By Zaid Mansuri
A problem of pain plagues the United States. According to a 2011 report from the Institute for Medicine, around 100 million Americans, about a third of the U.S. population, suffer from chronic pain. Such a number may come as a surprise, but it includes everyone on the chronic pain spectrum, from the silent majority of weak pain sufferers, to those with constant back pain, to those who may wish to end their lives because the pain is too great.
Yet most pain in the Western world is treated by physicians who have access to modern painkillers. This was not always the case. In the 1990s and 2000s there was a huge push for opioids- from drug companies in particular. The federal government pushed initiatives such as the “Pain as the Fifth Vital Sign” campaign (a body function to be assessed after temperature, heart rate, respiration rate and blood pressure) in combination with pharmaceutical backed advocacy efforts. The answer was a turn to opioids, even when physicians failed to adequately take into account opioids’ addictiveness, low therapeutic ratio, and lack of documented effectiveness in the treatment of chronic pain.
Keith Humphreys, a drug policy expert at Stanford University, explained that the scientific evidence for the effectiveness of opioid painkillers treating chronic pain is weak at best, and it is well understood that prolonged use can result in risks and complications.
According to America’s Centers for Disease Control (CDC), between 1994 and 2006 the share of American adults who had used prescription opioids in a given month jumped from 3.4% to nearly 7%. In 2012 alone, doctors wrote almost 259m prescriptions for opioids—enough for a bottle each for every adult. Americans guzzle six times more prescription opioids per person than 20 years ago.
A public health crisis dawned. The search for relief would have devastating consequences. Painkiller abuse proliferated and death by overdose linked to the opioids spiked. Doctors scrambled to pull back prescription of the drugs. However, data from the CDC shows that many of the addicted users did not quit as the prescriptions became harder to find. Some instead shifted to heroin, others to the stronger synthetic fentanyl.
A 2015 report from the CDC found that a small minority of prescribers are responsible for most opioid prescriptions, although it should be noted that there is a lot of variation from state to state. The top 1% of prescribers in Delaware accounted for 25% of all opioid prescriptions, while the top 1% of prescribers wrote 12.5% of all prescriptions in Maine.
Whatever the structural issues, haphazard clinical practices and spotty oversight will lead to death, and for thousands already has. From 1999-2014 more than 165,000 Americans died from prescription opioid overdoses. In 2015, more than 15,000 people died from overdoses involving prescription opioids. The average victim was male, poor, white, and single.
Opioids kill by slowing the respiratory system. A person suffering from an overdose, or who may have combined an acceptable dose with depressants such as alcohol, anti-anxiety medications or sleeping pills may pass out and stop breathing. According to the National Safety Council, an American non-profit, “these medication are especially dangerous because the amount needed to feel their effects and the amount needed to kill a person is small and unpredictable.” They also note that tolerance brings additional danger as opioid addicts increase dosage to get a rush, “not realizing they are not tolerant to the respiratory depression effects.”
Fortunately, policy has followed the epidemic. The CDC recently released guidelines that urge extreme caution when prescribing opioids to non cancer patients. Opioid prescriptions for pain have decreased 12% nationally since the peak in 2012. Many states have now made it mandatory for doctors to check databases to make sure that patients are not returning for painkillers after having been prescribed someplace else.
Curiously, while over-prescription may be a problem in America, the opposite is true in many poor and middle income countries. There, people suffering from excruciatingly painful mailiese such as cancer and other terminal illnesses often die without relief. The International Narcotics Control Board (INCB), an independent research and monitor that oversees the implementation and effect of UN drug policy, has estimated that 92% of all morphine is consumed in America, Canada, Australia, New Zealand, and countries in western Europe. 17% of the world’s population accounts for 92% of the world’s consumption of morphine. The ramifications are daunting.
The report notes, “This imbalance is particularly problematic because latest data available show that over 70 per cent of cancer deaths actually occur in low- and middle-income countries. Without sustained action, cancer incidence is projected to increase by 70 per cent in middle-income countries and 82 per cent in lower-income countries by 2030 ... As long as these drugs remain inaccessible to the large majority of people around the world, patients will not be able to derive the health benefits to which they are entitled under the Universal Declaration of Human Rights.”
In 1961, the U.N. adopted a popular international agreement – the 1961 Single Convention on Narcotic Drugs. The agreement advocated for the power of drugs and demanded that all countries make provision to ensure their availability for medical needs. Today, almost 60 years later, the unanimous will has largely passed without much result. Human Rights Watch reported from a 2008 WHO briefing that “approximately 80 percent of the world’s population had either no or insufficient access to treatment for moderate to severe pain.”
The lack of availability of pain treatment is absurd. Pain causes immense suffering, yet the medication to treat it is cheap, effective, and easy to mass produce. Furthermore, international law demands countries make adequate treatment available. Both the WHO and INCB have repeatedly reminded governmental organizations of their obligations from the 1961 agreement, but the warnings have fallen on deaf ears as governments passively stand by as their people suffer with pain.
A report from Human Rights Watch states, “Few governments have put in place effective supply and distribution systems for morphine; they have no pain management and palliative care policies or guidelines for practitioners; they have excessively strict drug control regulations that unnecessarily impede access to morphine or establish excessive penalties for mishandling it; they do not ensure healthcare workers get instruction on pain management and palliative care as part of their training; and they do not make sufficient efforts to ensure morphine is affordable. Fears that medical morphine may be diverted for illicit purposes are a key factor blocking improved access to pain treatment.”
Even in the case where tools of pain amelioration is available, most palliative care professionals are found in cities. ill patients in poor, rural areas are often more likely to suffer without access to pain relief than those in urban, developed areas.
Lack of training in palliative treatment is a final deciding factor. According to an article published in the Indian Journal of Palliative Care, of some 300 Indian medical colleges, only five taught palliative care. The consequence is that only a few doctors know how to prescribe opioids safely.
The lack of drugs across the developing world is particularly perplexing as the drugs are cheap to make and the raw ingredients plentiful. A monthly dose of opium should cost just $2-5, given that there are few opioids that are patented. However, even if the drugs are cheap to buy, in many circumstances the travel required to attain the drugs is more costly than the drugs themselves.
The INCB simultaneously mandates both the increased access to controlled substances and an end to its misuse. Many governments pay more attention to the former. The INCB, in an effort to control global supply of opium, requires countries wishing to import painkillers to provide estimates of necessary amount needed. Many nations of Africa, Asia and Latin America in the 1960s through the 1980s were chastised for making estimates the board thought was too high. The board used the number of physicians in a country to estimate the amount of opium it would need, a disastrous policy for states suffering from severe shortages of doctors.
A 1989 report from the INCB and World Health Organization revealed that national estimates of future opioid need were often calculated based on nothing more than previous years’ imports, thereby needlessly underestimating current need. Senegal, a country on Africa’s west coast with a population of 14 million, has asked for a similar morphine quota each year since the 1960s. In 2013 it applied for only 1 kilo of morphine—about enough to ameliorate the pain of 200 patients with advanced cancer.
One method of control the INCB used to prevent addiction was drafting “model laws” and encouraging states to enact them. One such law stated that physicians could be the only ones allowed to supply opioids. While such law may be effective and reasonable in developed nations, in countries where doctors are scarce and nurses/medical practitioners are the primary source of medical care, such a law would be disastrous. Such model laws encouraged countries in Latin America, Asia, and Africa to pass more restrictive laws regarding opioids in the 1970s and ‘80s. In India, the passage of the Narcotic Drugs and Psychotropic Substances Act in 1985 required hospitals to obtain such an excessive amount of licenses before each shipment of morphine that many stopped using the drug at all. Medicinal morphine consumption in India fell by 97 percent between 1985 and 1997.
The INCB is changing, albeit slowly. In 1999 the INCB began to contact governments that submitted “particularly low estimates” to encourage them to increase imports. The action has been largely ineffective as internal demand is low because health care policy makers fear prescribing opioids due to concerns over addiction. In fact, 50% of Nepal’s supply of sustained release morphine tablets went unused in 2011.
In 2010 the INCB agreed that countries with a restricted supply of doctors should allow nurses to prescribe morphine. The change is most welcomed, yet the persistence of the problem of untreated pain, particularly in the Global South, reveals the continued ignorance in international drug-control policy by international drug control organizations.
In a recent report, Human Rights watch highlighted the overtly complicated process cancer patients must go through to get morphine in Armenia. A patient must be diagnosed to have cancer by an oncologist (only cancer patients have access to strong painkillers). Then, the diagnosis must be confirmed through biopsy. Only 3 hospitals in Armenia offer this procedure. The oncologist must try several weaker painkillers before asking a panel to approve a prescription for morphine. A panel of 5 specialist must examine the patient at home and approve the morphine prescription. Each prescription requires 4 stamps and 3 signatures of approval. Patients or a relative must then travel to one of the few clinics or specialized pharmacies that carries morphine. Patients receive enough injectable morphine to subdue severe pain for only a few hours. The amount is so small, in fact, that the patient or relative must refill the prescription every 1-2 days.
Laws such as those in the case of Armenia are cruelly restrictive, far more so than any prescription in the U.N.’s drug conventions. But this comes as no surprise – countries have been told for decades that they must crack down on drug use. The UN’s adoption of the 1961 Single Convention on Narcotic Drugs has framed the problem of drugs as being an issue of criminal justice which has led to the promotion of ineffective eradication and interdiction policies.
For most patients in the developing world, untreated pain is the norm and ignorance of the injustice means no great agitation against unnecessary, severe controls. Recent legal reforms in India, Ukraine and Colombia have made it easier for some patients to procure painkillers, yet doctors note implementation is slow. However, as policy continues to push for greater distribution of legal opioids around the world, the problem of pain will become less and less dependent on geography.