Ever broken a bone? Recovered from a major surgery? Do you live with chronic pain? If so, you understand on a visceral level that access to opioids like morphine to manage pain is critical. Opioids are necessary to perform surgery, make recovery from traumatic injuries possible, and can grant terminally ill people a peaceful death.
“Lack of access to essential medicines such as morphine or methadone for treatment violates the right to the highest attainable standard of health, which is one of the human rights conventions that all countries in the world have signed on to,” says Dr. Katherine Pettus, an advocacy officer for the International Association for Hospice and Palliative Care. “It also violates the right to be free from torture and constitutes cruel and unusual punishment.”
The outbreak of Ebola that recently raged in West Africa offers a tragic case in point. The Ebola virus causes a hemmorhagic fever resulting in continuous diarrhea, vomiting, and internal and external bleeding. The end-stage suffering, with patients dying in pools of their own blood, truly is tantamount to torture. Because there is no cute, palliative care—above all, pain medication, including IV morphine—is the best that doctors and nurses can do to protect patients from agony. Yet the fact that the small proportion of Ebola patients who are in hospitals have been receiving such medication is thanks largely to Ebola’s status as an acute international crisis.
THE OPIOID GAP
Rich nations have access to a wide variety of opioids, from Tylenol with codeine to morphine tablets to fentanyl patches and lollipops. Just four countries—the U.S., Canada, the U.K., and Australia—consume an astonishing 68 percent of the opioids produced by the pharmaceutical industry. Low- and middle-income countries together account for just seven percent of global use.
The U.S. and Canada, as Felicia M. Knaul, director of the Harvard Global Equity Initiative, has noted, consume nearly 300,000 milligrams of opioids per pain-affected death from HIV/AIDS and cancer. People who die of these causes in China (less than 1,300mg per death), India (720mg) Mexico (2,350mg) Uganda (450mg), or Haiti (47mg) likely suffer a great deal more.
Put even more starkly, opioids are virtually unavailable in over 150 countries. According to the World Health Organization, this leaves over 5.5 billion people—83 percent of the world’s population—with little or no access. They estimate that therefore each year a staggering 5.5 million terminally ill cancer patients and one million patients in the end stage of HIV/AIDS are denied pain relief.
Opioids are on the WHO list of essential medicines for human health and well-being. Moreover, the drugs are inexpensive—just pennies per dose—and easy to administer. Crucially, most preparations are not under patent protection. So why do these disparities in access continue?
A CRUEL SYSTEM
The most significant barrier to equality is the international drug control system, led by the United Nations Office on Drugs and Crime (UNODC) and the International Narcotics Control Board (INCB).
Drug war propaganda promotes two myths about opioids: that they are always dangerous and instantly addictive. The exaggeration of the effects of opioids combined with “zero tolerance” spills over into the use of the drugs in medical settings. Widespread “opioidphobia” affects physicians and even patients who would benefit from taking narcotics. Pain is political.
The INCB’s onerous structure of surveillance and accountability makes it almost impossible for poor nations to comply.
The United Nations Single Convention on Narcotic Drugs was signed in 1961 and tasked the INCB with ensuring that a global supply of licit opioids was available for medical purposes. The convention states: “The medical use of narcotic drugs continues to be indispensable for the relief of pain and suffering and adequate provision must be made to ensure the availability of narcotic drugs for such purposes.” But for 50 years the INCB has focused on preventing illicit use and diversion of narcotics into the black market, rather than ensuring that countries have sufficient supplies of medical narcotics.
To that end, the INCB has created an unnecessarily complicated and expensive narcotic supply chain system. Production and distribution is strictly licensed and supervised. Governments have to provide estimates and statistical returns to the INCB on the quantities of drugs required, manufactured, and consumed.
INCB protocols dictate that: “Each individual transaction across international borders be authorized and registered by the INCB. On a national level, special drug control agencies are responsible for communicating with the INCB about the need for morphine, imports and exports, and for regulating and overseeing all domestic transactions involving controlled medications.”
This onerous structure of surveillance and accountability makes it almost impossible for poor nations to comply. “The Single Convention affects the availability of narcotics in several ways,” Pettus explains, “but I want to be clear that it really only affects low-resource, developing countries.”
In Pettus’ experiences with INCB reps, they tend to argue that poverty on the ground is the main driver of the shortage. “But it is the Single Convention itself in many ways,” she insists. “The INCB is set up to create barriers for countries to get licit drugs because it’s trying to keep out illicit drugs. On the one hand, it’s supposed to ensure adequate provision of narcotic drugs for medical purposes and, on the other, prevent diversion and abuse. Their sights are set on stopping the latter and as a result access to pain medication suffers.”
The complex system of control developed by the INCB, she explains, “is manageable for developed countries with good public health and regulatory systems. They can comply with the demand for estimates, statistics, receipts, and the regulations around where drugs are stored, the need to have qualified people distributing, prescribing, and dispensing them.” However, “All those things are obstacles for low-resource countries,” which, she says, lack the infrastructure to comply as well as even the educational requirements to assess their countries’ needs.
Still, not all the restricting regulations in poorer countries are directly due to the INCB or UNODC. A Human Rights Watch (HRW) report examined the barriers that limit access to pain medication around the world. “Thirty-three of the 40 countries surveyed impose some kind of restrictive regulation on morphine prescribing that is not required by the international drug conventions,” it found. “Thirty-one of the countries require that a special prescription form be used to prescribe morphine, and 14 require doctors to have a special license to prescribe morphine.”
In many countries in Africa, where some of the most severe opioid shortages are found, few hospitals or pharmacies choose to stock morphine—the gold standard in treating moderate to severe pain—because of administrative obstacles and cost. In Zambia, only hospitals can stock morphine, and in Nigeria—a nation of 173 million people—oral morphine is available only from the National Drug Store. Cameroon has just one pharmacy that stocks oral morphine.
Meanwhile in Mexico City, a metropolis of 21 million-plus people, just nine hospitals and pharmacies stock morphine due to cumbersome regulatory requirements. India is yet another example of a country where cancer patients must suffer unnecessarily; according to Dr. M.R. Rajagopal, a leading palliative care specialist, doctors in 27 of India’s 28 states are too afraid to prescribe morphine for fear of legal consequences.
The lack of access to pain medication has horrific consequences all over the planet. “In Russia, a country where access to morphine is restricted and methadone is illegal, several highly placed military officers have taken their own lives because they had cancer and were in such pain,” Pettus says. Also, “in countries where these medicines are very limited, family members who don’t want to see their loved ones suffering go to the illicit market to get heroin or whatever they can get on the street. Then they are often imprisoned and subjected to very harsh sentences for helping their family member.”
The DEA has cracked down on prescription narcotics like Oxycontin and Vicodin and the doctors who prescribe them. Their campaign includes enforcement tactics such as heavily armed SWAT raids on physicians’ offices, aggressive undercover investigations, asset forfeiture, and the use of coerced informers.
Russian doctors are also targets for drug convictions. Diederik Lohman, associate director for health and human rights, palliative care, and drug policy at Human Rights Watch, reported on a case in Russia where a physician who prescribed an opioid to a patient in severe pain because the patient’s own doctor would not is being prosecuted. “This has an obvious chilling effect on other physicians who will now be even less likely to prescribe these medicines,” said Lohman.
NGOs face an uphill struggle to improve the situation. International efforts have included the Global Access to Pain Relief Initiative, launched in 2010 with the backing of organizations like the American Cancer Society and the Union for International Cancer Control.
Hospice Africa Uganda was founded over 20 years ago by Dr. Anne Merriman, a British physician. After witnessing too many patients die in agonizing pain, Merriman realized that it was critical for Uganda to obtain a reliable supply of morphine. Through work with the Ugandan Ministry of Health, the country began to import powdered morphine—importing it in this form, rather than pills or patches, kept the price low.
In DIY style, Ugandan health workers were trained to mix the powder with water to create oral morphine, which is then poured into recycled, clean plastic bottles. Three different strengths are prepared. “Oral morphine, made up near to the patients in need, is now recognized as the most affordable and effective way to control severe pain for cancer and AIDS, in the African situation,” Merriman said. “Having proved that this affordable method works, we, who witness the terrible suffering still going on in Africa from cancer, AIDS, and other diseases, are ethically bound to try and make it reach all in need in Africa.”
War is yet another factor hitting the availability of narcotics. A Human Rights Watch Report found that countries engaged in wars suffered particularly from a lack of opioids. In Afghanistan, HRW researchers were unable to confirm that any patients were receiving adequate pain treatment. This is incredible, given that Afghanistan is the world’s top poppy grower and supplies Central Asia and Europe with tons of pain-killing heroin every year. Iraq, currently involved in a brutal sectarian war, also suffers from an acute shortage. War-torn countries are in no position to adhere to INCB procedures yet have even greater need of access to opioids to treat their wounded and dying.
National governments in rich as well as poor countries, taking their cue from the INCB, continue to erect additional hurdles to obtaining pain relief. In the U.S., where 24-hour pharmacies stock stacks of prescription painkillers, people in chronic pain are still routinely under-treated. Pain doctors and their patients are caught in the cross-hairs of the War on Drugs. All physicians who prescribe opioids must register with the Drug Enforcement Administration (DEA) and every prescription they write is put in a database and tracked.
The DEA has cracked down on prescription narcotics like Oxycontin and Vicodin and the doctors who prescribe them. Their campaign includes enforcement tactics such as heavily armed SWAT raids on physicians’ offices, aggressive undercover investigations, asset forfeiture, and the use of coerced informers. Dozens of doctors have been prosecuted and imprisoned. So now, as in India, there are shortages in some states of physicians willing to prescribe opioids for fear of raids or investigation. Pain patients pay the price.
REJECTING THE STATUS QUO
All this explains why the Global Commission on Drug Policy, composed of heavyweight figures including former U.N. Secretary General Kofi Annan and former presidents of countries such as Brazil, Colombia, Mexico, and Switzerland, recently released a report harshly criticizing the international drug control system’s failure to make essential pain medications available worldwide. The commission‘s recommendations state: “The international community must make equitable access to controlled medicines for pain, palliative care and opioid dependency a top priority as the developing world confronts the growing burden of ageing, accidents and non-communicable diseases.”
The War on Drugs has not only failed to prevent illicit drug use, but has also prevented the provision of legal narcotics to millions of people who are suffering from both curable and terminal illnesses. It is well past time to end this atrocity.