Palliative Care Extends Beyond Borders

Bringing pain relief to the five billion people currently lacking access

Opioids are the standard medications given to patients in need of pain relief as they live with serious and advanced disease. Morphine, the most commonly used opioid, is inexpensive to manufacture and in most high-income countries, easy to obtain. However, in low and middle-income countries, it can be a challenge to legally obtain these essential medications, even for palliative care needs. Due to the lack of accessibility, there are five billion people in the world for whom access to pain medicines, should they need it for either palliative care or other pain relief, would go unmet. The Pain and Policy Studies Group (PPSG) has been one of the most successful models of public health change in recent years. Ultimately, PPSG aims to expand its role and presence as the foremost leader in global efforts to increase patient access to opioid pain medicines for palliative care. This is accomplished via outreach, policy and systems change using a combination of policy activity, survey dissemination, and translational research to study and identify beneficial solutions that can be adopted to improve patient care throughout the world. As the director of the PPSG, Dr. James Cleary, of the University of Wisconsin, has produced research that examines global, regional, and country-level trends in opioid consumption which has clearly documented the unmet needs for pain relief and the effect of barriers to patients' accessing opioid pain medicines.

PPSG has a long-standing proven track record of working directly with countries, on the ground, to identify and address their barriers to opioid availability for pain relief and palliative care. A unique model of technical assistance is used to help national governments (upon invitation) assess regulatory barriers to essential medicines for pain relief and amend existing or develop new legislation that facilitates appropriate and sufficient opioid prescribing. A critical PPSG program is the International Pain Policy Fellowship (IPPF), inaugurated in 2006, which trains competitively selected experts in pain management and palliative care from low and middle-income countries to address policy and distribution issues that severely limit medical use of opioids in their country. Following a training session with a government official from their country, Fellows return home with partial salary support to implement their action plan with close technical assistance from PPSG staff and other volunteer expert mentors. To date, there have been four classes of Fellows, including 31 Fellows from 25 countries. This fellowship program highlights the importance of training individuals from the home countries in need of additional support, and the incredible impact of Dr. Cleary's work.

As a Professor at the University of Wisconsin and the Director of PPSG, Dr. Cleary works on many projects concurrently to ensure that more people have access to palliative care globally. Current research includes:

  • Workshops: Dr. Cleary and his team conduct initial workshops that stimulate and create the opportunity for systemic change. Workshops are an important aspect of educating and informing providers, allies, and the global community.

  • IPPF: The IPFF is the agent which drives the change that is possible. Through the IPPF, Dr. Cleary and his team are able to affect policy and conduct policy analyses of current policies. The work of the IPPF this year has lead to the passing of legislation that will improve access to pain control in India, which represents almost 20% of the global population.

  • Fellow Support: The support of fellows initially funded by the WHO initiative has resulted in 31 Fellows being trained to implement positive change in their home countries. Dr. Cleary hopes to make funding available to continue to support the Fellows and their incredible work.

  • Improvement: The new Palliative Care Resolution by the WHO aims for a improvement in 25% of opioid consumption. Dr. Cleary's team is hoping to see 100% improvement in all involved countries at this time in addition to the improvements in low to middle-income countries.

Bio

Cancer Medicine and Palliative Care have always been a part of Dr. Cleary's medical career. His first clinical rotation as a medical student was with the Breast, Lymphoma, and Thyroid Surgical Service where he subsequently was placed annually for the last three clinical years of Medical School and his internship. During his early career, surgeons were the major prescribers of anticancer therapies for breast cancer, primarily in the advanced disease setting. In the summer of 1980, Dr. Cleary worked on a registry project with the Royal Adelaide Hospital's Lymphoma Clinic. While having the opportunity to see patients in the weekly multidisciplinary clinic, the research work involved staging patients through the Ann Arbor Staging System. Dr. Cleary then had the opportunity to spend three months in the Home of the Dying in Calcutta, India. This experience was life-changing in many ways including igniting a passion for Global Health. While undertaking specialty training in Internal Medicine, opportunities to work with the Medical Oncology Service led to his increased interest in caring for patients with cancer.

A successful application to the new Medical Oncology Fellowship at the Royal Adelaide Hospital placed Dr. Cleary under the watchful eye of Dr. Charles Olweny, the former director of the National Cancer Institute of Uganda. The fellowship included 15 months of Medical Oncology, 12 months of Hematology and Bone Marrow Transplant and three months of Radiotherapy. Dr. Cleary's desire to engage in holistic care of patients at all stages of the cancer diagnosis, together with three years of research in opioid pharmacology, lead him increasingly to palliative care

After two years as a clinical instructor at the University of Wisconsin, Dr. Cleary joined the faculty in early 1996. The primary clinical aim was to develop a Palliative Care Clinical Service, a program that has slowly grown from a single part-time physician to a program served by seven physicians faculty, two advanced practice nurses, a social worker, a chaplain, and recently, ACGME-accredited fellowship that is rated by candidates as being in the top tier of programs around the country. As well as having students from Medical Students to Fellows, Dr. Cleary continues to co-lead a highly regarded Palliative Care Core Day for third year medical students. While the major providers of US Palliative care were hospices in the 1980s and 90s, the start of this century has seen a major growth in hospital-based palliative care of which the University of Wisconsin has been a leader.

For the last few years, Dr. Cleary has directed the PPSG. He has embraced the challenge of improving the palliative care needs and especially pain relief for the five billion people in the world for whom it is lacking.

In his free time, Dr. Cleary enjoys cycling. He and his brother rode the Tour Down Under (505 miles) in 2010 to which Dr. Cleary jokes, "Lance never caught us." He has recently ridden from London to Paris and up Mt. Vountux.  Aside from cycling, Dr. Cleary also enjoys playing guitar, piano, and singing in addition to collecting wines.

Website:  www.painpolicy.wisc.edu and http://painpolicy.wordpress.com

Click here to watch the "Freedom from Pain" film.

In the News

Freedom from pain

Al Jazeera

Pain Relievers

On Wisconsin Magazine

Awards

Madison Magazine, Top Doctors, 2006, 2008, 2010, 2012, 2014

US Top Cancer Doctors, 2009-2014

Grossman Award: UWSMPH Department of Medicine Faculty Professionalism Award, 2008

American Academy of Hospice & Palliative Med (AAHPM) Distinguished Service Award, 2009