alexa Availability of Pain Medication for Patients in the Middle East: Status of the Problem and the Role of the Middle East Cancer Consortium (MECC): Implications for other Regions
ISSN: 2165-7386
Journal of Palliative Care & Medicine
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Availability of Pain Medication for Patients in the Middle East: Status of the Problem and the Role of the Middle East Cancer Consortium (MECC): Implications for other Regions

Michael Silbermann*

Technion and Executive Director, Middle East Cancer Consortium, Haifa, Israel

*Corresponding Author:
Michael Silbermann
Technion & Executive Director
Middle East Cancer Consortium, Haifa, Israel
E-mail: [email protected]

Received date: July 16, 2012; Accepted date: July 17, 2012; Published date: July 20, 2012

Citation: Silbermann M (2012) Availability of Pain Medication for Patients in the Middle East: Status of the Problem and the Role of the Middle East Cancer Consortium (MECC): Implications for Other Regions. J Palliative Care Med 2:e118. doi: 10.4172/2165-7386.1000e118

Copyright: © 2012 Silbermann M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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In the Middle East the majority of cancer patients (70%) are diagnosed with advanced stage disease- LATE PRESENTATION.

For these patients, the only realistic treatment option is pain relief and palliative care, except for Israel and Turkey, in all other Middle Eastern countries there is still a lack of governmental policies recognizing palliative care. As a result in most Middle Eastern countries the consumption of opioids is either virtually negligent or very low (Table 1). By and large, Fentanyl is currently the opioid of choice whereby its consumption comprises 60-80% of all opioids consumed, whereas that of Morphine is negligible (Table 2). While comparing the most recent data with those of a decade ago, it can be noted that there is an increase in the consumption of opioid, but it is still far behind that of those of the USA (Figure 1). It is, therefore, clear that there are large disparities in the consumption levels of opioids in Middle Eastern countries, versus developed countries.

Country Need of Morphine
in mg per capita                  
Consumption of
Morphine Equivalents
in mg per capita
Egypt 4.89 0.85 0.0076 Virtually  no consumption
Morocco 3.78 0.47 0.0054 Virtually  no consumption
Pakistan 5.9 0.07 0.0005 Virtually  no consumption
UAE 5.44 2.29 0.018 Virtually  no consumption
Jordan 7.83 10.39 0.058 Very  low consumption
Lebanon 5.25 5.71 0.048 Very  low consumption
Oman 5.69 4.1 0.031 Very  low consumption
Saudi Arabia 5.93 5.65 0.042 Very  low consumption
Cyprus 5.09 13.89 0.119 Low consumption
Israel 7.3 64.31 0.385 Moderate consumption
USA 7.43 420.7 2.478 Adequate consumption

Table 1: Adequacy of Opioids Consumption Measure (ACM) in Middle Eastern Countries [4].

World Ranking Country Fentanyl Hydrocodone Morphine Oxycodone Total
1 USA 25%* 9,904 50% 20,066 5% 2,060 15% 5,962 39,487
23 Israel 80% 2,719 ------ 4% 140 14% 500 3,482
47 Cyprus 72% 474 ------ 11% 72 81 666
50 Turkey 85% 513 ------ 4% 23 ------ 595
64 Saudi Arabia 67% 132 ------ 8% 16 2 195
66 Jordan 60% 111 ------ 23% 43 ------ 186
67 Lebanon 67% 125 ------ 17% 35 ------ 185
112 Egypt 41 ------ 4 ------ 49
120 Morocco 26 ------ 7 ------ 33
157 Iraq 1 ------ 1 ------ 6
159 Pakistan 2 ------ 1 ------ 3

Table 2: Average Consumption of Narcotic Drugs in Middle Eastern Countries 2007-2009(Defined daily doses of statistical purposes per million inhabitants per day) [5].


Figure 1: Availability of opioid analgesics, 1997 – 1999 and 2007 – 2009 (mostly due to an increase in the consumption of Fentanyl) in Middle Eastern Countries and the USA [5].

Taking these facts in consideration, I fully support Foley’s statement that the issue of cancer pain prevention ought to be addressed as an integral part of a comprehensive cancer control program [1]. Further, in this meeting Holland clearly indicated to the very close association between cancer and mental disorders such as depression and/or anxiety; and added the need to monitor the levels of distress in cancer patients [2]. Therefore, one should not disassociate physical pains from emotional distress, as both contribute to the overall suffering of the patient. And indeed, Benzodiazepines are being used in an increasing quantities; both auxiolytics as well as sedative-hypnotics, in Middle Eastern countries (Figures 2 and 3). The latter are used in larger quantities in Cyprus and Israel which have the largest population of elderly people.


Figure 2: Average Consumption of Benzodiazepines (anxiolytics), 1997 –1999 and 2007–2009 in Middle Eastern Countries [5].


Figure 3: Average Consumption of Benzodiazepines (sedative-hypnotics)- TRIAZOLAM 1997 – 1999 and 2007 – 2009 in Middle Eastern Countries and the USA [5].

In the Middle East it is not uncommon that terminal cancer patients suffering from bone metastases; don’t complain about pains but appear to internalize the fact that pains are part of the disease and accept it. In these countries non-pharmacological modalities are being used to control physical pains, but not always emotional suffering. It is; therefore, clear that the assessment of both pains as well as distress should become a routine practice by recording these 5th and 6th vital signs respectively.

Barriers to Palliative Care and Pain Management in the Middle East

1. Lack of health policies in support of palliative care. MECC is instrumental in promoting processes leading to positive decisions in Parliaments by Regulators & Policy Makers; thereafter, implemented by the Ministries of Health.

2. Lack of relevant training to health care professionals – at all levels: Undergraduate, postgraduate and during specialty training of oncologists and nurses. This barrier, however, is not unique to the Middle East.

3. Poor accessibility of essential palliative care drugs. These are at least in part; available in Tertiary Care Facilities, but not in Primary Health Care Facilities in the community, and that is what concerns us most.

Therefore, Physicians and nurses not only in hospitals, but also in the community should be trained with at least the basic principles of palliative care.

To further illustrate the above problem, let us take as an example pediatric oncology patients in various Middle Eastern countries:

1. Palestinian Pediatric Patients treated in Israel

2. Pediatric Patients in Egypt treated in the Children Cancer Hospital, Cairo

3. Pediatric patients in Iraq treated in the Children’s cancer hospital, Baghdad

4. Pediatric patients in Jordan treated in the King Hussein Cancer Center (KHCC), Amman

5. Pediatric Patients in Pakistan treated in the Children Cancer Hospital, Karachi

6. Pediatric Patients in Turkey treated in the Pediatric Oncology Services in Ankara, Istanbul and Izmir

In all these countries, pediatric cancer patients receive very good treatment in the above mentioned institutes. However, following their return to their communities, the local pediatricians or family physicians refrain from treating complications such as febrile neutropenia.

Moreover, in the region, because of multiple traditional and social reasons, most patients prefer to die at home – not in Medical Centers. Therefore, taking into account the above situation along with local cultural practices, and the fact that most countries have limited resources; we feel that home-based services should become a high priority.

Additional Barriers to Palliative Care in the Middle East

1. Education of the public, while trying to overcome the opioidphobia that still prevails in the region.

2. The Issue of the perceptions of cancer and opioids, faces us with a double taboos and stigmatization.

These barriers existed in the US 20 years ago, but are still valid in most countries in the Middle East.

To the best of our knowledge and understanding these existing taboos and stigmas are not solely culturally- related, and, therefore, should be dealt with by an ongoing process of education; since, the public, at large, still considers cancer an inherited - lethal disease. Another example of stigmatization that one experiences in the Middle East refers to the feature of late presentation:

While visiting a young female patient who was at a terminal stage of breast cancer, she was asked as to why she had waited so long prior to seeking the advice of a doctor.

Her response was: “if my neighbors would have known that I have cancer, my daughters would not have a chance to marry”.

3. Protective attitude of the patient’s family- disclosure issues. In order to promote the consumption of opioids, care givers need to improve communication with patients and families, thereby explaining the advantage of using these drugs.

Also, more proactive advocacy efforts are needed, often by Non- Governmental Organizations.

In Conclusion

We feel that the most urgent task in the Middle East is to educate and train physicians and nurses about pain assessment and management.

So, where is MECC standing with regard to this situation?

MECC is involved in promoting the consumption of pain medication through the following measures:

1. Regional didactic courses which are aimed at Hospital Staff of the following services: Oncology, Anesthesiology, Internal Medicine and Pediatrics.

MECC activities are not confined to its original member states:

• Egypt

• Jordan

• Palestine

• Israel

• Cyprus

• Turkey

But involves countries expanding from the Maghreb (North Africa) via the Mashraq (Middle East) and the Gulf States to Central Asia (Pakistan, Afghanistan).

New palliative care initiatives have been recently established in:

• Turkey

• Cyprus

• Egypt

• Palestine

• Jordan

• Sultanate of Oman

• Pakistan

The Middle East is currently undergoing unprecedented historical social turnabout; yet, these geopolitical changes do not deter professionals from seeking training and education in order to either develop new supportive care services, in hospitals and communities; or upgrade existing ones.

Such cross-border collaborations in the region take place regardless of cultural, ethnic or political differences.

In Summary

It is, therefore, our conviction, that the MECC model can serve as a case example for other regions globally.


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