The city in which a terminal cancer patient lives should not determine whether he or she suffers pain, or has access to pain relief. Yet this is the reality we live in. Three-quarters of the world’s population – 5.5-billion people – have no access to effective pain medicine.
According to a 2016 report by the Open Society Foundation, every year tens of millions of people suffer pain and distress because they can’t get medication.
If freedom from unnecessary pain and suffering is a human right, this is a damning assessment of the state of the world. At a broad level, access to pain relief is impeded by attitudes, knowledge, skills, regulation and markets – and though these barriers are different in each country, most of us operate under the international system of drug control.
In 1961 and as revised in 1972, the United Nation’s Single Convention on Narcotic Drugs recognized that narcotic drugs such as morphine and opioid-based pain medicines are “indispensable” for medical and scientific purposes, including the relief of pain and suffering. It noted that “adequate provision must be made to ensure availability”. Preserved in the International Drug Conventions, this was intended to promote a balanced approach to drug policy, one that ensured access to controlled medicines while including appropriate protections against misuse.
An overwhelming focus on the control of illicit use of these drugs under the auspices of a war on drugs has, however, meant not enough attention and resources have been committed to ensuring the supply of controlled medicines for medical and scientific use.
Access to controlled medicines, including opioid-based pain medicines, is central to the delivery of quality palliative care – a concept of holistic care that seeks to improve the quality of life of people with life-limiting and life-threatening conditions and their families.
Palliative care was introduced in an African context in Zimbabwe in 1979, then in Kenya and Uganda in the 1990s. Uganda’s leadership in palliative care has been recognized globally: it is strongly committed to providing home-based palliative care services and has an innovative regime of nurse-led pain prescription. Low-cost morphine production through a public-private partnership ensures patients in rural areas have better access to pain relief, which is significant in a country where 82% of the population live in rural areas, and the doctor to patient ratio is about one per 24 725 people.
Countries suffer from ‘opiophobia’
There is much work to be done. Despite successes in scaling up, Uganda reports low annual use of morphine. People are still dying in unnecessary pain.
The attitudes of the general population, and to a larger extent our healthcare professionals, have been shaped by a punitive and stigmatizing war on drugs. In some African countries, this has resulted in fear of prescribing or consuming opioid-based pain relief, often referred to as “opiophobia”. We need our healthcare professionals to bring evidence-based and rational decisions to their prescription practices and broader policy decisions. This will ensure patients are treated appropriately for their individual needs and conditions regardless of whether the controlled medicine required treats pain, drug dependency or a neuropsychiatric or mental condition.
Regulation – often in excess of that required by the International Drug Conventions – significantly hampers access to controlled medicines for palliative care patients. This may include limiting prescribing to only doctors; limiting number of days for a prescription; or requiring special stamps, special prescription pads or multiple approvals for opioid prescriptions. The World Health Organization has observed that special multiple-copy prescription requirements typically reduce prescribing of covered drugs by at least 50%. In many less affluent countries pharmacies and pharmaceutical companies may decide not to supply opioid analgesics because of the excessive administrative burden that accompanies procurement and distribution of controlled medicines.
Cost of patented medicine is prohibitive
Market forces also lower access to controlled medicines. Although morphine is an effective, low-cost, relatively easy to make, generic medicine, there may be financial incentives for doctors, hospitals or pharmacies to supply patented analgesics. Where patented medicines dominate a market, cost can become a prohibitive factor. In Kenya, the government overcomes this problem by importing powdered morphine and reconstituting it locally into a liquid preparation. In Uganda, a public-private partnership, which includes the health ministry, National Medical Stores, Joint Medical Stores and Hospice Africa Uganda, run projects that get medicine to facilities around the country. Malawi, Swaziland and Rwanda have established a centralized system for the reconstitution of affordable oral liquid morphine. But it is not enough. Stock-outs are still reported in these and other African countries, affecting patients and healthcare providers.
The right to pain relief was recognized by the World Health Assembly in 2014. The resolution specifically recognizes the place of palliative care in treating noncommunicable and infectious diseases across all age groups and calls for palliative care to be provided in an equitable manner.
If every patient is treated and diagnosed as an individual with unique requirements, we can begin to overcome the ignorance, stigma and scaremongering associated with pain management medications and ensure all patients – regardless of where they live – have access to pain relief.