Page 338 Guide to Pain Management in Low-Resource Settings

326 David E. Joranson

Table 1
Lessons in the PPSG Internet Course*
Lesson 1: Understanding the Relationship between Pain and Drug Control Policy
Lesson 2: Th e Role of International and National Law and Organizations
Lesson 3: Barriers to Opioid Availability and Access
Lesson 4: WHO Guidelines to Evaluate National Opioids Control Policy
Lesson 5: WHO Guidelines to Evaluate National Administrative Systems for Estimating
Opioid Requirements and Reporting Consumption Statistics
Lesson 6: WHO Guidelines on Procurement and Distribution Systems for Opioid Analgesics
Lesson 7: How to Make Change in Your Country
* Th is is a self-paced noncredit course that can be taken at any one time or over a period of time.
It may take between 10 and 12 hours to complete. Each lesson has a pre-test and post-test; links
to background reading and many authoritative resources are provided. A certifi cate is issued upon
successful completion. Th e welcome and sign-in page is found at http://www.painpolicy.wisc.edu/
on-line_course/welcome.htm. Th e course is available only in English at present.

to Opioid Availability, which explains basics of pol- that physical dependence is an expected adaptation of
icy, as well as Guidelines for Achieving Balance in Na- the body to the presence of an opioid analgesic, and
tional Opioids Control Policy. Th e WHO Guidelines for that the withdrawal syndrome can be managed if the
Achieving Balance provides a framework for diagnosis opioid is stopped. Th e WHO no longer uses the term
of impediments in national drug control laws that has “addiction.” Th e current terminology is “dependence
been used extensively around the world. Th ese guide- syndrome,” which is a biopsychosocial condition, the
lines and the diagnostic checklist are available in 22 lan- markers of which are maladaptive behavior, compulsive
guages on the PPSG website at http://www.painpolicy. use, and continued use despite harm. However, in re-
wisc.edu/publicat/00whoabi/00whoabi.htm. ferring to dependence syndrome, use of the term “de-
From a practical point of view, what can clinicians pendence” by itself has the possibility of being confused
and government regulators do to improve cooperation? with physical dependence. Under these circumstances,
Table 2 presents recommendations from the it is important to be clear in clinical and scientifi c com-
WHO Guidelines for Achieving Balance about how munications whether one is referring to a diagnosis
health professionals and drug regulators can cooper- characterized by maladaptive behavior, or to physiolog-
ate through exchange of information and perspectives ical adaptation.
and establishment of mechanisms of communications Th e notion that morphine should only be used as a
and engagement. last resort is based on an outdated view of opioids and
addiction. Indeed, eff orts to prevent dependence/addic-
Do health professionals have beliefs tion that were based on this now outdated understand-
or attitudes that might interfere ing have led to excessively strict prescribing restrictions
with addressing opioid availability? that impede access. Examples include strict limits on
patient diagnoses that are eligible for opioid analgesics,
Possibly. Misinformation about the addictive potential restrictions on dosing and prescription amount, and
of opioids and confusing terminology have led to ex- complex prescription forms that require multiple ap-
aggerated concerns about the use of opioid analgesics provals and are diffi cult to obtain. Th ese matters are dis-
and overly strict regulations that impede eff orts to im- cussed more fully in the PPSG Internet course; articles
prove access to appropriate treatment for moderate to about progress to remove barriers in a number of coun-
severe pain. tries appear on the PPSG website.
Decades ago, experts said that mere exposure to If I want to assume more of a leadership role in my
morphine would inevitably result in “addiction.” At that country, is specialized training available?
time, addiction researchers studied the withdrawal syn- Yes. In addition to the Internet course, the PPSG
drome that occurs when opioid use is stopped abrupt- sponsors an International Pain Policy Fellowship (IPPF),
ly. Today in the fi eld of pain management, we know with support from the International Palliative Care