November 17-18th , 2014
Considering the announcement of the Italian Government in the media that they intend to list Chronic Pain and Palliative Care as Healthcare Priorities during their Presidency of the EU Council in 2014 the SIP programme committee decided to host SIP 2014 in the second half of the year. Please save the dates November 17-18th , 2014 - the event will be hosted in Brussels as usual and more details to follow soon.
Please find here the English transcript of the interview that was broadcasted by an Italian television station towards the end of last year that involves Prof. Guido Fanelli ( President of the Ministry of Health Commission for the application of Law No. 38/10 ) , Giuseppe Casale ( Ministry of Health Commision Law 38/10 - Health Coordinator , Scientific Director of Antea ) and Francesco Bevere ( General Director for Health Planning - Ministry of Health )
Presenter (Moderator): Thank you, Paolo Di Giannantonio, time to call a halt to this ever-present intolerable pain, to this chronic pain, enough, 38 times enough. This is not a rant, but an assertion of a right established by the Italian Law No. 38, 15 March 2010, to protect those who are ill, so that we can banish unnecessary suffering from our hospitals and from our own homes. This is a right that needs proper protection and today we have with us Guido Fanelli, Professor of Anaesthesia and Resuscitation at Parma University, President of the Ministry of Health Commission for the application of this Law No. 38, to talk about the campaign 38 times enough, Professor.
Prof. Guido Fanelli, (President of the Ministry of Health Commission for the application of Law No. 38/10): Good morning, even the opening words of this law are an example of what we should expect. Namely: this law protects the right of all citizens, including children, to access palliative care for pain therapy. This is already important as it highlights the clear difference between palliative care and pain therapy. Keep this in mind as we say that Article 7 of this law obliges all doctors, and also all nurses, to report pain levels in the patient’s medical record (hospital or otherwise), to measure the pain and also the analgesic therapy started and especially the results, whether or not the patient already was suffering pain in hospital.
Presenter: This right has been a long time coming, however, because it deals with….
Prof. Guido Fanelli: But, listen, this is the only law in the Western world dealing with pain. As far as I know there is only Andalusia, an autonomous region, and Washington state. This law, perhaps we will talk about it later, has even been taken as a model of good quality legislation by the European Commission. Two years ago I was at the European Commission to present it and the London School of Medicine came to understand how we made this law.
Presenter: Finally! Perhaps we shall succeed in being the first. Therefore pain will not be just a symptom but will become a pathology to be treated. Giuseppe Casale, Health Coordinator, Scientific Director of Antea, an organisation specialising in this subject, palliative care. True? Is that right? No more symptoms?
Giuseppe Casale, (Ministry of Health Commission Law 38/10 - Health Coordinator, Scientific Director of Antea): Palliative care, pain therapy, and pain have come to be one of the main objectives of palliative care. Obviously pain is not just a symptom, but is a real pathology, in other words it is a disease in the disease. You just have to imagine how invalidating pain can be, people cannot move about, have a proper social life, not even manage to do their shopping.
Presenter: Even the most ordinary daily tasks then.
Giuseppe Casale: Even the most ordinary things. So, at Antea we have promoted this campaign, 38 times enough, precisely to reiterate that there is a law, as Professor Fanelli has said, an extremely forward thinking law, and we are asking loud and clear that this law is enforced, applied in other words, because otherwise the people will continue to be looked after badly and be unable to work day after day and will not be able to live a normal life.
Presenter: Now we know what the law is called. It is time that we try to understand what the law is. We will try to summarise it as not everyone understands, as Professor Fanelli has rightly pointed out, and many more do not know anything about it, most importantly, those people who are meant to enforce it.
Professor Fanelli: Yes, it’s pretty incredible, because it is a law that gives protection against pain, that guarantees access to pain therapy and to palliative care, but the population – and unfortunately even the doctors - barely know anything about it. As we may well know if we have to travel at speeds of 130 on the motorway, we adapt to this, but pain therapy is still a challenge. One of the most important things we thought we would do when this law was enacted is to make the GP the first point of contact. I mean, a patient who is in pain, and we’re talking about chronic pain here, pain that has gone beyond 3 – 6 months from moderate to severe; we are not talking about trivial pain. From this perspective the General Practitioner is our first gatekeeper. Then, the next step, the more technical part, the patient will be directed to the hospital. We are talking about chronic pain here, even the sort of pain that can be termed benign pain. We are not only dealing with malignant chronic pain, like cancer for example, which fortunately is only a very small percentage, 5 – 6 – 7%. We are talking about chronic benign pain. Colloquially known as back pain, and I think that in this studio there are many people who would raise their hands to that….
Presenter: Well, yes, because working from the early morning our operatives, who are standing all the time, God forbid, know very well that this causes back pain.
Professor Fanelli: I believe that a very recent study has shown that the total cost of back pain in the UK is 7% of GDP.
Presenter: So let’s think …. how it influences …. Then Prof. Casale, ‘38 Times Enough’ is not only our right that we must claim, but it is also a very important campaign. Can you explain that?
Giuseppe Casale: We believe this campaign must reach everybody, as they all have the right not to suffer; and it’s a campaign that affects more than 15 million people in Italy who suffer from chronic pain. As we said earlier, it is back pain, but just think about sciatica, lower back sciatic pain, there is a lot of that. The campaign will raise awareness using the pharmacies, at this point we are starting in Rome but the campaign will be promoted at national level, to raise awareness within the population, because they must know about their right not to suffer.
Presenter: www.38voltebasta.it, this is the address for finding out more.
Giuseppe Casale: Yes, thank you. At present pain is not treated in an appropriate way, because the doctors are not taught, unfortunately, to provide pain therapy in an adequate manner; and this is exactly why we are seeking to raise awareness so that the population will say: “OK, I want to be cured”. It is absurd that a patient suffering from chronic pain will only see a pain specialist after suffering for 4-5 years.
Presenter: Precisely, exactly as Prof. Fanelli said, the first step should be the GP. An important contribution from Chiara del Gaudio with the director Antonio Morabito, then we will come back to the subject of pain therapy.
Chiara del Gaudio (Journalist/Moderator): Francesco Bevere is the General Director for Health Planning at the Ministry of Health. The first thing we need to know: Professor, why is there so much disparity in the application of Law 38 to fight unnecessary pain?
Francesco Bevere (General Director for Health Planning - Ministry of Health): Yes, in fact, it is unevenly promoted across the country and that is fixed by the reform of Title V of the Constitution. The regions, as we know, have the utmost autonomy when it comes to health service management, on one hand this is a huge benefit, as the population’s requirements can be figured out for each territory, but on the other hand this means that the system will have – let’s say – various models and therefore the application of the law is more advanced in some regions and a little bit behind in some others.
Chiara del Gaudio: Could they not just be fined then, as is actually provided for in Law 38?
Francesco Bevere: We will do it in fact. The regions who do not comply will be fined. The Ministry is scrutinising this via 2 monitoring organisations, these are the LEA National Committee, who deal with the care components, and the National Commission for Palliative Care. Therefore, every year we know which regions have fulfilled their requirements according to Law 38, and which others still require follow through. The problem is certainly also cultural, as these are not always issues that can be resolved with financial resources. We are driving forward planning at the national level by putting the individual’s needs at the centre and understanding how important this is, as well as initiating more sophisticated and appropriate care pathways, to accompany people at a very difficult time in their lives, such as when they are suffering, with a little more hope, serenity, and above all generosity, giving them more justice for their treatment, especially under some conditions.
Chiara del Gaudio: On 1st July 2014 Italy takes over the EU presidency. What room will be given to this health emergency?
Francesco Bevere: We will be foregrounding it, obviously. Law 38 is an example to everyone else, it is recognised as outstanding. We are the first in Europe, and we certainly want to remain so, indeed the Minister has given it priority, recently Minister Lorenzin has given priority to the issue of pain, ensuring it will be one of the topics addressed during Italy’s Presidency of the EU.
Chiara del Gaudio: Thank you Francesco Bevere. We will conclude with the words of Ian Semmons, the patient who founded “Action on Pain” in Great Britain: “We must push for access to innovative therapies, to ensure that chronic pain sufferers everywhere get to live the life they deserve”. This is a call that should not go unheeded.
Presenter: And we are here to make sure this happens. Thank you Chiara del Gaudio.
Presenter (Moderator): So, Dr. Casale, can we now discuss the use of opiates or opioids, the opiate derivatives, what they are and how they are used in the treatment of pain.
Giuseppe Casale: The World Health Organization recognises these drugs as the most useful for the treatment of pain. In Italy there is currently a very high consumption of NSAIDs, these are the anti-pain drugs we all know and many of you watching will be taking these, however little is known of their side effects. Opiates on the other hand have very few. The truth is that in Italy we are one of the lowest consumers of opiates and opioids, but one of the greatest consumers of NSAIDs. The side effects of long term NSAIDs use include heart and liver damage. Damage that should not be taken lightly. Unfortunately this is not explained properly, because we are afraid. This is why we have created this campaign. We are afraid to use them.
Presenter: A very important point, so to end this discussion, what other possibilities do patients have.
Prof. Fanelli: I would like to finish talking about opioids, as this is very important. Because, in 2007, in Italy, opioid consumption was 0.67 per capita. After Law 38 it is at 1.30. Not much. In Spain, a culturally similar country, it is 3 euros. And Germany, it is at 10 euros. This is somewhat culturally driven, where morphine – derived from opioids – is seen as something to fear, even by doctors. Presenter: A dangerous thing, a negative thing. However, we have discovered that it is a very useful and specific substance, with few side effects compared with other substances.
Prof. Fanelli: Basically, with the new drugs we have today, if they are used with care, they have no side effects, even less than NSAIDs. Other devices that can be used …. when you look at the opiate-phobia we have in Italy, because this is one of the most important things. For example the classic back pain, also called sciatica, you can see the possibilities for treating diseases of the spine with implants providing spinal cord stimulation. This should be used as a last resort, when all the drug treatments have failed. Most importantly back pain is responsible for 500 million working days lost in the United States.
Presenter: It will always have an effect on GDP, as we have already mentioned. In short, chronic pain and cancer pain should be treated, they are two different things, and should be treated in different ways?
Giuseppe Casale: No, pain is always pain. Obviously, there is the so-called benign pain, caused by chronic diseases such as arthritis, but they should both be treated in the same way.
Presenter: This is a very important point, let’s reiterate that for all our viewers: if you are in pain, go and see your doctor and ask them for treatment for that pain, because you should never have to tolerate pain, it is not right.
Presenter: Thank you Guido Fanelli, thank you Dr. Giuseppe Casale and don’t forget this IN TOUR initiative by Antea on 18thNovember. TG1