Cancer pain – progress and ongoing issues in Thailand

Thailand is an independent country that lies in the heart of Southeast Asia. It has approximately 65 million people. Approximately 80% of the population is ethnically Thai and 95% of all Thais are Buddhist (1). Based on the national statistical report, malignant neoplasm causes 12.8% of all deaths and has been the leading cause of deaths since 2004 (1). These data are consistent with the report on the hospital admission rates for people with cancer per 100,000 people, which has increased dramatically from 34.7 in 1994 to 89.4 in 2003 (2). Therefore, cancer is considered to be one of the major health issues in Thailand. The prevalence of cancer pain of those cancer patients admitted was approximately 62% (3). Nevertheless, cancer pain remains underdetected and undertreated in most cancer patients (4). A study to demonstrate prevalence, characteristics and patterns of management at a teaching hospital revealed that one-third of cancer patients with pain never received any pain control intervention. Approximately one-half of those with persistent pain only received treatment by requesting it and then ended up with only simple analgesics (5).

Challenges in cancer pain management

There are several challenges in cancer pain management in Thailand. First, there is the lack of education and resources. There is still inadequate undergraduate and postgraduate training in palliative care and pain management. Among 13 medical schools in Thailand, only six have a pain clinic and specialists (6). A study of physicians’ basic knowledge and attitudes toward pain medication in cancer patients revealed that 59.3% of recently graduated physicians and residents did not know how to start pain medication, 59.1% could not differentiate between physical and psychological dependence and 51.9% thought that most terminal cancer patients will develop opioid tolerance and addiction. The study suggested that the majority of physicians not only lacked knowledge of cancer pain management but also had negative attitudes toward treatment. In the same study, 86.4% of physicians identified their need to attend pain management courses (7).

Additionally, compared with other Asian countries, consumption of opioids in Thailand remains extremely low despite increased medical needs. According to the Global Report of Opioid Consumption in 2005 (8), annual consumption of morphine in Thailand is only 0.6219 mg per capita, which ranks it as 70th in global morphine consumption. Due to concern with eradication programs that tackle drug trafficking, Thai government policy limits the quantity and duration of opioid prescriptions. Currently, only 4 kg of morphine are consumed annually, although the expected amount of morphine to treat cancer pain is 1000 kg. A government hospital can access only 400 g of morphine, while private hospitals can have 50 g annually (9). In addition, the national health priorities have not included cancer pain relief. Thai health care society is still ‘opiophobic’ and reluctant to legitimize opioid analgesics because of the fear of addiction. The rigid drug policy restricts doctors and nurses in their ability to prescribe and use opioids, including those with adequate education and training and a willingness to use these drugs appropriately. In addition, access to other treatments such as radiotherapy is not equal in each region. Among 26 radiotherapy facilities in Thailand, 17 of them are in the central part of the country, with the majority in Bangkok. There are shortages of staff, including qualified radiotherapists, physicists and radiographers (10).

Finally, there are also several obstacles for patients and their family to manage cancer pain at home. According to a study on health problems experienced by Thai cancer patients and families, lack of education and fear of the side effects of the medications, especially respiratory depression and addiction, were among their major concerns (11). In the same study, as a result of limited supply of the opioids in primary care facilities, patients reported inconvenience in refilling their prescriptions.

Despite these obstacles, however, some progress has been made. In 1990, the Thai Association for the Study of Pain was established, and has subsequently had a strong influence in pain education and the development of effective pain management strategies. In 1992, the International Association for the Study of Pain, with sponsorship from the World Health Organization and the Ministry of Public Health, conducted a national workshop that acknowledged problems in cancer pain management and promoted the World Health Organization method of controlling cancer pain. Following this, participants issued a consensus recommendation that education and training in cancer pain management was needed, urging a review of the national legislation regarding drug use for medical purposes including specific guidelines on the use of opioids for cancer pain, with urgent consideration for forming a national policy for cancer pain management. In 2004, with the collaboration of the National Cancer Institute, the Thai Food and Drug Administration and the Thai Association for the Study of Pain, clinical practice guidelines for cancer pain management were successfully developed.

CONCLUSION AND RECOMMENDATIONS

Issues surrounding cancer pain management in Thailand are multidimensional, involving education for health care professionals and a rigid national drug policy, as well as negative public attitudes toward pain medications. These problems emphasize the importance of establishing more intensive educational programs, reviewing national drug legislation for medical purposes, and raising public awareness around palliative care and cancer pain management.