Abstract
1. Yin and Yang under opiophobia
The double-edged role of opioids is a perfect model of Yin and Yang. The bright side, Yang, is a potent analgesic medication to relieve intractable pain. Timely morphine injection is mandatory for dying and traumatic patients regardless of race and religion. The dark side, Yin, is the notorious psychotropic characteristic in corrupting humanity. Once addicted, individual craving drastically boosters the prohibited demand over the scant availability with a skewed demand–supply mismatch. Illicit trafficking driven by a most lucrative reward becomes a global threat. Notably, growing penetrance into the juvenile generation has been regarded as a global crisis of the 21st century.
In 2014, the Taiwan Pain Forum invited a group of domestic and World Health Organization (WHO) experts to explore why opioid consumption in a country with the world's best health resource has fallen behind underdeveloped countries. The aim of this study is to propose a useful recommendation in overcoming pain management barrier in Taiwan. We found opiophobia to be prevalent throughout all ranks of health practitioners—physician, nurse, pharmacist, and administrator.1 Misunderstandings range from deadly side effects to addiction. Historical background must be verified before any action is taken towards resolution. We believe that the lack of confidence in prescribing opioids would refrain physicians from proactively treating the pain while leaving suffering to passive recovery along with illness.
2. Milestone for historical Chinese collapse
Narcotic abuse has been more than a criminal concern for Chinese since the 19th century. In 1839, banning opium trade from the United Kingdom resulted in the first Opium War. A subsequent defeat in 1895 yielded Taiwan province to Japan’s governance until 1945. The collective breakdown of economy and territory marked the eventual collapse of a dominant and proud nationality across 6000 consecutive years. For a century, both Taiwanese and mainland Chinese unarguably defined opium as the stigma of nationality humiliation.2 To avoid disseminating abuse medication, the government formulated a stringent controlled drug act by containing both medical and illicit availability under the social security supervision.3
Consequently, maximal prohibition in abuse minimized optimal availability of analgesia. The scant morphine consumption and drug of choice has reflected the cumulative effect of controlled regulation in Taiwan over the past decades.4 A recent survey among physicians treating noncancer patients with chronic pain revealed that redundant documentation and monitoring clearly aggravates clinical loading and thereby undermining their attempt in prescription and titration. Based on the cultural influence, people in Taiwan tend to tolerate pain. According to a survey from June 2014 to August 2014 by Taiwan Breast Cancer Alliance, 59% of 807 female participants aged from 26 years to 82 years reported that they suffered from pain after diagnosis of cancer; 72% did not use analgesics, and 44% never received a pain scale evaluation. After using pain medication, 34% still suffered from pain. For severe pain, only 36% of patients received pain medication, and most just want to bear with it.5 Furthermore, the stringent labeling on the convicted abusers across the country may protect the drug diversion through plagiarism but has critically jeopardized their legitimate right in relieving acute and chronic pain. As there is no significant presence of medication abuse reported in Taiwan, we compared the readily available OTC opioids in the form of codeine-containing cough mixture with the prescribed medication counterpart to reveal that medication diversion and/or abuse is an over-estimated concern in Taiwan.6
3. Balance between dark and bright world: healthy ecosystem
Gauging the complex interaction between analgesia and abuse, we propose the law of Yin and Yang (Figure 1) to elucidate the fundamental basis for a comprehensive controlled drug ecosystem (Table 1).
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4. Moving toward a holistic ecosystem in Taiwan
Based on the Yin and Yang law, we summarize the consensus of the Taiwan Pain Forum to ensure a nationwide good pain management and pain-free country promotion for the coming decade. Teamwork included the Taiwan Pain Society, Taiwan Society of Anesthesiologists, Taiwan Society of Cancer Palliative Medicine, and Taiwan Oncology Nurse Society. The immediate action plan is to integrate all stakeholders into an update and health ecosystem of global standard
(1)
WHO standard of controlled drug policy
The emphasis needs to be on improving the infrastructure of controlled drug committee hierarchy to enhance wider drug availability and to resolve on both government and physician concerns over prescribing them.1 The coverage of pain control medications by the National Health Insurance is limited. Most physicians are not motivated to treat patients under the unjustifiable payment system. As pain is a disease state requiring involvement of multiple specialties, National Health Insurance must offer more liberal reimbursement and less restriction on self-payment.
(2)
Global standard of drug lists
The policy of Bureau of Narcotic Enforcement must adopt WHO guideline to switch from harm reduction to maximal analgesia. More formulations and varieties of controlled drugs should be approved. Local clinical studies focused on ethnic variation should be encouraged.7
(3)
National standard of pain-free hospital
Top down is the most legitimate and powerful approach to implement policy in medical society. One proactive way is to incorporate pain-free hospital as standard hospital accreditation criteria. Once adopted, all ranks of health care professionals will follow spontaneously. Although more opioid medications are approved by the Food and Drug Administration, pharmacy and therapeutics committees in hospitals are reluctant to list new drugs according to the one in and one out rule. As a result, many hospitals do not have sufficient variety of opioids to meet clinical requirement. Clinical pharmacists can be a bridge between physicians and government officers.8
(4)
Comprehensive education among ecosystem
The education can be started from medical associations of all related specialties, particularly among young generations. Pharmacy association must provide update regulation to change the first-line pharmacists from barrier into the most helpful gatekeeper for better pain control. Know-how, but not know-what, bedside teaching is a more useful approach for nurse education than traditional classroom teaching.
(5)
International standard of corporate social responsibility
The global connectivity of international pharmaceutical companies could help in providing update information to Taiwanese government and medical society. Their accountability of providing the best service should be encouraged and appreciated.9