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International Pain Policy Fellowship

Why the International Pain Policy Fellowship?

Pain relief is a fundamental part of palliative care. Toward this end, access to opioid analgesic medicines is essential. Because opioid medicines also have a potential for non-medical use, they are controlled by international treaties and national laws. Very limited access to opioid medicines in some countries results, at least in part, from unduly strict national drug control and healthcare regulatory policies. 

Although the incidence of cancer is increasing globally, the disease burden falls disproportionately on low- and middle-income countries. Many patients in these countries lack access to the opioid medicines that the World Health Organization designates as essential medicines. This International Pain Policy Fellowship (IPPF) program, led by some of the world's experts in opioid availability, can empower motivated health professionals and policy makers to evaluate and improve their country's regulatory environment without sacrificing the security of the existing drug control system. 

"The faculty has created a curriculum on opioid accessibility that is both comprehensive and understandable and that provides a simple but powerful method to overcome barriers to access. The IPPF equips its Fellows with all the tools they need to be able to make opioids available and accessible in their countries."

Eric Krakauer, MD, International Expert Committee member 

The Fellowship's Four Components

At the beginning of the Fellowship program, IPPF conducts an intensive training workship to provide Fellows foundational information about the roles and function of the international drug control system and how to become a strategic change-agent for opioid availability in their country. Staff and expert mentors assist the Fellows in identifying barriers in their country's policies and systems governing the use of controlled medicines. Fellows then develop an Action Plan to define three to five barriers to opioid availability in their countries and detail the objectives, activities, and resources necessary for eliminating each barrier. 

Each Fellow is responsible for implementing the Action Plan during the remainder of the IPPF.

Throughout the IPPF, staff and international expert mentors are in frequent contact with each Fellow to provide technical assistance related to their in-country project to ensure progress in meeting the Action Plan objectives. 

Examples of Technical Assistance

  • Review and comment on national policies
  • Analyze opioid supply systems to identify barriers and suggest solutions
  • Write strategic letters of support to key government officials or decision-makers
  • Assist in organizing and presenting at national workshops or high-level meetings with Ministry of Health officials to provide international expert opinion or to facilitate government action regarding opioid availability
  • Act as a liaison between the Fellow and the World Health Organization of the International Narcotics Control Board
  • Problem-solve and strategize when road blocks arise
  • Facilitate communication and sharing of strategies and resources between Fellows and other experts in various fields (pharmacy, nursing, education, etc.)

At the mid-point of the IPPF program, an Update & Review meeting is held to provide Fellows an opportunity to network and develop strategies to overcome outstanding challenges as well as to share approaches that have led to success. 

Examples of IPPF Successes*

Opioid Prescribing

  • New prescription form now allows two opioids to be prescribed on the same form, while requiring only one additional signature for monitoring purposes but not for treatment approval (Ministry of Labour, Health and Social Affairs)
  • Prescription validity increased from 48 hours to 5 days (Executive Decree)
  • Repealed 30 mg maximum daily prescribing doses and 5 day prescription duration limit (Ministry of Health Regulation)
  • Expanded prescribing beyond patients with cancer or AIDS diagnoses (Ministry of Health Regulation)

Opioid Availability

  • Successful procurement of slow-release oral morphine for the first time in 5 years (Ministry of Health)
  • Began manufacture of immediate-release oral morphine, making it available at the national cancer hospital (by government license to local pharmaceutical company)
  • First-ever shipment of morphine powder received by the only hospice, resulting in the development of record-keeping databases and written procedure on safe-handling; subsequent larger shipments arrived based on positive outcomes (National Pharmacy Board)

National Policy/Strategy

  • Developed national strategy for palliative care, with an objective to "Refine the legal and regulatory systems and support implementation to ensure access and availability of opioids for medical and scientific use while maintaining measure for preventing diversion and non-medical use" (Ministry of Health and Family Welfare)
  • Created National Association for Palliative Care to develop national palliative care policy, clinical tools to improve pain management, and sponsor trainings for healthcare workers on palliative care (palliative care providers)
  • Approved National Palliative Care Strategy that recognized: opioids as essential for pain relief and palliative care, and the need to examine national drug control laws and conform them to international drug control conventions (Ministry of Health)

Opioid Distribution System

  • Ordered regional controlled medication offices to ensure continuous availability of morphine (i.e., 24 hours a day and 7 days a week) in at least one pharmacy per region (Ministry of Health Resolution)
  • Initiated a transport permit for transferring opioids from distributors to healthcare facilities, as well as among healthcare institutions, facilitating the safe, government-managed distribution of opioids to all pharmacies (National Drug Regulatory Office)

Education/Training

  • Established the first "Palliative Care in Oncology" course and a training program, "Pain Management for 100 Health Professionals," which involved practitioners from 22 different hospitals (Ministry of Higher Education)
  • Developed educational brochures for healthcare professionals and drug regulators about the modern use of opioids to manage cancer pain (Ministry of Health)
  • Organized a series of workshops throughout the country to inform drug regulators and law enforcement officials about the importance of opioids for pain and palliative care and to discuss their roles (Palliative Care experts and national Department of Narcotics Control)
  • Established a post-graduate diploma on palliative care and pain relief (Ministry of Health and the Post Graduate Institute of Medicine)

Accessibility of Opioid Medicines

  • Added immediate- and sustained-release morphine to list of reimbursable medicines (Ministry of Health)
  • Added methadone, hydromorphone and injectable morphine to the list of medicines to be dispensed free of charge to patients with a prescription (Ministry of Health, National Obligatory Health Plan)
  • Eliminated a tax on oral morphine powder, making it more affordable for hospices and palliative care programs (Ministry of Finance)

*It is important to note that some of the progress can be attributed, in part, to advocacy efforts seperate from the IPPF progam.

After the Fellowship

After completing the IPPF, several Fellows have become members of the IPPF International Expert Committee, a select group of professionals with expertise in opioid availability. In that capacity, they have served as mentors to subsequent Fellows.

Within their home countries, many of the Fellows developed a reputation as champions for access to opioid medicines, have published articles about their work, attended international meetings on forming policy, and successfully advocated for positive changes in the laws and regulations in their countries.

Fellows have described the knowledge and experience gained through the IPPF as career-changing and many have continued to pursue their work to address barriers to opioid availability, long after their formal program involvement had ended. 

"The knowledge and experience I gained in the fellowship are engrained in me for the rest of my life. Since the Fellowship ended, I've continued working with that knowledge and have tried to learn more as I encounter new challenges. I'm fortunate to be a part of the IPPF world network of people working hard to support one another as we work to improve the availability of opioids."

Marta Leon, Colombia, 2006 Cohort Fellow

Walther Global Palliative Care & Supportive Oncology

IU School of Medicine & IU Simon Comprehensive Cancer Center

540 Barnhill Drive
CL 370 H INTM
Indianapolis, IN 46202
Phone: +1-(317) 278-4006