Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

Relieving Pain and Suffering in Colombia: One Regulator's Journey

Maria Cristina Chirolla, JD

[Citation: Chirolla MC. Relieving pain and suffering in Colombia: One regulator's journey. Innovations in End-of-Life Care. 2003;5(1):www.edc.org/lastacts]

During the last ten years, my life has evolved around "drug matters." I have been involved in two worlds of drug use, first as a rehabilitation worker with women who were drug abusers, and later as an advocate creating a national system to make opioids available to patients who are gravely ill and need them to manage their pain. It has been a colorful and fascinating journey between these two worlds.

My first experience was with the women of the streets, when I took a position with the mayor's office in Bogotá as coordinator of the rehabilitation program for prostitutes. Many of the women I met were peasants who had left their towns and moved to the cities in search of jobs. What they found instead was the option of selling their bodies to earn some income for themselves and their children. These women used drugs to forget these sad circumstances and many got lost in the drug world. Working in the rehabilitation programs, I became involved with them and got to know their world. I spent time with them, learned their language and their stories, and earned their trust.

To help these women alleviate their situation in ways other than using drugs, I convinced them to take action and form a network to demonstrate their rights. We decided it was necessary to form an organization to represent them, since it was almost impossible to achieve anything individually. With the help of the mayor, a not-for-profit organization called Women for Ecology 2000 was created with the purpose of serving as a network of support and a way to channel funding for their rehabilitation. A new century was approaching, and we all had hopes for a new life. These peasant women yearned to go back to their farms in the country and to a more dignified way of life. When the women elected directors to this organization, they named me as their representative to the government, a role which I gladly accepted and undertook on a pro bono basis for two years. During that time, we met twice every month to discuss programs, problems, and solutions. After these two years, I felt that some of the women were ready to take on leadership positions, and resigned so that somebody else could fill my job. It was with great pride that I was able to see how the person who succeeded me was able to represent the women effectively.

At that time, I returned to finish my master's degree in international relations at the Universidad Javeriana in Bogotá. After graduation, I took a position as chief of Bilateral and Multilateral Projects in the Ministry of Justice. In this role, I was overseeing the legal aspects of of Colombia's compliance with the International Treaties and obligations governing controlled substances, and so, I had my first contact with the Fondo Nacional de Estupefacientes (the regulatory body for Controlled Substances and Precursors of the Ministry of Health). I received a lot of support from this office in matters regarding the International Treaties, such as the wording required in the international conventions and agreements against drug trafficking and diversion. Through this process, I became involved in the interpretation of the law and the treaties regarding drug abuse, drug diversion, and trafficking. I also became more knowledgeable and involved in the battle against drug trafficking, which later led to my next appointment as director of the Fondo Nacional de Estupefacientes.

Although I had in mind what I perceived to be the mission and objectives of the Fondo, framed within the legal and regulatory aspects, something happened which changed my way of thinking. As the director of the Fondo, I was invited in 2000 to participate as a representative of Colombia in a workshop in Quito, Ecuador organized by the Pan American Health Organization (PAHO). The workshop was designed to bring together regulators and clinicians in an effort to educate one another about our work, and to guarantee the availability of opioids for pain relief and palliative care in our own countries.

I have to confess that I was totally lost when several topics were discussed during the workshop, mostly the ones which dealt with opioid receptors and drug composition. But I immediately understood the scope of the problem. The workshop leaders showed us data and figures that described the problem in terms of current legal opioid consumption in our respective countries, and compared it to the WHO benchmarks for adequate pain control. We could not help but see the impact on patients of the difficulties in the distribution and inadequate availability of the opioids for medical and scientific needs in our countries.

This picture was totally new for me, since I had never considered this dimension of human suffering, which could be caused by the absence of these drugs. I had observed much human suffering caused by drug abuse, poverty, and the absence of economic opportunity, but I had framed my response in terms of preventing drug diversion and illicit trade. For the first time, I realized that lack of access to drugs—when medications do not reach patients in time or in the quantities they require—could be also a source of pain and suffering.

I decided that my priority as the director of the Fondo Nacional de Estupefacientes of Colombia was to make opioids available to the vast number of patients who needed them. The millions who suffer severe pain had become visible to me, and I was determined to work with others to transform our policies and procedures to address their needs. Many countries do not have the necessary infrastructure to make these drugs available effectively. However, in Colombia we are ahead in this regard, because the Fondo has a central office in Bogotá and 32 regional offices in each departamento (state) with which the Fondo communicates constantly.

Once back in Bogotá, I organized a meeting to address this new goal with staff members of the Fondo, delegates from PAHO, and representatives from the Instituto Nacional de Cancerologia (National Cancer Institute), the Asociación Colombiana para el Estudio del Dolor (Colombian Association for the Study of Pain - IASP Colombian Chapter), and the Asociación Colombiana de Cuidados Paliativos (Colombian Palliative Care Association). In this meeting, we outlined the short, medium, and long-term objectives for a national pain relief plan, which we called Red Nacional para el Manejo del Dolor (National Network for the Treatment of Pain). This was the first such meeting of its kind in the country. The participants were highly motivated to address the issues, and we discussed many subjects, such as the management of pain as a public health problem, and the national guidelines for cancer pain management. Some of the projects we planned at that meeting included workshops with the public hospitals throughout the country, publication and national dissemination of information about opioids, and the designation of a demonstration site that would provide a model for public hospitals.

The excitement generated at this initial meeting led to meetings every two weeks, in which representatives from the Fondo, PAHO, and scientific organizations participated. Participants included Dr. Francisco Fernandez, director of the Colombian Association for the Study of Pain and Dr. Maria Helena Restrepo, from the National Cancer Institute (who also attended the Quito workshop).

The Quito workshop, the commitment of Drs. Restrepo and Fernandez and the support from the Fondo and PAHO, all started to produce some results. The group developed strategies and alliances with institutions, professionals, and organizations with a common objective: to provide relief to patients with severe pain through the use of correctly prescribed opioid analgesics. We met with the National League against Cancer, the Military Health Office, and the Police Directives to inform them about the program and in some cases, to request their support and endorsement of the activities. Making opioids available required a lot of players at different levels and in different government departments, and I had to make sure that we would not be stopped once the program was started.

After four months, we convened another meeting at the Ministry of Health with all the sectional directors of the Fondo. During this meeting, I presented the National Network for the Treatment of Pain as a strategy to establish a model capable of fulfilling the needs for opioids of the regional hospitals in Colombia, while Drs. Restrepo and Fernandez presented the clinical aspects and requirements of the program. In addition, we organized a symposium for staff from 22 hospitals around the county, and selected Hospital Tunal to serve as a demonstration site for a pilot project that would be a model for the rest of the hospitals in the country.

The main educational objectives of this pilot effort were as follows: to teach the principles of pain assessment, evaluation, and pain management; and to outline the process for obtaining medications, and demonstrate approved methods for their storage, dispensing, and prescribing. At the Hospital Tunal, physicians and nurses were able to experience and witness good and appropriate pain management.

The Red Nacional del Manejo del Dolor (National Network for the Treatment of Pain) has gone beyond project status to become an ongoing, sustained entity in Colombia, continuing with an allocated budget and personnel paid by the Fondo and the city of Bogotá, and shared by the institutional stakeholders in the field of pain relief. Its work yielded results. After eight months, the demand for opioid medication increased by 10 percent in the main cities and the Fondo Nacional de Estupefacientes was capable of supplying it in a fast and efficient way. Although there is no way to prove it, we hope the increase in demand for opioids to treat pain is one of the outcomes of our program, Red Nacional de Dolor.

I always felt that this project could serve as a role model for other countries of the region, so I took advantage of the fact that at that time I was president of the Chemical Group of the Comision Interamericana para el Control del Abuso de Drogas (CICAD), of the Organization of American States (OAS), to introduce a proposal to improve the availability and use of opioid medication into the agenda of their meeting in 2001. (The CICAD is the commission to control drug abuse and its purpose is to form a network of support to prevent and control drug trafficking among the countries in the Americas. All the UN bodies of the Americas (143 in total) are represented in OAS).

The objectives of the Chemical Group were to establish a strategic plan for all the countries in the Americas in relation to the use of controlled substances and chemical precursors. The strategic plan is revised every two years during the OAS Regular Sessions. While at the Thirtieth Session in Caracas, Venezuela, in November 2001, I proposed the idea to have a Plan Nacional de Dolor in each country, and for the Fondo of each country to act as the motivator and coordinator of the plan. The proposal was accepted unanimously and incorporated into the strategic plan for CICAD.

In 2002, I took on a new position as the Chief of Money and Asset Laundering with the State Prosecutor's office, so I am back in the fight against illegal drug traffic. However, my experience as a rehabilitator and as a regulator has broadened my views, and I am now able to see that there are many shades to the grey. I am aware that there is not just one side in the drug world, but rather many sides, depending on who you are and where are you standing. I remain grateful to Mr. Joranson and Ms. De Lima for their support, and teaching, and for the opportunity they gave me to open my world to a new kind of pain. I still keep in touch with the Fondo and with the individuals in charge of the Programa Nacional de Dolor. I am sure it will continue to grow and become the role model we envisioned it to be.

Acknowledgement:
I wish to thank Liliana De Lima for translating this piece from Spanish to English.