| | "Notice: this article appears on the PPSG website with the express permission of the copyright holder, who should be consulted for further permission to reproduce." |
This new cancer pain relief policy has been developed in a country that 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 eradicated within 3 years in the early 1950s, the disaster caused by opium has deep roots in the minds of the Chinese people. One result was the strict control of all opioid analgesics for clinical use, with the aim of limiting nonmedical use. However, this control severely limited access to opioids 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 Drugs; Estimated World Requirements--Statistics 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-step analgesic ladder for cancer pain was introduced to Chinese medical professionals by Dr. Jan Stjernswärd of the World Health Organization, and, in 1991, the Ministry of Health issued a document to spread the summary of the Guangzhou 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. Sun Yan from the Cancer Hospital of the Chinese Academy of Sciences, had been distributed to major hospitals throughout the country. More opioid analgesics, including the first sustained release oral morphine preparations, became available. With changes in supply and regulation, doctors could at last prescribe morphine at doses that could relieve pain.
In 1992, an international meeting on cancer pain relief and palliative care was held in Beijing, sponsored by the Beijing Bureau of Public Health with the cooperation of the Pain Research Group and WHO Collaborating Center for Symptom Evaluation in the USA. The meeting was chaired by Dr. Gou Shou-Zheng and included many international participants, including Prof. Fumikazu Takeda of the WHO Collaborating Center in Japan. Distinguished Chinese oncologists and public health officials also took part. Mr. Chen Yin-Qing, of the Bureau of Drug Administration and Policy, unveiled major changes in opioid control policy at that time. This came as the first of a series of official "red headed documents" (so called because of their importance) directed at improving cancer pain management in the country.
One of the most important activities in improving cancer pain relief has been the cooperative program between the Pain Research Group of the University of Wisconsin, led by Charles Cleeland, and the Ministry of Health, Bureau of Drug Administration and Policy. Meeting in Madison, Wisconsin, USA, in March 1993, the Pain Research Group and the Ministry of Health signed a document outlining a 3-year collaborative program. This program specified a strategy to implement the Chinese Cancer Pain and Palliative Care Program.
During the first phase of this 3-year program, five national training seminars were held by the Ministry of Health and the Pain Research Group in geographically distributed Chinese population centers, including Beijing (June 1993), Shanghai (December 1993), Chengdu (March 1994), Guangzhou (December 1994), and Xian (April 1995). More than 500 medical professionals, including doctors, nurses, pharmacists, and administrators from various provinces, have participated. Experts from the Pain Research Group, other U.S. institutions, and China gave presentations on WHO and U.S. cancer pain guidelines, pain assessment, opioid pharmacology and efficacy, case studies of cancer pain management, and opioid policy and regulations.
While China has many professors who understand pain management, a major concern has been to prepare a younger generation of health professionals to teach cancer pain relief to other doctors, pharmacists, and nurses throughout the country. To this end, the Pain Research Group and the Bureau of Drug Administration and Policy organized a 3-week intensive training course at the Tianjin Tumor Hospital, hosted by its director, Prof. Hao Xi-Shan. Core teams from Tianjin, Guangzhou, and Shanghai attended. Each team comprised a doctor, nurse, and pharmacist. Volunteer experts from the Pain Research Group, The University of Wisconsin Cancer Center, Fox Chase Cancer Center, Massachusetts General Hospital, Johns Hopkins Hospital, Rush-Presbyterian--Saint-Luke's Medical Center, and Memorial Sloan-Kettering Cancer Center taught the Chinese core teams about cancer pain assessment, titration of drugs, monitoring of patients, management of side effects, and how to teach cancer pain management and palliative care. Each day included the collaborative care of cancer patients with pain, a critical aspect of the training.
During this same period, the Bureau of Drug Administration and Policy finished the translation of both the abbreviated form of the "Cancer Pain Management" booklet and the Management of Cancer Pain--Patient Guide, published by the U.S. Agency for Health Care Policy and Research (AHCPR). These booklets have been disseminated to hospitals as teaching materials for health professionals and cancer patients. In cooperation with members of the Pain Research Group, Chinese experts at Tianjin Tumor Hospital and other institutions have translated the full text "Clinical Practice Guideline--Management of Cancer Pain" published by the AHCPR. It will be a major reference for Chinese oncologists in their clinical practice of cancer pain relief. A Chinese-character version of a pain assessment tool, the Brief Pain Inventory has been developed as a way of improving cancer pain assessment, clinical research, and program evaluation.
Chinese experts have conducted dozens of seminars on cancer pain management, both locally and regionally throughout the country. Many health professionals have been taught by Profs. Li Tong Du, Professor of Surgical Oncology, Anhui Tumor Hospital, and Cai Zhiji, Director of the National Institute on Drug Dependence, who have provided leadership for the program among Chinese health care professionals. Major figures in the Chinese oncology community, including Profs. Hao Xi-shan, Sun Yan, and Xu Guang-wei, have offered support to the program throughout China.
During the first national seminar in Beijing (1993), a survey on attitudes of health professionals about the use of opioid analgesics, authored by David Joranson, Director of Policy Studies of the Pain Research Group, was conducted. More than 100 health professionals participated. Ten major barriers on the use of opioid analgesics for cancer pain relief were ranked, and published in the Chinese Bulletin on Drug Dependence.1 Concern about addiction ranked high. This study has been 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 provinces in China. The survey indicated that 17% of the medical professional have received pain relief training at a national or regional level. The survey indicated that the fear of addicting patients 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 Ministry of Health signed an additional 3-year agreement for program progress at the Pain Research Group in Madison. This new agreement stresses the importance of in-depth training similar to the Tianjin program 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. Gu Wei-ping and Zhang Hong of the Bureau, along with David Joranson, have worked out a plan to monitor changes in opioid consumption and diversion, and to develop model hospital policies for handling opioids.
A program to provide pain relief for all Chinese cancer patients has begun, but many barriers will need to 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 program is one illustration of how government and health-care professionals can work together in a systematic way to relieve pain for those who suffer with cancer.