Pain Relief for the Poor

Are we content to allow more than half of the world's cancer patients die in severe pain? Current global policy on opiate access says that we are. I was never aware of the global shortage of opiates for pain management for terminally and chronically ill patients until a very moving series published in the NYT last fall brought it to my attention. In this paper I explore the barriers to increased access and call for a review of existing restrictions on production and access to opiates, as well as an overhaul of regulations in developing countries that constrain the use of these powerful drugs for people in pain.

Pain Relief for the Poor:
Increasing opiate access in developing countries
Before death, agony. The World Health Organization estimates that 80 percent of the six million people who die from cancer each year suffer severe pain, as do 50 percent of those dying from AIDS.1 As development progresses and the world's population lives longer, people in developing countries now have the perverse “opportunity” to suffer and die from the diseases of the developed world—cancer, diabetes, and heart disease being the most common—while lacking the diagnostic and treatment tools that could help manage their illnesses and accompanying pain. Lack of diagnosis and unavailability of or inability to pay for treatment make palliative care and access to potent painkillers more than just an issue of proper medical pain management, but also an issue of inequality and social justice. This paper presents compelling health, political, and human rights arguments for making increased opiate access a priority in global health policy. It then proposes possible measures to greater access that have benefits for stakeholders in both the developed and developing world.

Palliative Care and Health Policy
Palliative care covers symptom management of acute and chronic illness as well as end-of-life care.2 When it is no longer possible to prevent a patient from dying, palliative care aims to alleviate suffering, make the final days as good as possible for both patient and family, and to help the patient die peacefully.3 Palliative care offers the dying patient and their family a support system to live as actively as possible until death occurs. Pain-relief medication such as morphine by no means constitutes the entirety of a comprehensive palliative care program, however, it does play a key role in advanced pain management. Other palliative care treatments include discussing anxieties, spiritual guidance, support of family and friends, physical comfort, and other measures.4 At its essence, palliative care is about enhancing quality of life. Palliative care is an essential part of public health, but one that is often overlooked. The World Health Organization writes:

“Assessing cancer palliative care needs is in many ways equivalent to assessing an urgent humanitarian need to reduce unnecessary suffering of patients and their families. It is important to bear in mind that although – in the medium to long term – effective prevention, early detection and treatment will reduce palliative care needs, palliative care needs will never be eliminated, because some types of cancer will inevitably remain fatal for some patients.”5

The World Health Organization defines essential medicines as “those that satisfy the priority health care needs of the population.”6 Opiates are on the WHO list of essential medicines for all countries, but access to opiates is obstructed by lack of availability of drugs, regulatory and policy barriers, and lack of education about the drugs.7 Recognizing that misperceptions persist around pain management and treatment, the World Health Organization created a three-tier ladder for pain treatment for cancer patients. This logic has been replicated and applied to pain relief and palliative care in other treatment settings as well, such as HIV/AIDS. The first “rung” on the ladder of pain treatment is non-opioids, such as aspirin and paracetamol. Then, as pain intensifies to what the WHO classifies as “mild to moderate” levels, and the first rung of treatment options are no longer effective, mild opioids such as codeine are administered. When the patient is in what they would consider moderate to severe pain, opioids are added to treatment options.8

Misperceptions about addiction—by the patient, their family, and even the medical community—present barriers to medicinal pain relief. The American Cancer Society acknowledges that fear of addiction is a major reason people with access to opiates opt not to take them, even though there is a difference between continued medicinal use of opiates and addiction, and that “when opioids—the strongest pain relievers available—are taken for pain, they rarely cause addiction.”9 Developing countries have additional barriers to comprehensive pain management. Poor health care system infrastructure development, staffing shortages, and limited funds for public health all conspire to prevent palliative care from becoming a priority in national health policies. The WHO reports that “there is a close correlation between the proportion of the population needing palliative care and the proportion of adults living with HIV/AIDS. The highest proportions are found in Botswana and Zimbabwe.”10 Given the lack of access to anti-retroviral drugs for HIV/AIDS and the fact that the majority of cancer cases in Africa are incurable by the time they are diagnosed, palliative care needs to be incorporated into national health priorities.11 The emphasis on national plans that address HIV/AIDS by countries and funders have also directed efforts away from creating national public health plans that deal with the emerging challenges of chronic disease. The World Health Organization found that Ethiopia, for example, inadequately addressed cancer in its national health plan.12

Political Barriers to Opiate Access
Morphine and other opiates appear on the list of essential medicines published by the WHO for inclusion in all national health programs. There is no doubt that opiates are powerful drugs with potential for abuse and that their use must be carefully monitored in the course of treatment. All opiates derive from the same source, the opium poppy, and include heroin, morphine, oxycodone, methadone, codeine, fentanyl, buprenorphine, tradmadol, and others.13 All opiates create a sense of euphoria for the user, but they can also kill by suppressing breathing. Long term use can create dependence, and with use over time greater and greater doses are needed to achieve the same high relief. However, opiates can be used for shorter-term management of severe pain without addiction.

Opiates also have the distinction of being listed as both essential medicines and class 1 narcotics. Two of the best-known derivatives of the opium poppy, morphine and heroin, are both included on the list of Class 1 narcotics, as are several other products of the opium poppy.14 Opium production is tightly controlled by regulations in the 1961 Convention; five articles govern the cultivation and distribution of opium poppy, while only two dictate control and cultivation of coca leaves and cocaine. Yet because of the relatively low cost of production and high resale value of the crop, the end result of these numerous articles and qualifications is restrictions on poppy cultivation and export that limits legitimate medical use while at the same time fueling a lucrative market for illicit drug use.

Legalizing opium poppy production in developing nations is one possible answer to the medical shortage of opiates, and this is not the first paper to propose such measures. The International Narcotics Control Board's 2007 Annual Report acknowledges such advocacy in a recent annual report, though it falls back on its earlier stances and regulations instead of opening the door to further discussion of creative alternative policies.15 Yet the current restrictions on the cultivation and transformation of opium poppy ignore the realities on the ground of the trade in opiates. Article 23 of the 1961 Convention calls for the creation of a national oversight office to closely regulate the cultivation of poppy crops, determine which land and farmer can grow the crop, collect the harvest, and have the exclusive right of import, export, and trade of the crop.16 All of which, upon initial inspection, do not seem overly onerous until one thinks of the top opium poppy producer, Afghanistan, and its government whose rule of law extends not much farther than the city limits of Kabul. Afghanistan produces over 90% of the world's opiates, with 30% of its population engaged in poppy cultivation and production.17 With help from Western military and contractors, the Karzai government continues to routinely destroy poppy crops in an attempt to decrease the supply of raw poppy for the heroin market.

This approach is problematic for a number of reasons, not the least of which is the destruction of a crop whose medicinal use is much needed for poor patients around the world. Destroying crops without compensating farmers creates hostility towards Western forces and countries, including those engaged in peacekeeping and relief efforts. Such actions also deprive farmers in Afghanistan, a country with a GDP per capita of $1,000,18 of the means to support their families, which may lead the men or boys to join rebel movements, become even further indebted to creditors, and ultimately face the decision to give up a daughter as payment or emigrate to Pakistan.19 None of these scenarios are beneficial to the development of Afghanistan.

Human Rights and Access to Opiates
The UN High Commissioner for Human Rights states that the right to health is a fundamental human right, upheld in the Universal Declaration of Human Rights, where it is included as part of an adequate standard of living, as well as in the International Covenant on Economic, Social, and Cultural Rights. According to the High Commissioner, “every State has ratified at least one international human rights treaty recognizing the right to health.”20 What is included in that right, however, is often truncated in the conversation on this human right.

By now, the medical and NGO community is well-acquainted with the rhetoric surrounding the debate on access to essential medicines. Arguments on access to essential medicines usually start and end with access to anti-retroviral medicines or malaria and TB treatments. This narrow focus on treatments for only contagious diseases overlooks the growing problem of treatment for chronic illnesses in developing countries. Disease prevention should of course be a priority in all nations, prevention being cross the board a more cost-effective approach than treatment. Yet the right to health seems to be increasingly construed to the right to a long life, without as much emphasis on a productive life.

Worldwide, most cancer patients are in advanced stages of illness when diagnosed. For them, the only realistic option is pain relief and palliative care. Treatment is no longer an option, if indeed it ever was due to availability of chemotherapy, radiation, and other treatments. In the absence of early and effective treatment, having all the resources available for proper pain management becomes even more necessary to a country's health policy. The vast majority of the world's legally produced opiates—more than 85%—are consumed by just 20 developed nations.21 Pain medication should not be the luxury of those who die in hospitals or hospice only in the developed world.

The economic benefits of pain management are also an important consideration in advancing access to opiates. Coping with chronic illness and disease can drive families living on limited resources even deeper into poverty. Proper pain management allows poor patients to remain active and productive members of their communities. It may even allow them to return to work, which in even a limited capacity can help earn income to feed their families and continue to send children to school.

Solutions: Pay the Farmer, Place Reasonable Restrictions
Patients in the developing world need access to pain medication. Nations developing and developed all want a decrease in illegal drug use and trade for their own security and the health of their citizens. Afghanistan's development must improve for state security and regional and global stability. To address these goals, a two-fold solution is needed: increased access to raw materials for medicinal opiates and rational restrictions on its trade and use.

Destroying poppy crops is not the answer to any of the objectives above. Achieving increased access to medicinal poppy requires that there be adequate crops. Farmers sell the product because there exists a demand. A World Bank study on market prices for Afghan opium poppy shows that prices have varied widely over the past few years, ranging from a low of $30 to a high of $600. Prices over the past few years have stabilized somewhat, to around $150/kg, likely due to bumper crops in the opinion of the Bank.22 According to the Bank, “Just as the de-facto legal status of the opium trade under the Taliban regime may have helped keep prices low, increasing criminalization and law enforcement efforts subsequently have tended to induce higher prices through higher risk premia, even if success in reducing opium production has been limited.”23 This creates a perverse incentive for farmers to gamble on producing poppy: if their field is the one not destroyed, their returns can be quite great. Legalizing poppy production for medicine would instead provide farmers with predictable, steady income. While some may still decide to gamble in the illicit market, the majority likely will not, preferring instead to be able to feed their families and earn a steady income. Further, making opium poppy a mainstream crop and legal would generate tax revenue to help build up weak government institutions in Afghanistan, while also freeing up hundreds of millions of dollars that could be used for development.

This is not uncharted territory. Since becoming independent, India has legalized poppy production, bringing $40 million in revenue for that nation and its farmers.24 In the 1970's, the United States and Turkey developed a legal poppy production agreement to divert that nation's crop to medicinal uses after total eradication of the crop was rejected by Turkey. Today, the United States gets 80% of its medicinal poppy from Turkey, which in turn earns that nation $60 million a year in export revenue.25 Given that Turkey and India's poppy production still do not meet the global demand for opiates in palliative care, adding Afghanistan to the list of legal providers would create competition, but not an insurmountable amount, for both these countries whose economies are increasingly dependent on other industries for economic growth. Afghanistan will need serious assistance in developing proper controls to regulate its poppy crops but these efforts, supporting farmers and their livelihoods, would likely be received with more enthusiasm by the Afghan people.

Availability due to limited crops is one obstacle, but national and state laws restricting the administration, prescription, and handling of the finished products of opium poppy are perhaps easier to alleviate in the short term. In some cases, countries may have legitimate concerns about expanding access to such powerful drugs, particularly if they are operating in a post-conflict environment where drugs may have fueled wars, either by providing funds for different groups or by manipulating child soldiers, such as in Sierra Leone or Liberia. It is here that the World Health Organization needs to provide more guidance and assistance on implementing reasonable restrictions on these powerful drugs. In a recent survey of sub-Saharan countries and their palliative care policies, the WHO found significant deficiencies in pain management policies, including misperceptions of opiates, lack of workers trained in palliative care, non-existent policies on opiates, and overly-strict regulations on prescription of opiate drugs.26 In India, states issue their own policies on opiate access and regulation, creating a complex web of bureaucracy to navigate when looking to transport opiates across state borders.27 Simplified, national guidelines and licensing schemes would significantly ease the burden facing pharmacies and hospitals seeking opiates and other strong painkillers for their patients.

Increasing access to opiates for those in severe pain will require the participation of several stakeholders. Developed countries and donor institutions have a role to play by easing restrictions on the funds they provide for national health in developing nations and looking beyond infectious diseases when deciding on funding priorities. Global health and regulatory institutions need to help developing countries create reasonable restrictions on opiates that take into account each country's particular development challenges, especially those in post-conflict environments. States need to take assessments of their own internal policies on opiate production and use. Finally, the global community needs to reassess the benefits of opium poppy eradication when considering the effects of such a policy on global access to painkillers, the development of poppy-producing countries and their economies, and the use of funds which could otherwise be spent on regulation and development. Patients suffering around the world deserve better than the status quo currently on offer.

1 McNeil, Donald (September 10, 2007) “Drugs banned, many of the world's poor suffer in pain.” The New York Times. Retrieved on June 3, 2008 from http://www.nytimes.com/2007/09/10/health/10pain.html
2 World Health Organization (2004) Palliative Care: Symptom Management and End-of-Life Care. pp.2 Retrieved on June 20, 2008 from http://ftp.who.int/htm/IMAI/Modules/IMAI_palliative.pdf
3World Health Organization (year unavailable) Care for the Dying Patient and the Family. pp.205 Retrieved on June 7, 2008 from www.wpro.who.int/internet/files/pub/85/205-210.pdf
4Ibid, pp.208-209
5World Health Organization (2007) Cancer Control, Knowledge into Action: WHO Guide for Effective Programmes, Palliative Care. pp.15 Retrieved on June 15, 2008 from www.who.int/cancer/modules/en/index.html
6World Heath Organization. (2008) “Selection and Rational Use of Medicines.” Retrieved on July 8, 2008 from http://www.who.int/medicines/areas/rational_use/en/index.html
7World Health Organization (2000) Narcotic and Psychotropic Drugs: Achieving Balance in National Opioids Control Policy, Guidelines for Assessment. pp.7 Retrieved on June 9, 2008 from http://whqlibdoc.who.int/hq/2000/WHO_EDM_QSM_2000.4.pdf
8World Health Organization (2008) WHO's pain ladder. Retrieved on July 17, 2008 from http://www.who.int/cancer/palliative/painladder/en/
9American Cancer Society (2007) Pain Control: A guide for patients with cancer and their families. Retrieved on July 11, 2008 from http://www.cancer.org/docroot/MIT/content/MIT_7_2x_Pain_Control_A_Guide_for_People_with_Cancer_and_Their_Families.asp
10World Health Organization (2007) A Community Health Approach to Palliative Care for HIV/AIDS and Cancer Patients in Sub-Saharan Africa. pp.5 Retrieved on June 8, 2008 from http://www.who.int/cancer/media/FINAL-Palliative%20Care%20Module.pdf
11Ibid, pp.6
12 Ibid, pp.21
13International Narcotics Control Board (1997) INCB Report 1997: Drugs of Abuse. pp.1 Retrieved on June 22, 2008 from http://www.incb.org/pdf/e/press/1997/e_bn_09.pdf
14United Nations. (1961) “List of Drugs Included in Schedule 1.” Single Convention on Narcotic Drugs, 1961. pp.41 Retrieved on June 5, 2008 from http://www.incb.org/pdf/e/conv/convention_1961_en.pdf
15Ibid, pp.49
16Ibid, pp.26
17World Bank (2006). South Asia-Afghanistan: Drug Industry and Counter-Narcotics Policy. Retrieved on July 15, 2008 from http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/0,,contentMDK:21133060~pagePK:146736~piPK:146830~theSitePK:223547,00.html
18CIA World Factbook. (2008) Afghanistan. Retrieved on July 11, 2008 from https://www.cia.gov/library/publications/the-world-factbook/geos/af.html#Econ
19Vanda Felbab-Brown (March 23, 2006) Hasty Poppy Eradication in Afghanistan Can Sow More Problems. Christian Science Monitor. Retrieved on July 11, 2008 from http://www.csmonitor.com/2006/0323/p09s01-coop.html
20United Nations Commissioner for Human Rights, World Health Organization (2008) The Right to Health: Fact Sheet No.31, pp.5. Retrieved on July 19, 2008 from http://www.ohchr.org/Documents/Publications/Factsheet31.pdf
21 David E. Joranson, MSSW (1994) Global Opioid consumption: trends, barriers, and diversion. IASP Newsletter. 4-5. Retrieved on June 21, 2008 from http://www.painpolicy.wisc.edu/publicat/94iaspg.htm
22World Bank (2006). South Asia-Afghanistan: Drug Industry and Counter-Narcotics Policy. Chapter 5: Prices and Market Interactions in the Opium Economy. Retrieved on July 15, 2008 from http://siteresources.worldbank.org/SOUTHASIAEXT/Resources/Publications/448813-1164651372704/UNDC_Ch5.pdf, pp.3
23Ibid, pp.5
24Romesh Bhattacharji (2007) India's experience in licensing poppy cultivation for the production of essential medicines: Lessons for Afghanistan. Retrieved on July 11, 2008 from http://www.selinascouncil.net/documents/india_case_study
25Jorrit Jamminga (2006) The Political History of Turkey's Opium Licensing System for the Production of Medicines: Lessons for Afghanistan, pp.6. Retrieved on July 15, 2008 from http://www.senliscouncil.net/documents/Political_History_Poppy_Licensing_Turkey_May_2006.
26World Health Organization (2008) A Community Health Approach to Palliative Care for HIV/AIDS and Cancer Patients in Sub-Saharan Africa. pp.21 Retrieved on June 13, 2008 from http://www.who.int/hiv/pub/prev_care/palliativecare/en/
27M.R. Rajagopal, David Joranson, Aaron Gilson (2001) Medical use, misuse, and diversion of opioids in India. The Lancet. Vol. 358, pp.140.