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 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
1985
1990
1995
2000
2005
Sex
Number
%
CR
ASR
Male
2 564
51.2
31.7
34.9
Female
2 448
48.8
31.5
39.4
Total
5 012
31.6
37.6
Male
2 979
49.1
34.4
38.6
Female
3 084
50.9
37.0
46.9
Total
6 063
35.7
43.1
Male
3 450
47.1
37.3
43.6
Female
3 875
52.9
43.6
58.6
Total
7 325
40.4
51.2
Male
5 130
47.0
52.0
63.7
Female
5 795
53.0
61.1
84.9
56.4
74.6
Total
10 925
Male
6 058
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
9.7
Lip Oral Cavity & Pharynx
1617
8.2
8.7
Esophagus
1022
5.2
5.6
Cervix Uteri
881
4.5
4.6
Trachea Bronchus & Lungs
832
4.2
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
3.0
Leukaemia
570
2.9
3.0
13372
67.9
70.6
All Sites
Leading Cancer sites in Male (2005)
Male
Site
No
CR
ASR
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
2.7
2.9
10
Brain
171
1.8
1.8
6058
62.3
68.1
All Sites
Leading Cancer sites in Female (2005)
Female
Site
Rank
1
Breast
2
No
CR
ASR
1859
18.7
Uterine Cervix
881
8.9
18.3
8.9
3
Ovary
496
5.9
5.9
4
Thyroid
3592
5.6
5.6
5
Oesophagus
524
5.5
5.5
6
Lip Oral Cavity & Pharynx
377
3.8
3.8
7
Colon & Rectum
353
3.6
3.6
8
Leukaemia
257
2.8
2,8
9
Lymphoma
243
2.5
2.5
10
Uterus
237
12.4
2.4
73.4
73.3
All Sites
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
Early
Detection &
Screening
Cancer
Research
Cancer
Surveillance
(Cancer
Registry)
Cancer
Prevention
& Control
Strategies
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
45
40
40
35
Number
30
28
25
22
20
18
15
10
10
5
0
15
14
2
2
3
2
11
11
11
12
9
3
Year
Source: National STD/AIDS Control Programme, Sri Lanka. (2010).
14
13
20
19
13
7
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 (oPEP) 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 oPEP 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
10mg 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
15mg/ml injection
Morphine Sulphate
Belco Pharma ltd, India
15mg/ml injection
Morphine Sulphate
S GmbH/Germany Hospira Australia
pty Ltd Hameln Pharmaceutical,
Australia
Opoid Analgesics available in Sri Lanka
Opioid
analgesic
Fentanyl
Pethidine
Dosage Form
Generic / Trade
Name
Manufacturer
100mcg/2 ml injection
Fentanyl citrate
S GmbH/Germany Hospira Australia
pty Ltd Hameln Pharmaceutical,
Germany
0.05mg/ml injection
FENTANYL JANSSEN
Janssen Pharmaceutica,, Belgium
0.1mg/2 ml injection
TALGESIL
Duo Pharma (M) Sdn, B hd, Malaysia
50mg /ml injection
Pethidine
Belco Pharma Ltd, India
50mg /ml injection
Pethidine
NEON Laboratories, India
50mg /ml injection
Pethidine
S GmbH/Germany Hospira Australia
pty Ltd Hameln Pharmaceutical,
Germany
75mg / 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
THANK YOU