International Pain Policy Fellowship Cohort III Country Report

International Pain Policy Fellowship, Cohort III Country Report : Sri Lanka

Country Report For SRI LANKA Part I Cancer Pain and Palliative Care Dr. N. Jeyakumaran MD Consultant Clinical Oncologist. Teaching Hospital, Jaffna Sri Lanka

Sri Lanka • Total Land area : 65, 610 Sq km • Population : 20. 2 Million Sri a Lank

Sri Lanka Nine Provinces. Nine Cancer Units

Cancer Pain and Palliative Care Management mainly at Cancer Hospitals. • One Cancer Unit in each province. – Varying pattern of pain management policies. • Pain Management. – Mainly By… • Oncologists. • Anaethetists. – WHO Pain Management. – Radiation treatment. – IV preparations.

No / 100, 000 Cancer Incidence in Sri Lanka

Cancer Pattern (1985 – 2005) Year Sex Number % CR ASR 1985 Male 2 564 51. 2 31. 7 34. 9 1990 Female 2 448 48. 8 31. 5 39. 4 Total 5 012 37. 6 Male 2 979 31. 6 49. 1 34. 4 38. 6 1995 Female 3 084 50. 9 37. 0 46. 9 Total 6 063 43. 1 Male 3 450 35. 7 47. 1 37. 3 43. 6 2000 Female 3 875 52. 9 43. 6 58. 6 Total 7 325 51. 2 Male 5 130 40. 4 47. 0 52. 0 63. 7 2005 Female 5 795 53. 0 61. 1 84. 9 74. 6 Total 10 925 Male 6 058 56. 4 45. 3 62. 3 68. 1 Female 7 314 54. 7 73. 4 73. 3 67. 9 70. 6 Total 13 372

Leading Cancer sites overall (2005) All Site No CR ASR Breast 1908 9. 7 Lip Oral Cavity & Pharynx 1617 8. 2 8. 7 Esophagus 1022 5. 6 Cervix Uteri 881 4. 5 4. 6 Trachea Bronchus & Lungs 832 4. 5 Thyroid 752 3. 8 3. 6 Colon & Rectum 741 3. 8 3. 6 Lymphoma 604 3. 1 3. 3 Ovary 596 3. 0 Leukaemia 570 2. 9 3. 0 13372 67. 9 70. 6 All Sites

Leading Cancer sites in Male (2005) Rank 1 Lip Oral Cavity & Pharynx 1240 12. 7 14. 1 2 Trachea Bronchus & Lung 666 6. 9 7. 7 3 Esophagus 498 5. 1 5. 8 4 Colon & Rectum 388 4. 0 4. 4 5 Lymphoma 360 3. 7 3. 9 6 Larynx 324 3. 3 3. 7 7 Leukaemia 313 3. 2 3. 3 8 Prostate 303 3. 1 3. 5 9 Unknown Primary Site 257 2. 9 10 Brain 171 1. 8 All Sites 6058 62. 3 68. 1 Site Male No CR ASR

Leading Cancer sites in Female (2005) Rank 1 Breast 2 Site Female No CR ASR 1859 18. 7 Uterine Cervix 881 8. 9 18. 3 8. 9 3 Ovary 496 5. 9 4 Thyroid 3592 5. 6 5 Oesophagus 524 5. 5 6 Lip Oral Cavity & Pharynx 377 3. 8 7 Colon & Rectum 353 3. 6 8 Leukaemia 257 2. 8 2, 8 9 Lymphoma 243 2. 5 10 Uterus 237 12. 4 All Sites 73. 4 73. 3

Source : GLOBOCAN 2008 Estimates

Source : GLOBOCAN 2008 Estimates

Cancer Mortality Data (1985 – 2003) Year No. of Cancer Deaths Crude Death Rate Proportionate mortality rate 1985 4416 27. 9 4. 5 1990 4479 26. 4 4. 6 1995 5710 31. 5 5. 5 2000 7, 842 41. 1 6. 7 2001 8063 42. 9 7. 1 2002 7986 42. 0 7. 1 2003 8, 396 43. 8 7. 3 2004 9, 127 47. 0 7. 9 2005 9, 403 47. 9 7. 1 2006 10, 386 52. 3 8. 8

National Cancer Control Programme. (NCCP) Director - NCCP. Policy - Is being drawn. Primary Prevention Cancer Research Cancer Surveillance (Cancer Registry) Cancer Prevention & Control Strategies Early Detection & Screening Diagnosis and Treatment Rehabilitation & Palliative Care

Role of Govt. in Pain Relief… • Education: – Specialist Training. • Palliative Care included. • Analgesics including Opioids. – Given Free of charge in all Hospitals • Policy towards improved Health Care

Pain Management at Cancer Hospitals • Most Cancer Patients present at Late Stages. • Govt. of Sri Lanka provides free Health Care. • Pain Management. – WHO method. – WHO Ladder is followed. – Opioid available in Cancer Hospitals. • Few hospices. • Training Programmes. – Need to be organized.

Availability of Pain Relief and Palliative Care Services • Places of Treatment. – At all Cancer Units. – At the Hospices. • Drugs: – Mild Analgesics. – Moderate Analgesics. – Strong Analgesics. – Adjuvant drugs. • For Children. – Oral solutions – Not available.

Hospices

Sathya Sai Suva Sevana

Play Therapy

Art Therapy

Art Therapy

Partners in Palliative Care • Training institutions. – Postgraduate Institute of Medicine. • Professional Organizations. – Sri Lanka Medical Association. – Sri Lanka College of Oncologists. • NGO – Sri Lanka Cancer Society. – Cancer Aid for North and East. • International Partners – WHO Palliative Care Centre. • Kerala Palliative Care Centre. • PPSG. • Pallium India & Trivendram Centres

Part II HIV/AIDS & Palliative Care Dr. Suraj Perera MBBS, MSc, MD Consultant Community Physician National Cancer Control Programme, Ministry of Health , Sri Lanka

Number of HIV cases reported up to end of 2011 Sri Lanka Period 1987 - 1989 1990 - 1994 1995 - 1999 2000 - 2004 2005 - 2009 2010 - 2011 Total Male Female Total % 13 3 16 1. 1 76 31 107 7. 3 101 80 181 12. 4 173 137 310 21. 2 344 238 582 39. 8 159 108 267 18. 2 866 597 1463 100. 00 Source : National STD/AIDS Control Programme, Ministry of Health, Sri Lanka

Trend of reported deaths due to AIDS in Sri Lanka 1987 -2009 Source: National STD/AIDS Control Programme, Sri Lanka. (2010).

Estimated number of adults and children living with HIV, new infections and AIDS deaths, 1990 -2009 Source: Prepared by www. aidsdatahub. org based on UNAIDS (2010). Global Report: UNAIDS Report on the Global AIDS Epidemic.

National STD/AIDS Control Programme Ministry of Health Anti Venereal Disease Campaign - established in 1952. With the advent of HIV/AIDS the Anti VD Campaign was restructured as the National STD/AIDS Control Programme (NSACP) in 1985, even before the first case of HIV infection was reported in Sri Lanka. Dr. Nimal Edirisinghe, Director National STD/AIDS Control Programme Ministry of Health No. 29, De Saram place, Colombo 10, Sri Lanka (94) 011 26 67163, (94) 011 533 6873 / (94) 011 2682859

Objectives for pain relief and palliative care in National STD/AIDS Control Programme • “To maintain the provision of HIV treatment, care and support services for people living with and affected by HIV/AIDS and occupational post exposure prophylaxis (o. PEP) for health care workers (HCWs) through the service delivery points of the National STD/AIDS control Programme or other relevant government health facilities in quality assured manner. ” • “To coordinate with and support institutions within and outside the Ministry of Health in the expansion of appropriate, high quality HIV treatment, care and support services for people living with and affected by HIV/AIDS and for o. PEP in Sri Lanka. ”

Availability of pain relief and palliative care services in the country for HIV/AIDS patients • Pain relief medications are available for HIV/AIDS patients. • But patients are not experiencing any ‘significant pain’ during their HIV/AIDS journey from diagnosis to death according to the verbal communication of staff of inward facility for AIDS Patients in Sri Lanka.

Part III : Opioid Availability

Opioid Availability - National Competent Authority (NCA) Medical Supplies Division (MSD), Ministry of Health Director / Medical Supplies Division, Ministry of Health submits annual estimates of medical requirements of narcotic drugs including Morphine

Calculating Annual estimates for Opoids • Medical Supplies Division (MSD) of Ministry of Health calculates annual estimates based on estimates send by the Directors of Hospitals in the line Ministry and Provincial Ministries of Health • Additional 10% is added, based on previous year consumption • MSD provides annual statistics to INCB

Palliative Care Pain Relief Drugs in Essential Medicines List Morphine & Tramadol is included (National Essential Medicine List Sri Lanka , 2009)

Opoid Analgesics available in Sri Lanka Opioid analgesic Dosage Form Generic / Trade Name Manufacturer Morphine 10 mg tablet ‘ ‘DURAMOR 10’ Biological E Ltd, India 30 mg tablet Morphine Sulphate Belco Pharma Ltd, India 30 mg tablet ‘ANAMORPH’ Sigma Pharmacetical Pty Ltd, Australia 30 mg tablet CR ‘DURAMOR 30’ Biological E Ltd, India 30 mg tablet ‘RELIMAL CR 30’ Pharmachemie BV Netherlands 15 mg/ml injection Morphine Sulphate Belco Pharma ltd, India 15 mg/ml injection Morphine Sulphate S Gmb. H/Germany Hospira Australia pty Ltd Hameln Pharmaceutical, Australia

Opoid Analgesics available in Sri Lanka Opioid analgesic Fentanyl Dosage Form Generic / Trade Name Manufacturer Fentanyl citrate S Gmb. H/Germany Hospira Australia pty Ltd Hameln Pharmaceutical, Germany 0. 05 mg/ml injection FENTANYL JANSSEN Janssen Pharmaceutica, , Belgium 0. 1 mg/2 ml injection Pethidine 100 mcg/2 ml injection TALGESIL Duo Pharma (M) Sdn, B hd, Malaysia 50 mg /ml injection Pethidine Belco Pharma Ltd, India 50 mg /ml injection Pethidine NEON Laboratories, India 50 mg /ml injection Pethidine S Gmb. H/Germany Hospira Australia pty Ltd Hameln Pharmaceutical, Germany 75 mg / 1. 5 ml injection Pethidine Belco Pharma Ltd, India

Additional Opioids which are needed Oral morphine liquid form Fentanyl dermal patches

Availability of Morphine • Sufficiently available most of the times at the Cancer Units. But the instant release Morphine tablets some times are out of stock. • Hospices receive oral morphine stocks from near by Cancer Units. Injectables are bought from Medical Supplies division. • The duration of Morphine prescribed is from one week – one month

Prescribing Morphine • Any registered Medical Practitioner at the Sri Lanka Medical Council (SLMC) can prescribe • No special prescription forms required • No special training required. • Nurses are not allowed to prescribe •

Prescribing Morphine • It is usually started using WHO Pain ladder concept from mild pain medicines to Strong Opioids. • Then doses are increased to achieve a good pain relief. • But when prescribing Morphine to take home the duration varies from 1 – 4 weeks from one cancer unit to other. • As long as the patient is not having much side effects, full course is given depending on the availability of drugs.

Prescribing Morphine • As Oral morphine is only available in the Government sector, when prescribe on a particular date, on the same day patient has to get the drug free of charge from the hospital pharmacy. ( This applies to all medications).

Prescribing Morphine • If a doctor violates general prescribing principles for any medications, he/ she can be called for explanations by the Ministry of Health Administration or Sri Lanka Medical Council. • Regulation does not require reporting names of patients who receive opioid prescriptions to the government.

Prescribing Morphine • Ministry of Health, Sri Lanka provide free health care through government hospitals through out the country. Therefore cost is not a factor for prescription of Opioids

Supply Chain of Opioids in Sri Lanka Medical Supplies Division (MSD) of Ministry of Health purchased all controlled drugs through the State Pharmaceutical Corporation (SPC) through competitive bidding via Global Tenders MSD directly supplies drugs to all hospitals (Teaching, Provincial General Hospitals, Special Hospitals including National Cancer Institute, Maharagama) belong to Line Ministry of Health. Drugs to hospitals belong to Provincial Ministries of Health are provided through the Regional Medical Supplies Divisions (RMSD) of 25 districts.

Mg/capita Consumption of Morphine, Sri Lanka, 1980 -2009 Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2011

Mg/capita Consumption of Fentanyl, Sri Lanka, 1980 -2009 Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2011

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