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Strong opioids are a cornerstone of pain treatment, of which morphine is considered an essential analgesic by the World Health Organization. Access to opioids is limited, due to restrictive laws, limited education, and high prices. This is the second phase of a global project to monitor and report the dispensing price of opioids with the specific aim to expand and increase the information and allow further analysis of the challenges in their availability and affordability.Participants were asked to provide the lowest dispensing price of the smallest selling unit and lowest strength of five opioids in 13 formulations from a licensed pharmacy located closest to a public facility that provides diagnosis/treatment for life-threatening conditions. Data were collected from July 2015 to March 2016. Average availability, median (Me), and interquartile range (IQR) price were calculated for four gross national income (GNI) categories: higher income countries (HIC), upper middle income countries (UMIC), low middle income countries (LMIC), and low income countries (LIC). Affordability for one month of treatment with morphine immediate release (IR) tablet was also calculated.Data were submitted by 67 participants from 43 countries. Availability is strongly related to GNI level (Kruskal-Wallis tests p 0.0001). Mean price for morphine IR tablets for a 30-day treatment within the GNI categories ranged between USD 3.28 and 376; average USD 78.5 (SD = 92, Me = 49.7, IQR = 80.5). Methadone oral liquid and hydromorphone slow release were the lowest priced (Me = 13.1, IQR = 70 and Me = 14.9, IQR = 89.1, respectively). Morphine IR tablet is less affordable in countries in lower income groups: LIC (mean = 54.1 ± 0.873, Me = 54.1); LMIC (mean = 21.1 ± 19.6, Me = 10.6); UMIC (mean = 14.1 ± 14.1, Me = 10.23); and HIC (mean = 3.2 ± 5.2, Me = 1.33). A negative correlation between the number of days and the countries' income category (Rs = -0.7; p 0.001) was identified.Patients in LIC and MIC have less access to opioid medications. This highlights the need to continue efforts at improving access, availability, and affordability.

Research in palliative care has increased significantly in the last decade, while the vast majority of the global disease burden occurs in developing countries.To explore the palliative care research activity in Latin America and the Caribbean (LAC) and its visibility in the international palliative care literature, with a special focus on research studies.A bibliometric analysis was conducted in MEDLINE(®), Embase(®), PsycINFO(®), and CINAHL(®). Inclusion criteria were: (1) articles published in peer-reviewed scientific journals; (2) main subject was palliative care; (3) research study; (4) the first author or coauthors was based in LAC; and/or (5) the data collected derived from LAC.One hundred six articles from 10 countries were identified in the literature research. The first publication dates from 1989 and was a qualitative study in Brazil. This study shows a modest contribution of publications from LAC. However, the volume of publications within the region is distributed unequally, reflecting the heterogeneity of the region: Brazil published more than half of the articles, while 35 countries have no publications. Most of the studies were quantitative research, predominantly cross-sectional studies. Qualitative studies often used interviews. Health care service was the most researched issue. Seventy percent of studies were carried out in institutions.Palliative care research should have a place in LAC. The development of a regional research agenda tailored to the needs and features of the region considering the health care structure and local resources available is indispensable.

The aim of this study was to determine by consensus the components of an opioid essential prescription package (OEPP) to be used when initiating a prescription for the control of moderate to severe chronic pain. Palliative care physicians (n=60) were sampled from the International Association for Hospice and Palliative Care (IAHPC) membership list to represent a range of countries of varying economic levels and diverse geographical regions. Using a Delphi study method, physicians were asked to rank preferences of drug and dosing schedule for first-line opioid, antiemetic, and laxative for the treatment of adults with chronic pain due to cancer and other life-threatening conditions. Overall response rates after two Delphi survey rounds were 95% (n=57) and 82% (n=49), respectively. A consensus (set at ≥75% agreement) was reached to include morphine as first-line opioid at a dose of 5 mg orally every 4 hours. Consensus was reached to include metoclopramide as a first-line antiemetic, but there was no consensus on "regular" or "as needed" administration. No consensus was reached regarding a first-line laxative, but a combination of senna and docusate secured 59% agreement. There was consensus (93% agreement) that laxatives should always be given regularly when opioid treatment is started. Further work is needed to establish a recommended dose of metoclopramide and a type and dose of laxative. The resulting OEPP is international in scope and is designed to ensure that opioids are better tolerated by reducing adverse effects of opioids, which could lead to more sustained improvements in pain management.

Dear Editor: Noncommunicable diseases (NCDs) are the leading global cause of death worldwide. Of the 57 million deaths that occurred in 2008, 36 million were due to NCDs, mainly cardiovascular diseases, cancers, diabetes, and chronic lung diseases. The World Health Organization (WHO) Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases addresses key components of surveillance, prevention, and care. The proposed monitoring framework includes indicators of outcomes, exposures, and health systems capacity and response. For several years the palliative care community has advocated for systematic monitoring of palliative care at national and global levels. Although several palliative care organizations report on the status of palliative care development, WHO member states have no obligation to monitor or report on palliative care, and available reports have had limited impact on the provision of care. The WHO revised discussion paper on the global monitoring framework includes a palliative care indicator, a step forward that is welcomed by the international palliative care community. The proposed indicator is

In recent years, there has been an increase in the amount of palliative care research in developing countries. However, it is still very limited in the developing regions of the world, including Latin America.To determine the current status of palliative care research in Latin America.A survey was developed in Spanish and translated to Portuguese. Questions included demographic characteristics and specific research issues. Distribution was done through e-mail and personal hand-outs.Data were collected and analyzed using descriptive statistics and multivariate analysis.Two hundred sixty-three surveys (17.5% response rate) were received from 17 countries. A small number (10%, n = 263) reported participating in research within the last 5 years. Slightly over half of them received some training and had access to mentorship and guidance from an expert: multivariate analysis showed that training in research (odds ratio [OR] 3.46; 95% confidence interval [CI] 1.71-6.98) and support from an expert (OR 3.03; 95% CI 1.51-6.10) were positive predictor factors, even when adjusted for gender, age, years since graduation, and years working in palliative care. Barriers to conduct research most frequently cited were: lack of funding, insufficient knowledge and expertise, and lack of interest (54%, 21%, and 15%, respectively).Palliative care research in Latin America is very limited. Regional palliative care teams must adopt and implement systematic research in their practice to improve, guarantee, and sustain quality. Changes in policy, education, and allocation of funds are needed to guarantee the development of research in Latin America.