Noncommunicable diseases and their risk factors

The Preventable Pain Pandemic

Patricia (42) has benefitted from Mexico’s more balanced national policies on controlled medicines.

Recent developments in Mexico allow many more patients like Patricia (42) to receive palliative care so that they can live their remaining time free from severe pain. However, around the world millions of patients live and die every year in extreme and preventable suffering due to lack of access to pain medicines. For those patients, this “constitutes cruel, inhuman or degrading treatment or punishment”, according to the UN Special Rapporteur on torture and other such conditions.

The cause of this global pandemic of preventable pain is not the cost of medicines; oral morphine can be made for pennies per dose. Yet according to the International Narcotics Control Board, over 121 countries have ‘inadequate’ or ‘very inadequate’ opioid consumption to meet basic medical needs. This places an estimated 83% of the world’s population at considerable risk of pain, if they acquire common diseases, such as cancer, cardiovascular disease, HIV, chronic lung disease, and diabetes.

States have a dual obligation to ensure that opioid medicines are available for medical use and also to protect populations against abuse of and dependence on them. Many countries place disproportionate emphasis on the latter, at the expense of the former.

As a result of such unbalanced policies, many patients cannot access essential medicines like oral morphine and other effective analgesics. They may be inappropriately classified as ineligible, may need an appointment with a specialist, and even once they have a prescription, may be allowed to receive only a few days’ worth of morphine, which they must request in person. Other issues include a lack of training of health care providers about pain medicines, concern of patients in using them, and fear of recrimination on the part of doctors to prescribe them due to excessively strict laws.

But patients do not have to live and die in pain. Patricia was admitted to hospital in November 2013 with advanced cervical cancer. In March 2016 she was transferred to palliative care services in the hospital and receives morphine to help control her pain. Although she worries about the care of her elderly parents, she is now free from pain for the first time. Just two years ago in Mexico, she would not have received such treatment as regulations were so burdensome that most doctors simply did not prescribe these medications and very few pharmacies had them in stock. But Mexico has recently made huge leaps forward.

“Access to opioids has always been difficult in Mexico”, says Dr Silvia Allende, a palliative care physician in Mexico. “Morphine and other strong opioid prescriptions were limited to anesthesiologists and pain specialists who were willing to fulfill the complex requirements of the Regulatory Authority. The new regulations have resulted in an increased number of physicians who can prescribe strong opioids, a larger number of pharmacies with morphine available, and improvement in the access to opioids of patients with pain.”

On the other side of the world, in India, there has been recent success in simplifying national and state regulations on controlled medicines, passed by the Parliament of India in 2013-2014. However, as with many countries, if pain relief and palliative care are to become accessible to all of India’s 1.25 billion people, individual states will need to implement these simplified regulations and - importantly - professional organisations will need to incorporate palliative care training in undergraduate medical and nursing curricula.

While the preventable pain pandemic continues, WHO is providing assistance on an international level. “WHO placed morphine on its first Essential Medicines List in 1977 and considers it the gold standard in pain management and relief,” says Gilles Forte, Coordinator for Policy Access and Use at WHO. “Every country should include morphine in its national list of essential medicines and ensure its uninterrupted supply in health facilities.”

Other WHO activities will help increase access to pain medications. Guidance has been issued on ensuring balance in national policies on controlled medications; clinical management guidelines for cancer pain are being updated; and a guidance manual on palliative care policies and services is being finalized for publication in late 2016. Furthermore, WHO works with countries to assess the requirements for increasing access to opioid analgesics. Among others, these activities will assist the development of services that can help end the preventable pain pandemic.