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People in pain – calling for improved global access to controlled medications

Author: Kate Jackson, ehospice
11 March 2016

Mrs Thakur* went to a government hospital with an 8cm cancerous lump in her breast. The doctor she saw told her the cancer was too advanced and sent her home with a prescription of paracetamol, saying: “There is nothing more we can do.”

Her husband found out by chance about a palliative care clinic in the area. He visited the healthcare staff there, saying his wife could not come because she was in too much pain. The doctors gave Mr Thakur some painkillers from the clinic, and arranged a home visit for the following week.

Palliative care is an approach which cares for people with life threatening or life limiting illness and their families. Palliative care teams address physical pain and symptoms, as well as offering social, psychological and spiritual care.

Mrs Thakur was only 30 years old, suffering from advanced breast cancer. She was in so much pain that she could not sit up, sleep, eat, or drink. The palliative care doctor gave her an injection of a painkiller, antiemetic, and sedatives, which he used as a substitute for morphine.

In Kolkata, India, where the Thakurs live, and in much of the rest of the world, morphine and other opioid pain medications are very difficult to access. This is because of regulatory barriers such as unduly restrictive laws, attitudinal factors such as concerns about addiction and reluctance to prescribe or stock these medicines, or insufficient training for health professionals (See WHO, 2011).

As a result of these barriers, each year over 18 million people around the world die in pain without access to essential medicines (WHPCA). Mrs Thakur’s doctor was not able to give her morphine to help relieve her pain, even though this medication is safe, cheap and effective.

In India, certain major hospitals stock morphine, but often people with – sometimes advanced – diseases such as cancer have to travel many miles to access this essential pain medication. If a doctor is practicing privately, the licensing is very complicated and people are left without proper pain management.

In a report released this year, the International Narcotics Control Board (INCB) recognised that around 5.5 billion people still have limited or no access to medicines containing narcotic drugs, such as codeine or morphine, leaving 75 per cent of the world population without access to proper pain relief treatment.

Around 92 per cent of morphine used worldwide is consumed in countries in which only 17 per cent of the world population lives: primarily the United States of America, Canada, Western Europe, Australia and New Zealand. These countries may be faced with the opposite problem of opioid dependence syndrome and illicit use of these medications intended for pain relief, although this is very rare outside the US.

Dr Hannah Fox, a visiting British doctor who attended the consultation with Mrs Thakur, said: “These situations are incredibly sad. Before we arrived, Mrs Thakur had not taken any pain relief. Seeing that level of suffering is really shocking. 

"The United Kingdom has the National Health Service that is currently free to all and a network of charitable hospices. As a result, you would not see a young woman dying of cancer without any support. Cases such as this illustrate why palliative care and access to morphine is so important.”

In April this year, the General Assembly of the United Nations will meet in a Special Session to discuss “the world drug problem.” In the past, the issue of access to essential pain relieving medications such as morphine has been overshadowed by a fervent campaign to stop the trade of illicit drugs through legal action.

The Single Convention on Narcotic Drugs was drawn up and signed by UN member states in 1961. This document calls for both the halting of trade in illicit substances and the need to ensure adequate access to these medicines for medical use. 

However, in the decades since the adoption of the Single Convention, the need for access to controlled substances for medical use has been sidelined as the infamous ‘War on Drugs’ has led to the creation of national laws and policies, in excess even of the Convention guidance, which restrict access to all narcotic substances, harmful drugs and helpful medications alike.

Inadequate access to pain relieving medications contradicts the notion of article 25 of the Universal Declaration of Human Rights, including the right to medical care, which also encompasses palliative care.

Dr Stephen Connor, Executive Director of the Worldwide Hospice Palliative Care Alliance, said: “We call upon the UN General Assembly to ensure that there is balance between the medical use of controlled substances and prevention of misuse. Lack of access to pain relief is a global crisis.”

For people like Mrs Thakur, hope rests on the decisions made and actions taken by the United Nations member states to improve access to essential pain relieving medications. 

Health must be a central consideration in the global response to the world drug problem so that people in serious pain can access the medications they need, no matter where in the world they live.

*Names have been changed.

Mrs Thakur’s story originally appeared on Dr Hannah Fox’s blog.

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