The ATOME project comes to a close after five years of research and advocacy. The results strengthen our knowledge of barriers and challenges to access to opioid medication and more importantly how to overcome them. The project outputs include: the revised WHO policy guidelines on ensuring balance to controlled medicines and detailed reports on barriers towards access to opioid medicines in 12 European countries.
“At the first ATOME project meeting we learned that methadone could be prescribed by doctors other than psychiatrists. We now prescribe methadone with strict records kept for the Ministry of Health. The use of methadone shows very good results in patients whose pain was otherwise not well controlled and who suffered from severe side effects.”
“Recently some networking of different groups happened. For example, through organising the ATOME project nurses working at the Ministry of Health and universities have included pain management as a core subject and palliative care as an extra (elective) option in nursing education.”
These quotes are two examples how national key contacts and representatives of the national ATOME country teams assessed the impact of the ATOME project.
The Access to Opioid Medication in Europe (ATOME) project was a five-year endeavour funded under the 7th Framework Programme of the European Community [FP7/2007-2013] under grant agreement n° 222994. The overall goal of the ATOME project was to undertake applied research into the reasons why opioid medicines for moderate to severe pain, and for the treatment of opioid dependence, are not used adequately in 12 European countries where there was statistical evidence of low per capita morphine consumption (see figure). For each of the 12 countries, an individual situational analysis has been done, providing examples for potential barriers affecting the accessibility, availability and affordability of opioid medicines. Tailor-made recommendations were developed for each country to address barriers on different levels. Based on the research outcomes the ATOME final report was prepared. Changes related to identified barriers that have been applied during the project are mentioned as far as they were reported by the country teams during the validation procedure of the results. Moreover, the report sensitizes to different perception of barriers in different stakeholder groups.
European countries involved in ATOME project – Estonia, Latvia, Lithuania, Poland, Slovakia, Hungary, Slovenia, Serbia, Bulgaria, Turkey, Greece and Cyprus
The ATOME final report describes the requirements of a balanced approach on access to opioid medication referring to the revised World Health Organization (WHO) policy guidelines Ensuring Balance in National Policies on Controlled Substances, Guidance for Availability and Accessibility for Controlled Medicines and provides data that illuminate the reasons and consequences of unbalanced national legislations and policies. Besides the self-assessment checklist as part of the WHO policy guidelines, the methodology of the review of national legislations used in the project as well as of research activities related to the examination of national policies and circumstances provide tools for a critical analysis of a country’s situation. The ATOME final report illustrates the results of the application of those tools.
Access to Opioid Medication in Europe – Final report and recommendations to the Ministries of Health was edited by Lukas Radbruch, Saskia Jünger, Sheila Payne, Willem Scholten on behalf of the ATOME consortium and is freely accessible via the ATOME project website: www.atome-project.eu
Why is ATOME important?
Opioid medicines are the mainstay of medical treatment of severe pain and breathlessness, and the treatment of opioid dependence. They are effective and cheap medicines to relieve unbearable suffering from physical symptoms in severe progressive illness, and to prevent unnecessary harm and deterioration of health in people suffering from opioid dependence. For these reasons, WHO defines opioid medications as essential medicines. Access to opioid medicines is considered a human right.
Due to their potentially harmful effects, opioids are defined as controlled substances and are controlled under the Single Convention on Narcotic Drugs. The purpose of this treaty is to prevent the misuse of controlled substances while guaranteeing their availability for scientific and medical use. This implies a dual obligation for governments – that is, to implement regulations and policies that help to prevent potential harm resulting from opioids while ensuring that they are adequately available, accessible and affordable for those in need of them (the ‘principle of balance’). However, in many countries the emphasis is on control and restriction, hereby unduly interfering with availability of opioid medicines.
ATOME consortium, Bonn 2012
What did ATOME find out?
In the twelve European countries addressed by this project, strict regulations and inappropriate policies were found to have negative impact on adequate access to opioid medicines. Major barriers were found to exist in these countries in the field of legislation; national policies; knowledge and societal attitudes; and economic aspects, including affordability.
Based on the analyses and the outcomes of the ATOME project general recommendations can be derived for all countries aiming to achieve and to ensure a balanced approach in national policies on controlled substances. A selection of them is presented in below.
Ø Implement the WHO policy guidelines Ensuring Balance in National Policies on Controlled Substances, Guidance for Availability and Accessibility for Controlled Medicines;
Ø Ensure non-stigmatizing language in legal documents and language in official documents (e.g. by using the term ‘Narcotic drug’ only for referring to substances controlled under the Single Convention);
Ø Establish regular exchange opportunities (communication networks) between legal and governmental authorities, healthcare professionals and patients/families in order to raise awareness for practical impact and requirements of legal and policy decisions (target-performance comparison) regarding opioid availability and accessibility;
Ø Provide and support the implementation and development of national databases (including data on long-term outcomes and national fear of opioids) suitable for scientific research, evaluation of models of treatment with opioids and for monitoring the national demand on Essential Medicines;
Ø Ensure that treatment with opioids (knowledge, skills, attitudes) will be included in undergraduate and postgraduate education for relevant healthcare professionals (primarily physicians, nurses, pharmacists);
Ø Raise awareness in the general public, e.g. via media campaigns or information, brochures for patients and relatives.
What has changed since the start of ATOME?
Throughout the lifetime of the ATOME project remarkable changes have been occurred in some of the participating countries regarding an improved access to opioid medication: the validity of prescriptions for controlled medicines have been extended; some countries started to implement an e-prescription system or offered an option for pharmacists to fill a prescription with a higher amount in emergency cases.
Next to these exemplary changes in national legislation ATOME activities resulted in more subtle improvements, bringing together stakeholders from government, palliative care and pain management as well as harm reduction. This collaboration and networking has resulted in a change of atmosphere, and will produce more changes in legislation in the medium and long-term development that will overcome regulatory and legislative barriers.
Eugenia Larjow is a sociologist at the University Hospital of Bonn, Germany and writes on behalf of the ATOME Consortium. Email: Eugenia.Larjow@ukb.uni-bonn.de