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Indian journal of palliative care : IJPC 27(2), 299-305 (2021). doi:10.25259/IJPC_6_21, Published by Vellore

ObjectiveWith over two million deaths and almost 100 million confirmed cases, the COVID-19 pandemic has caused a “tsunami of suffering.” Health care workers, including palliative care workers, have been severely impacted. This study explores how the COVID-19 pandemic has impacted palliative care workers around the world and describes the coping strategies they have adopted to face their specific situation.MethodWe conducted a qualitative analysis of written, unstructured comments provided by respondents to a survey of IAHPC members between May and June 2020. Free text was exported to MAX QDA, and a thematic analysis was performed by reading the comments and developing a coding frame.ResultsSeventy-seven palliative care workers from 41 countries submitted at least one written comment, resulting in a data corpus of 10,694 words and a total of 374 coded comments. Eight main themes are emerged from the analysis: palliative care development, workforce impact, work reorganization, palliative care reconceptualization, economic and financial impacts, increased risk, emotional impact, and coping strategies.Significance of resultsThe pandemic has had a huge impact on palliative care workers including their ability to work and their financial status. It has generated increased workloads and placed them in vulnerable positions that affect their emotional well-being, resulting in distress and burnout. Counseling and support networks provide important resilience-building buffers. Coping strategies such as team and family support are important factors in workers’ capacity to adapt and respond. The pandemic is changing the concept and praxis of palliative care. Government officials, academia, providers, and affected populations need to work together to develop, and implement steps to ensure palliative care integration into response preparedness plans so as not to leave anyone behind, including health workers.

Background: The International Association for Hospice and Palliative Care (IAHPC) developed a consensus-based definition of palliative care (PC) that focuses on the relief of serious health related suffering, a concept put forward by the Lancet Commission Global Access to Palliative Care and Pain Relief. Aim: The objective of this paper is to present the research behind the new definition. Methods: The three-phased consensus process involved health care workers from countries in all income levels. In phase one, 38 PC experts evaluated the components of the World Health Organization (WHO) definition and suggested new/revised ones. In phase two, 412 IAHPC members in 88 countries expressed their level of agreement with the suggested components. In phase three, using results from phase two, the expert panel developed the definition. Results: The consensus-based definition is “Palliative care is the active holistic care of individuals across all ages with serious health-related suffering due to severe illness and especially of those near the end of life. It aims to improve the quality of life of patients, their families and their caregivers.” The definition includes a number of bullet points with additional details as well as recommendations for governments to reduce barriers to palliative care. Conclusions: Participants had significantly different perceptions and interpretations of PC. The greatest challenge faced by the core group was trying to find a middle ground between those who think that PC is the relief of all suffering, and those who believe that PC describes the care of those with a very limited remaining life span.

Resumen En muchos paises de Latinoamerica el desarrollo del cuidado paliativo es aun incipiente. Una razon fundamental es que la formacion de los profesionales de la salud en esta disciplina, aunque intensa y progresivamente mayor, es todavia insuficiente y de calidad variable. Diferentes instituciones y organizaciones relacionadas con la promocion e implementacion del cuidado paliativo promovieron un primer encuentro regional sobre aspectos tecnicos de la ensenanza de cuidado paliativo en el pregrado y el primer nivel de atencion. La reunion se celebro en Buenos Aires, Argentina, en noviembre de 2012 y conto con la participacion de 60 profesionales de diversas disciplinas con actividad docente en cuidado paliativo procedentes de 11 diferentes paises latinoamericanos. Se identificaron y analizaron temas centrales en la ensenanza basica de cuidado paliativo, se identificaron aspectos que deben ser optimizados y se efectuaron recomendaciones para hacerlo. Todo el grupo estuvo de acuerdo con que el cuidado paliativo deberia estar disponible y ser accesible para la mayor cantidad posible de pacientes con enfermedades de riesgo vital en estadios avanzados. Tambien con la evidencia que muestra que mas pacientes pueden recibir atencion adecuada provista por profesionales del primer nivel de atencion de salud, si adquieren los conocimientos, habilidades y actitudes basicas del cuidado paliativo. Este reporte describe el diseno y la organizacion del encuentro y se presentan los resultados y recomendaciones relacionadas con la docencia en el pregrado y el primer nivel de asistencia.

Resumen Antecedentes y objetivo La educacion es considerada uno de los componentes de la estrategia en salud publica para cuidados paliativos (CP) en el modelo planteado por la Organizacion Mundial de la Salud. Sin embargo, en Colombia solo 3 de 57 facultades de Medicina ensenan CP. Como parte de un proyecto con el fin de promocionar la ensenanza de los CP en las facultades de Ciencias de la Salud de Colombia y su integracion al curriculo de pregrado se realizaron debates con estudiantes de Medicina y/o Enfermeria de 3 universidades de Colombia. El objetivo de este trabajo es describir y analizar el nivel de comodidad y el interes de los estudiantes en CP en 3 universidades de Colombia. Metodo Estudio multicentrico de tipo transversal. La muestra fue constituida por los participantes a los debates de 3 universidades. Se utilizo un cuestionario de preparacion percibida respecto a situaciones comunes en CP («cuestionario de comodidad») y un cuestionario de interes. Ademas se registraron datos sociodemograficos y academicos. Resultados Doscientos tres estudiantes participaron en los debates (101 de Enfermeria, 96 de Medicina). El 25% tuvieron un curso previo en CP. Los estudiantes con cursos previos de CP y los estudiantes de Medicina tuvieron puntuaciones mas altas en comodidad. En general, las situaciones de transmision de malas noticias , manejo del duelo y comunicacion de una limitacion/adecuacion terapeutica fueron reportadas como menos comodas. Las situaciones clinicas como control de sintomas y manejo de la escala analgesica de la Organizacion Mundial de la Salud fueron reportadas como mas comodas. El 99% de los estudiantes estuvieron de acuerdo con incorporar el CP en el curriculo de pregrado. En una pregunta abierta sobre los temas que consideran importantes, los estudiantes mencionaron: comunicacion (especialmente la transmision de malas noticias), aspectos generales de CP, aspectos eticos y manejo de dolor y otros sintomas. Conclusiones Estos resultados indican que la formacion en CP durante el pregrado mejora el comodidad de los estudiantes en las situaciones habituales de los CP. Tambien senala la necesidad de educacion en CP para los futuros medicos. La integracion de CP en los programas de Medicina y Enfermeria existentes en Colombia es deseada y urgente.

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.

Prior to 1960 severe under-treatment of cancer pain was the rule of thumb in Argentina and was described as unavoidable. Cancer prevention, diagnosis, and treatment were subjects of interest, but symptom control was excluded. The majority of cancer patients was not treated for pain at all, or was treated inadequately. In the period from 1960 to 1980, cancer pain management was the duty of some anesthesiologists that performed different analgesic procedures with erratic results. Around 1980 a growing number of health professionals became aware of the magnitude of cancer symptoms and many of them began to provide adequate control for them. Palliative care was then introduced in the medical scenario and since then the health authority, health professionals, and the community slowly and progressively recognized its importance. Yet despite the progress made in the last decades, access to palliative care is inconsistent and only a small fraction of patients with cancer pain receive adequate treatment. T...

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.

Strong opioids such as morphine are rarely accessible in low- and middle-income countries, even for patients with the most severe pain. The three cases reported here from three diverse countries provide examples of the terrible and unnecessary suffering that occurs everyday when this essential, inexpensive, and safe medication is not adequately accessible by patients in pain. The reasons for this lack of accessibility are explored, and ways to resolve the problem are proposed.

Half of Argentina’s 35 million inhabitants live in the urban areas scattered throughout the country’s 23 provinces. The health services comprise 3 providers: public services (50% of the population with 81,000 beds), mutuals or social plans (45%), and a private sector (5%). Health care development varies considerably, with areas of excellent medical facilities and others with insufficient basic primary care. 1 At present, the country is undergoing a severe economic and social crisis, which has huge repercussions in the health system. The purpose of this paper is to describe the status of palliative care (PC) in Argentina. Much is known, but some information could be incomplete because there are no up-to-date national data.

Background: The School of Medicine of Austral University incorporated palliative care as an elective in undergraduate medicine curriculum during 2010. Objective: We analyzed the experience and results after 3 years of teaching palliative care. We compared students who chose palliative care as an elective subject (PC Group) with students who did not (Non-PC Group). We focused on the experience of contact with palliative care patients and self-perceived attitudes. Additionally, the impact produced by palliative care education in knowledge, self-perceived attitudes, and comfort was evaluated. Methods: All the students tested completed a questionnaire on their attitude when exposed to dying patients. Students in the PC Group completed an additional questionnaire to assess their level of knowledge and their self-perceived comfort when interacting with patients. Results: We tested 146 students. All students in the PC Group and 95.2% in the Non-PC Group considered that specific death issues ought to be part of the curriculum. Some students indicated that they could be present in a mandatory course. Before taking their elective, students in the PC Group confirmed a lack of technical training to understand palliative care patients, as did those students in the Non-PC Group. After taking a palliative care elective students expressed an improvement in self-perceived attitudes toward suffering and there was a significant increase (p

Objective: Versions of the McGill Pain Questionnaire are available in a several languages and are used in clinical studies and sociocultural or ethnic comparisons of pain issues. However, there is a lack of studies that compare the validity and reliability of the instrument in the countries where it is used. The current study investigates the psychometric properties of a Spanish version of the McGill Pain Questionnaire in five Spanish-speaking countries. Design: The authors conducted a multicenter and transnational study with one investigator in each center. Patients were evaluated once with a Spanish version of the McGill Pain Questionnaire, a visual analog scale, and a verbal rating scale. Setting: The study was performed in pain clinics and acute pain units of four Latin American countries (Argentina, Costa Rica, Mexico, and Panama) and Spain. Patients: The study included 205 patients (84 with acute pain, 121 with chronic pain) from Latin America. Their data were compared with those of 282 Spanish patients. Interventions: The McGill Pain Questionnaire, visual analog scale, and verbal rating scale were administered once to all patients. The McGill Pain Questionnaire was administered again to patients from Latin America countries to ascertain descriptor comprehension. Outcome measures: Demographic data, McGill Pain Questionnaire parameters, and visual analog scale and a verbal rating scale scores were obtained from patients with chronic and acute pain. Psychometric properties of the Spanish version of the McGill Pain Questionnaire were established for each country by calculating the ordinal consistency by means of rank-scale correlation (Spearman test), intercategory correlation, and interparameter correlation (Pearson test). Concurrent validity was also calculated by comparing scores from the visual analog scale (Pearson test) and verbal rating scale (Spearman test) with questionnaire parameters (qualitative-to-quantitative comparisons). Results: The Spanish version of the McGill Pain Questionnaire maintained a high internal validity when tested in different countries. Ordinal consistency, intercategory, interparameter, and qualitative-to-quantitative parameter correlations were similar in all countries. Few descriptors were considered to be inappropriate or difficult to understand. Conclusions: The psychometric properties of the Spanish version of the McGill Pain Questionnaire assessed in different Latin-American countries suggest that the questionnaire may be used to evaluate Spanish-speaking patients. The validity of this test should be extended with reliability studies to further establish its usefulness in the evaluation of pain.

The World Health Organization (WHO) has indicated that opioid analgesics are insufficiently available, particularly in developing countries, due to a variety of reasons, including legislative, educational, and policy issues. In its effort to promote the rational use of medical opioids and the adequate treatment of patients with cancer, WHO has sponsored a meeting of Latin American representatives every 2 years, which includes health professionals and government regulators. During March 24-27, 1996, a group of 86 representatives of cancer pain relief and palliative care programs from nine Latin American countries met in Santo Domingo under the auspices of the WHO Palliative Care Program for Latin America. For the first time since the First Latin American Meeting, government regulators were present to help address the issue of opioid availability from their perspective. During the meeting, issues pertaining to cancer pain, opioid availability, and palliative care were discussed. This report summarizes some of the events and presents a summary of the conclusions of an earlier meeting in 1994, as described in the Declaration of Florianopolis, and presents its follow-up, The Santo Domingo Report, generated following the 1996 meeting.

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

The objective of this study was to identify, through a consensus process, the essential practices in primary palliative care. A three-phase study was designed. Phase 1 methods included development of a working group; a literature review; development of a baseline list of practices; and identification of levels of intervention. In Phase 2, physicians, nurses, and nurse aides (n = 425) from 63 countries were asked in three Delphi rounds to rate the baseline practices as essential or nonessential and select the appropriate levels of intervention for each. In Phase 3, representatives of 45 palliative care organizations were asked to select and rank the 10 most important practices resulting from Phase 2. Scores (1-10) were assigned to each, based on the selected level of importance. Results of Phase 1 were a baseline list of 140 practices. Three levels of intervention were identified: Identification/Evaluation; Diagnosis; and Treatment/Solution measures. In Phase 2, the response rates (RR) for the Delphi rounds were 96.5%, 73.6%, and 71.8%, respectively. A consensus point (≥80% agreement) was applied, resulting in 62 practices. In Phase 3, RR was 100%. Forty-nine practices were selected and ranked. "Evaluation, Diagnosis and Treatment of Pain" scored the highest (352 points). The working group (WG) arranged the resulting practices in four categories: Physical care needs, Psychological/Emotional/Spiritual care needs, Care Planning and Coordination, and Communication. The IAHPC List of Essential Practices in Palliative care may help define appropriate primary palliative care and improve the quality of care delivered globally. Further studies are needed to evaluate their uptake and impact.

This declaration was formulated by consensus of the various government agencies and other organizations involved. It is hoped that it will be widely circulated.

In observance of World Hospice and Palliative Care Day, October 6, 2007, the Worldwide Palliative Care Alliance developed a comprehensive publication advocating access to pain relief as a basic human right. The British Charity help the Hospices distributed this publication, which describes the current state of pain relief in advanced disease throughout the world, availability and lack of access to opioid analgesics, clinical case examples of how pain can be managed, governmental and private initiatives and barriers to pain relief, and statistics to support the position that pain relief is a basic human right.

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.

Many Latin American and Caribbean national health systems mainly focus on disease prevention, prenatal assistance, undernourishment, etc. They still do not have the conditions for developing palliative care (PC). In general, quality of life during the dying process is poor, with fragmented assistance, uncontrolled suffering, poor communication between professionals, patients, and families, and a great burden on family caregivers. The development of PC in the region started around 1981, but it is still not available to an acceptable number of patients.

Background Despite a National Policy on Pain and Palliative Care (working since 2002) and the Family Health Strategy (primary care), Brazil does not have a strategy to integrate palliative care in primary care. The Atlas of Palliative Care in Latino America (ALCP-2013) did not find any team working with this mode: a primary care teach working. Aim Propose a model of palliative care in the Public Health Service of Brazil offered through the Primary Care to community. Method The Pilot Project is in the city of Rio Grande, south of Brazil, covering the area 29 with 3000 persons. This area has a team with a family physician, a nurse, a technical nurse and 6 Community Agents of Health (persons of area who work directly with population). The team has 3 aims 1) care: identification of possible patients (using the tracking and opinions of community health workers and the area diagnostics) > evaluation using PIG and SPCIT > care according to needs of these patients 2) awareness and needs assessment of the local/area community with ongoing monthly meetings and community engagement 3) awareness of management institutions in the city. Results The project started in November of 2014 and the first identification found 51 patients. Evaluation and assessment will begins and this number will be reduced. The first local meeting will happen in January/2015. Conclusion This project seeks to provide a proposal for palliative care offered through primary care in a public health service which does not exist in Brazil.

Two hundred and seventy-seven patients were admitted to this prospective multicenter study in order to assess the accuracy of a staging system for cancer pain. The staging system (SS) was completed by a trained physician during the initial consultation. This system included the assessment of pain mechanism (PM, neuropathic versus nonneuropathic), pain characteristic (PC, continuous versus incidental), previous opioid dose (OD), cognitive function (CF), psychological distress (PD), tolerance (T), past history of alcohol or drugs (A). During day 21, a final assessment of pain control was made. Agreement for staging was observed in 96% of cases for investigators 1 and 2 (kappa 0.76, P < 0.001), and in 84% of cases between investigators 1 and 3 (kappa 0.723, P < 0.001). Of 276 evaluable patients, 86/92 Stage I (good prognosis) patients achieved good PC (93%) versus 102/184 Stage II and III (poor prognosis) patients (55%, P < 0.001). Sensitivity and specificity of the system were found to be 0.93 and 0.46, respectively. Univariate correlation found significant correlation between pain control and all variables except CF. In logistic regression, CF and OD showed no significant correlation. We, therefore, propose a more simple SS of five categories (PM, PC, PD, T, and A) and two stages (good and poor prognosis). We conclude that the SS is highly accurate in predicting patients with good prognosis, but patients with "poor prognosis" can still achieve good pain control in more than 50% of cases.

Z?it?lhCth Palliative Care (PC) in Argentina began in 1984-1985 and has experienced continued growth. It is in the hands of highly motivated groups of peopie (lay persons and professionals, mostly volunteers) working in many cities at various healthsare facilities, public as well as private. They all follow World Health Organization (WHO) guidelines and their work has progressively generated changes in areas related to the development of PC,’ such as growing interest from the healthcare community and general public, increase in morphine consumption, and involvement of the pharmaceutical industry in providing oral opioid formulations.

We treat cancer pain patients at their homes, in collaboration with their relatives and primary physician. Assistance is free. Our team is monodisciplinary and trained volunteers are the liaison between team and patients. In 118 patients treated with our model between October 1987 and December 1988, we assessed the symptoms that moved them to seek assistance, their previous therapies, and the effectiveness of our intervention. The data obtained suggest that (a) in our country, the majority of cancer patients do not obtain effective pain and symptom control; (b) our model yields satisfactory pain control and improvement in quality of life; and (c) there is a need for centers that teach and practice terminal care; our model may be useful as a working outline for such centers.

ContextOpioids are essential medicines. The World Health Organization and Health Action International monitor the price of essential medicines. However, their surveys do not include opioids, and there is no information on their affordability.ObjectivesTo provide information on access to pain treatment, as measured by the availability and dispensed price of five opioids in 13 formulations, and the affordability of oral immediate-release (IR) morphine.MethodsThe International Association for Hospice and Palliative Care members were distributed by their countries' Gross National Income (GNI) level using the World Bank categories, i.e., high income country (HIC), upper middle income country (UMIC), lower middle income country (LMIC), low income country (LIC), and randomized. A total of 10 participants were selected from each (n=40) domain. Participants were asked to identify a pharmacy located closest to a public facility that provides diagnosis/treatment for life-threatening conditions and report the lowest dispensed price of the smallest selling unit and strength of each formulation. Availability and median (Me) price were calculated for each. Affordability and percentage of international buyer price (IBP) were calculated for morphine oral solid IR.ResultsA total of 30 participants from 26 countries (response rate=75%) responded. Significant correlation was found between availability and GNI (range: 65–68% [HIC and LIC]; R=0.781; P