The Lancet Commission on Palliative Care and Pain Relief—findings, recommendations, and future directions
Authors: Felicia M Knaul, Afsan Bhadelia, Natalia M Rodriguez, Hector Arreola-Ornelas, Camilla Zimmermann
Journal: The Lancet Global Health (2018)

The burden of serious health-related suffering is huge and could in large part be alleviated with palliative care and pain relief. About 25·5 million of 56·2 million people who died in 2015 experienced serious health-related suffering, and another 35·5 million experienced serious health-related suffering due to life-threatening and life-limiting conditions. A disproportionate number (more than 80%) of these 61 million individuals live in low-income and middle-income countries (LMICs) with severely limited access to any palliative care, even oral morphine for pain relief. Furthermore, nearly 2·5 million children worldwide die in need of palliative care and pain relief, and more than 90% of paediatric deaths associated with serious health-related suffering are avoidable. These are a few of the most salient findings of the report of the Lancet Commission on Global Access to Palliative Care and Pain Relief.1Knaul FM Farmer PE Krakauer El et al.Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report.Lancet. 2017; (published online Oct 11.)http://dx.doi.org/10.1016/S0140-6736(17)32513-8Summary Full Text Full Text PDF PubMed Scopus (511) Google Scholar The global cancer community has a crucial role in helping achieve universal access to palliative care. HIV and cancer cause the largest number of people experiencing serious health-related suffering. Cancer is emblematic of the need for pain relief and palliative care (for those who are cured and for those who are not) and can drive forward systemic policy and advocacy responses. Many of the barriers limiting access to pain relief are systemic and related to overly restrictive legislation driven by concern about the addictive nature of opioid medicines, known as opiophobia. Efforts to reduce barriers to pain relief for cancer care can be readily applied to other health conditions using a diagonal approach. The Commission provides policy pathways and recommendations to drive this systemic change. The Commission designed an essential package of palliative care medicines, basic equipment, and human resources that could alleviate much of avoidable suffering in LMICs. This essential package must be part of universal health coverage platforms and the drive to achieve the Sustainable Development Goals by 2030.2United NationsSustainable Development Goals. 17 goals to transform our world. United Nations, New York2015Google Scholar The cost of this essential package in LMICs is about US$3 per capita. A next step is to design broader packages that include cancer care. The core component of the essential package is inexpensive, off-patent, injectable and oral immediate-release morphine. Just more than $1 million would address the unmet medical need for opioid analgesics for children experiencing serious health-related suffering in low-income countries, and $145 million would close the global gap in the need for morphine in palliative care and provide relief to millions of people with preventable pain worldwide. The Commission's report1Knaul FM Farmer PE Krakauer El et al.Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report.Lancet. 2017; (published online Oct 11.)http://dx.doi.org/10.1016/S0140-6736(17)32513-8Summary Full Text Full Text PDF PubMed Scopus (511) Google Scholar focuses on the most basic need to alleviate pain and is a response to the equity and health imperative of closing the global divide in access to palliative care, a heinous injustice that has been largely ignored in global health. Of the 298·5 million metric tonnes of morphine-equivalent opioids distributed in the world each year,3International Narcotics Control BoardAvailability of internationally controlled drugs: ensuring adequate access for medical and scientific purposes. United Nations, New York2016Google Scholar only 0·1 metric tonnes are distributed to low-income countries, and 50% of the global population (3·6 billion people who reside in the poorest countries) receive less than 1% of the morphine distributed worldwide. Indeed, most of these countries have only a small percentage of the morphine necessary to meet estimates of palliative care need based on serious health-related suffering (figure). The Commission1Knaul FM Farmer PE Krakauer El et al.Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report.Lancet. 2017; (published online Oct 11.)http://dx.doi.org/10.1016/S0140-6736(17)32513-8Summary Full Text Full Text PDF PubMed Scopus (511) Google Scholar provides the evidence base to develop and implement systemic solutions that align with the 2014 World Health Assembly resolution, which established palliative care as a core component of universal health coverage.4WHOWHA67.19. Strengthening of palliative care as a component of comprehensive care throughout the life course. World Health Organization, Geneva2014Google Scholar It also offers an impetus for disease-specific communities (eg, global cancer clinicians and advocates) to work across disease silos to address the growing need for palliative care. At the Toronto Global Cancer Control Conference, March 1–3, 2018, we will identify and begin to implement the Commission's recommendations at the national, regional, and global levels and to translate evidence into action, spearheaded by the global cancer community. The results will contribute to the work of the Commission's Implementation Group put forward in the report.1Knaul FM Farmer PE Krakauer El et al.Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report.Lancet. 2017; (published online Oct 11.)http://dx.doi.org/10.1016/S0140-6736(17)32513-8Summary Full Text Full Text PDF PubMed Scopus (511) Google Scholar We will discuss the development of monitoring frameworks to assess progress; promotion of training and capacity-building; catalysing of effective international collective action, such as establishing a financing platform that synchronises the procurement of medicines for treatment of cancer with pain relief and palliative care; and engagement of global and national cancer control advocates and advocacy groups to catalyse access to palliative care and pain relief. Strengthening the evidence base is key to implementation, and the Commission1Knaul FM Farmer PE Krakauer El et al.Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report.Lancet. 2017; (published online Oct 11.)http://dx.doi.org/10.1016/S0140-6736(17)32513-8Summary Full Text Full Text PDF PubMed Scopus (511) Google Scholar put forward a research agenda. The conference also provides an opportunity to move that agenda forward, building on other recent reports, most notably the Disease Control Priorities, 3rd edition.5Jamison DT Gelband H Horton S Volume 9: disease control priorities: improving health and reducing poverty. Disease control priorities. 3rd edn. World Bank, Washington, DC2017Google Scholar Priority topics include: augmenting the proposed package of palliative care services with chemotherapy, radiotherapy, and surgery; designing metrics for priority-setting that include and value the patient perspective; and designing national palliative care and pain relief plans that are systemic and linked to national cancer planning. The Lancet has invited the Commission to submit a report paper summarising 1-year results and future challenges for the implementation agenda and to achieving universal access to palliative care and pain relief by 2030. Several sessions at the Toronto Global Cancer Control Conference will provide key inputs into this paper. FMK declares grants from Pfizer, Mayday Fund, American Cancer Society, Roche, CRDF Global, JM Foundation, Grunenthal, and GDS; grants, personal fees, and non-financial support from Roche and Merck/EMD Serono; grants from Pfizer, Novartis, GlaxoSmithKline, Sanofi, Chinoin, and NADRO; and grants and non-financial support from Asociacion Mexicana de Industrias de Investigacion Farmaceutica, outside the submitted work. AB declares unrestricted gifts from Pfizer and grants from Roche. All other authors declare no competing interests.