As opioid overdoses and deaths continue to spiral in many Western countries, three quarters of the world’s population face a very different but devastating opioid crisis: inadequate access to opioid pain relief.
International law outlines that people must be allowed access to pain-relieving narcotic drugs. The UN’s Single Convention on Narcotic Drugs 1961, the foundation of modern drug law, states that the “medical use of narcotic drugs continues to be indispensable for the relief of pain and suffering … [so] adequate provision must be made to ensure the availability of narcotic drugs for such purposes”. The universal right to the highest attainable standard of health obliges all states to provide access to such substances for medical purposes. Medical access to opioids is particularly important, as these drugs can block signals traveling from a patient’s nerves to their brain – thus reducing pain and suffering.
Nonetheless, in 2015, the International Narcotics Control Board (INCB) estimated that approximately 5.5 billion people live in countries with “low levels of, or non-existent, access to medicines containing narcotic drugs, and have inadequate access to treatment for moderate to severe pain”.
A recent journal article in the Lancet described a “broad and deep” abyss between wealthy countries with an excess of opioid availability, and developing countries with a gross lack of access and use. A staggering 90 per cent of the world’s morphine, the most commonly prescribed opioid, is consumed by the world’s richest 10 per cent.
This failure to ensure adequate access to pain relief has drawn criticism from UN experts on health and torture. In a recent BBC documentary, Diederick Lohman, health director of Human Rights Watch, argued that people without access to these medicines “are essentially being tortured”, and many become suicidal as a result of their intense pain.
Although this gap in pain relief provision largely corresponds with the global wealth gap, the cost of opioids is not the primary concern. The average morphine tablet costs a mere 3 cents and, according to the Lancet, it would cost $145 million per year to provide enough morphine for palliative relief to everyone who needs it worldwide. While this figure is not small, it pales in comparison to the estimated $100 billion spent each year on enforcing the global prohibition of drug use. It is this – the war on drugs – which lies at the root of the problem.
The INCB has a long history of pressuring states to limit their use of opioids, as the suppression of illicit use is consistently prioritised over medical accessibility – and the strict controls promoted by the Board tended to have a disproportionate impact on developing countries. For instance, as the INCB – until recently – instructed that only doctors may supply opioids, countries that rely on nurses to prescribe drugs due to a scarcity of doctors have been unable to provide sufficient pain relief to patients.
Despite the INCB now acknowledging the under-provision problem, the culture of fear fostered by the Board for many years, referred to by some as “opiophobia”, remains ingrained in many developing countries.
This opiophobia has undoubtedly been compounded by the current opioid deaths crisis in the US. There are certainly important lessons to be learned from the experience of the US but these should not be overstated. Meg O’Brien, the founder of Treat the Pain – an international programme aimed at improving access to pain relief medicines in developing countries – warns that a rise in opioid harms in one country should not mean a denial of pain-relief opioid mediation in another: “the US also has an obesity epidemic, but no one is proposing that we withhold food aid from South Sudan”, she remarked.
Experts say that a balance must be struck between ensuring sufficient access to opioids and ensuring that they do not become too easily available so that they risk being misused. The problem in the US, and other countries with opioid-related deaths crises, is therefore not the use of opioids per se, but the lack of effective monitoring and regulation of distribution – in some cases aggravated by irresponsible advertising by pharmaceutical companies.
“Also, many developed countries do not treat pain sufficiently”, said Willem Scholten, an expert on access to controlled medicines who worked many years for the World Health Organisation. “The emphasis is often too much on the prevention of non-medical use of opioids, while the contribution of pain to the global burden of disease (which is measured in DALYs: disability-adjusted life years) is about 37 times higher.”
“Moreover, very often, the situation is badly analysed. Even in the US, the problem is not caused by people to whom opioids were prescribed for their pain. The distinction between prescription medicines and prescribed medicines is not properly made, as is the distinction between the medicine fentanyl and the illicit fentanils used for adulterating heroin not made. As a result, pain patients have their medicines taken away and suffer serious pain now. In my view these policies are equal to torture.”
One country actively seeking to obtain the right balance is Uganda. The government makes all of its own oral morphine, and distributes it for free to those in need. This approach not only cuts out Big Pharma, but also enables the government to strictly monitor supply and usage. Moreover, oral morphine is easier to control and much less susceptible to misuse as, according to a report in the Journal of Pharmacology and Pharmacotherapeutics, it "cannot produce the 'high' that intravenous morphine produces"
Although Uganda has risen to 35th in the Economist’s 2015 world rankings for quality of death, the situation is still far from perfect – as less than 20 per cent of the country’s opioid needs are currently being met. Nonetheless, it marks a significant step in the right direction, and several other African countries – including Rwanda and Swaziland – have begun to follow Uganda’s example.
With the current spotlight on the crisis in the US, an opportunity exists for global and national health experts and authorities to re-evaluate and rebalance the entire drug control system in favour of health. For now, there continues to be a danger that the focus on overuse will result in the blanket application of even stricter policies in developing countries – resulting in devastating consequences for the millions of people who continue to unnecessarily suffer without pain relief.