that step 2 of the WHO letter, the prescription of weak opioids must be omitted. Since the guideline is introduced, we know that structured pain assessment using a pain instrument was rarely used. Also the registration of pain and medication records was done poorly. Although in the Netherlands, medication for pain like opioids are easily available, the overall treatment of pain could be improved for patients with cancer.

Skip to 1 minute and 45 seconds We need to change the attitudes towards pain management. Other countries have much lower rates of morphine consumption. A useful set of videos entitled Life Before Death demonstrates the difficulties some countries face in accessing opioids. There is a link to these videos on this week’s page. Some countries in Europe have developed palliative care more recently and have really started to tackle opioid availability. An example of this is Hungary with an average consumption of 62 milligrammes per capita per year. Most long acting strong and weak opioids are steadily available in Hungary. Fentanyl is the most used opioid in the country, taking about up 90% of all strong opioids used in the country. There is a limited availability of short-acting strong opioids.

Skip to 2 minutes and 38 seconds Only morphine injectable and tablets can be prescribed.

Skip to 2 minutes and 44 seconds The [INAUDIBLE] short-acting strong opioids and not available in Hungary. All doctors can prescribe opioids in an emergency or an acute case, but the long-term prescribers are the GPs in the country. In a minority of countries, opioid use is very high such as in Germany at 330 milligrammes per capita per year. I think we are very comfortable in Germany. There is a wide range of opioids. All opioids and types of application, including immediate release and slow release forms available. Methadone is used for substitution only in Germany, but levomethadone is available for pain management. Heroine or diamorphine is available for substitution in some model centres, but not for pain management.

Skip to 3 minutes and 36 seconds The amount of opiates prescribed is huge, but no detailed information about what proportion is used for palliative care. The larger proportion is used for chronic pain management. And as in the US, there is some discussion that this group of patients may be over treated with opioids by now. This is, for example, highlighted in the recent guidelines on long-term opioid therapy for non-cancer pain.

Pain control

The management and control of pain is incredibly important, with opioid availability considered to be a marker of good palliative care.

In this film, speakers discuss the availability, use and consumption of opioids across different European countries.

Additional reading

For those of you who are interested, you can find some optional reading in the downloads section below.

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Palliative Care: Making it Work

Lancaster University