The Essential Medicines List (EML) was first developed by the World Health Organization (WHO) in 1977 as a means of promoting equitable access to safe, effective, and low-cost medicines directed at the priority health conditions of a global population.1 Essential medicines (EM) are a requirement of basic health systems, and access to EM is considered part of the human right to the highest attainable standard of health.2
Since its inception, the EML has been revised, expanded, and adapted for specific populations, such as children3 and patients receiving palliative care.4 Discrepancies invariably exist between the WHO EML, national EMLs, and recommendations put forth by expert committees and multilateral organizations.1
This chapter aims to provide a broad overview of medicines commonly used in palliative care and applicable to the provision of palliative care in humanitarian crises, recognizing that a distinction must often be made between what is optimal, what is essential, and what is readily available.
Access to Essential Medicines in Humanitarian Crises
According to WHO estimates, 80% of the global population lacks access to EM required for the relief of pain and other symptoms.2 Humanitarian emergencies further impede access to EM and other necessary resources by interrupting critical supply chains.
A list of priority EM for the provision of palliative care in humanitarian crises was highlighted in the 2018 WHO document, Integrating palliative care and symptom relief into the response to humanitarian emergencies and crises.5 While not specific to palliative care in humanitarian crises, additional EMLs have been published by the International Association of Hospice and Palliative Care (IAHPC),6 the Lancet Commission,7 and Médecins San Frontières (Doctors Without Borders).8
Box 13.1 collates the recommendations of these sources and includes additional medicines commonly used by the book’s authors and international colleagues in the field along with dosage guidelines.
*WHO, Integrating Palliative Care and Symptom Relief into the Response to Humanitarian Emergencies and Crises5;
†IAHPC List of Essential Medicines for Palliative Care6;
‡The Lancet Commission Report on lack of access to palliative care7;
§Médecins San Frontières, Essential Drugs.8
Source of Recommendation:
Abbreviation Key: IM, intramuscular; IV, intravenous; mo, months old; PO, by mouth; PR, per rectum; q, every; SC, subcutaneous; SL, sublingual; TD, transdermal; yo, years old.
The following list of essential equipment has been recommended for the provision of palliative care in humanitarian emergencies:
• Pressure-reducing mattress
• Nasogastric drainage and feeding tube
• Urinary catheters
• Opioid lock box
• Flashlight with rechargeable battery (if no access to electricity)
• Adult diapers or plastic and cotton5
Subcutaneous Administration of Medication
Intravenous access may be difficult at the end of life. A number of medications may be administered subcutaneously, either intermittently or by continuous infusion (see Box 13.2). Commonly used sites include the anterior abdominal wall, anterior aspect of upper arms, and anterior aspect of thighs.
Subcutaneous medications can be administered using an indwelling winged set (i.e., butterfly) needle when available.16 A 1 mL saline flush should be administered after single doses or a series of compatible medications. A 1 mL saline flush should be administered between incompatible medications. If compatibility is not known, a 1 mL saline flush should be used in between medications.
Subcutaneous catheters should be changed every 7 days, and sooner if redness or induration occur.16
1. Laing R, Waning B, Gray A, Ford N, 't Hoen E. 25 years of the WHO essential medicines lists: progress and challenges. Lancet. 2003;361(9370):1723–1729. doi:10.1016/s0140-6736(03)13375-2Find this resource:
2. Gómez Batiste X, Connor SR (eds.). Building Integrated Palliative Care Programs and Services. 2017.Find this resource:
3. World Health Organization. WHO Model List of Essential Medicines for Children, 5th List. Geneva: World Health Organization; April 2015. https://www.who.int/medicines/publications/essentialmedicines/en/. Accessed June 30, 2019.Find this resource:
4. World Health Organization. Essential Medicines in Palliative Care Executive Summary. Geneva: World Health Organization; 2017. https://medicalguidelines.msf.org/viewport/MG/en/guidelines-16681097.html. Accessed June 30, 2019.Find this resource:
5. World Health Organization. Integrating Palliative Care and Symptom Relief into the Response to Humanitarian Emergencies and Crises. Geneva: World Health Organization; 2018.Find this resource:
6. De Lima L, Doyle D. International Association For Hospice And Palliative Care list of essential medicines for palliative care. Ann Oncol. 2006;18(2):395–399. doi:10.1093/annonc/mdl373Find this resource:
7. Knaul FM, et al. Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission Report. Lancet. 2018;391(10128):1391–1454. doi:10.1016/s0140-6736(17)32513-8Find this resource:
8. Médecins Sans Frontières. Essential Drugs—Practical Guidelines. 2018 edition. https://medicalguidelines.msf.org/viewport/MG/en/guidelines-16681097.html. Accessed June 30, 2019.Find this resource:
9. Uptodate. 2019. https://www.uptodate.com/home. Accessed April 15, 2019.
10. Wolters Kluver. Clinical Drug Information. Lexicomp, Medi-Span, and Facts & Comparisons. 2019. https://www.wolterskluwercdi.com/. Accessed April 15, 2019.
11. Shrestha R, Pant S, Shrestha A, Batajoo KH, Thapa R, Vaidya S. Intranasal ketamine for the treatment of patients with acute pain in the emergency department. World J Emerg Med. 2016;7(1):19. doi:10.5847/wjem.j.1920-8642.2016.01.003Find this resource:
12. Frey TM, Florin TA, Caruso M, Zhang N, Zhang Y, Mittiga MR. Effect of intranasal ketamine vs fentanyl on pain reduction for extremity injuries in children. JAMA Pediatr. 2019;173(2):140. doi:10.1001/jamapediatrics.2018.4582Find this resource:
13. Vadivelu N, Schermer E, Kodumudi V, Belani K, Urman RD, Kaye AD. Role of ketamine for analgesia in adults and children. J Anaesthesiol Clin Pharmacol. 2016;32(3):298. doi:10.4103/0970-9185.168149Find this resource:
14. Nikolova I, Tencheva J, Voinikov J, Petkova V, Benbasat N, Danchev N. Metamizole: a review profile of a well-known “forgotten” drug. Part I: pharmaceutical and nonclinical profile. Biotechnology & Biotechnological Equipment. 2012;26(6):3329–3337. doi:10.5504/bbeq.2012.0089Find this resource:
15. Izhar T. Novalgin in pain and fever. J Pakistan Med Assoc. 1999;49(9):226–227.Find this resource:
16. Capital Health. Initiation and administration of medications via an indwelling winged set (subcutaneous butterfly needle). 2007. http://policy.nshealth.ca/Site_Published/dha9/document_render.aspx?documentRender.IdType=6&documentRender.GenericField=&documentRender.Id=27985. Accessed April 15, 2019.