These anecdotes are from more than 40 years ago, but the patterns are hardly a thing of the past. Across rich and poor countries alike, people are still routinely failed through a lack of access to proper pain relief.
Having no access to pain relief can be agonizing. Cancer patients in Vietnam describe waiting for others to die so that they could get the leftover morphine. Kenyan patients speak of their wish to hasten their deaths due to their inability to find peace from pain. I experienced uncontrolled and agonizing pain myself when, as a child in Uruguay, I had second-degree burns on both legs. Without appropriate pain relief, my pain was more than just physical. As I counted down the hours to the next dressing change, the anxiety I experienced was just as distressing and memorable as the deep burn of the gauze coming unstuck from my raw flesh.
Some form of suffering is a core experience for most of us around the world. Depending on the country and survey, between 5% and 10% of people from the UK, US and Middle East report having pain that impedes their daily functioning. More than two-thirds of advanced cancer patients have serious pain, and recent estimates suggest over 70 million people endure at least one day of serious health-related suffering a year.
As populations grow older and we make gains against communicable disease, the burden of disease is shifting to chronic diseases like cancers and other diseases of old age, which can be painful and long-lasting. In much of the world, where people still can’t access good-quality healthcare, many conditions that are easily treatable remain serious causes of pain. We need better systems to help people deal with pain and death in a dignified way. [...]
For the Few, Not the Many
In some settings, suffering from a painful medical condition can be like a sentence to ongoing torture. This torture is far more common in low- and middle-income countries (LMICs) than in rich ones. 99% of children with serious health-related suffering are in LMICs. The lack of treatment for pain is especially common for the most severe types of pain, such as postsurgical and cancer pain. In Haiti, for instance, 99% of severe pain relief needs are unmet.
Worldwide, the top 10% of countries by opioid consumption consume as much as 90% of all distributed opioids (converted into doses with the potency of morphine).
To put this into perspective, one paper estimates that the average yearly controlled opioid consumption is 32 mg per person worldwide, but Germans consume around 480 mg per person. Note that this is not due to Germans overconsuming opioids; it is simply that pain elsewhere is not treated.
In some settings, suffering from a painful medical condition can be like a sentence to ongoing torture. This torture is far more common in low- and middle-income countries (LMICs) than in rich ones. 99% of children with serious health-related suffering are in LMICs. The lack of treatment for pain is especially common for the most severe types of pain, such as postsurgical and cancer pain. In Haiti, for instance, 99% of severe pain relief needs are unmet.
Worldwide, the top 10% of countries by opioid consumption consume as much as 90% of all distributed opioids (converted into doses with the potency of morphine).
To put this into perspective, one paper estimates that the average yearly controlled opioid consumption is 32 mg per person worldwide, but Germans consume around 480 mg per person. Note that this is not due to Germans overconsuming opioids; it is simply that pain elsewhere is not treated.
Many issues in global health and development can be boiled down to lack of money, but the lack of pain control is not one of them. Morphine is among the cheapest essential medicines out there; oral morphine for 10 days costs about the same as a loaf of bread. Instead, lack of pain management is driven by a fear of opioids’ side effects, accentuated by the opioid epidemic in the United States and the closely related War on Drugs.
Traditionally, clinicians have avoided using opioids as much as possible, as they can cause central nervous system depression. This reduces the rate of breathing and in doing so could potentially hasten death. As recently as 2012, a third of medical ethics educators in the United States believed this to be the case. However, while it is true that morphine and other opioids have a narrow therapeutic index, meaning that the safety margin for their use is fairly small, it is not true that they hasten death when correctly administered.
Doctors’ fears of overusing opioids have only increased with time. Opioids are addictive, and overuse is dangerous. The United States has experienced significant public health harm from the overprescription of opioids, with the opioid crisis peaking at perhaps 80,000 opioid-caused deaths per year. The start of the crisis was caused by the unscrupulous drug pushing of pharmaceutical companies for types of pain where opioids are not very helpful. In response, doctors became much more hesitant to prescribe. Indeed, doctors could even be prosecuted for overprescription.
But while this first wave of the opioid crisis in the U.S. was driven by the prescribing dynamics of doctors, this was not the lasting mechanism for increased opioid deaths into the 2020s. Between 2011 and 2021, opioid deaths tripled, even as opioid prescriptions decreased by nearly 40% during the same period. Pain medication might have kicked off the epidemic, but it was not the lasting driver. [...]
It is true that prescribing opioid pain medications comes with risks. Estimates of the true rate of opioid use disorder as a consequence of prescribing are very heterogeneous. One study has estimated the prevalence of problematic pharmaceutical opioid use at 9.3% in patients with non-cancer pain, while other studies estimated the risk as 0.2% for individuals with no preexisting addiction issues. Even a 0.2% risk of addiction is not trivial, but it must be weighed against the harm of leaving patients in debilitating pain.
Crucially, opioid pain medication must be treated like all other possibly addictive pain medications — worth the risk in some circumstances, but not in others. Different cases require different approaches. And when opioids are used in end-of-life settings, there are fewer concerns about addiction — if a patient is dying, even addiction might be a reasonable choice to make the last few months of their life more bearable.
But despite these nuances, over time, regulation has tended to tighten restrictions on pain relief, further constraining who can access relief.
Restrictions begin at the international level. Countries must report their need for opiates to the International Narcotics Control Board before importing them. Unfortunately, countries often underestimate their own needs for opioids and fear being seen as lax on drug control. Thus, they rarely choose to deviate from their current level of imports — even if it is far too low. Furthermore, since pain medication is not seen as “lifesaving,” it is an easy place for governments to cut corners. [...]
Traditionally, clinicians have avoided using opioids as much as possible, as they can cause central nervous system depression. This reduces the rate of breathing and in doing so could potentially hasten death. As recently as 2012, a third of medical ethics educators in the United States believed this to be the case. However, while it is true that morphine and other opioids have a narrow therapeutic index, meaning that the safety margin for their use is fairly small, it is not true that they hasten death when correctly administered.
Doctors’ fears of overusing opioids have only increased with time. Opioids are addictive, and overuse is dangerous. The United States has experienced significant public health harm from the overprescription of opioids, with the opioid crisis peaking at perhaps 80,000 opioid-caused deaths per year. The start of the crisis was caused by the unscrupulous drug pushing of pharmaceutical companies for types of pain where opioids are not very helpful. In response, doctors became much more hesitant to prescribe. Indeed, doctors could even be prosecuted for overprescription.
But while this first wave of the opioid crisis in the U.S. was driven by the prescribing dynamics of doctors, this was not the lasting mechanism for increased opioid deaths into the 2020s. Between 2011 and 2021, opioid deaths tripled, even as opioid prescriptions decreased by nearly 40% during the same period. Pain medication might have kicked off the epidemic, but it was not the lasting driver. [...]
It is true that prescribing opioid pain medications comes with risks. Estimates of the true rate of opioid use disorder as a consequence of prescribing are very heterogeneous. One study has estimated the prevalence of problematic pharmaceutical opioid use at 9.3% in patients with non-cancer pain, while other studies estimated the risk as 0.2% for individuals with no preexisting addiction issues. Even a 0.2% risk of addiction is not trivial, but it must be weighed against the harm of leaving patients in debilitating pain.
Crucially, opioid pain medication must be treated like all other possibly addictive pain medications — worth the risk in some circumstances, but not in others. Different cases require different approaches. And when opioids are used in end-of-life settings, there are fewer concerns about addiction — if a patient is dying, even addiction might be a reasonable choice to make the last few months of their life more bearable.
But despite these nuances, over time, regulation has tended to tighten restrictions on pain relief, further constraining who can access relief.
Restrictions begin at the international level. Countries must report their need for opiates to the International Narcotics Control Board before importing them. Unfortunately, countries often underestimate their own needs for opioids and fear being seen as lax on drug control. Thus, they rarely choose to deviate from their current level of imports — even if it is far too low. Furthermore, since pain medication is not seen as “lifesaving,” it is an easy place for governments to cut corners. [...]
In many countries, the bureaucratic procedures one must follow to prescribe opioids remain difficult to navigate, too few clinicians are allowed to prescribe and updates in regulation take too long to trickle down to clinical practice.
Instead, clinicians lean heavily on ibuprofen and paracetamol. However, these medications are only suitable for fairly mild pain; for postsurgical pain and cancer pain, they barely make a dent. [...]
What Would It Take to Prioritize Pain?
Even in countries with excellent medication availability, progress in palliative care is often stuck for deeply human reasons: misconceptions, regulation, governance and lack of training. The barrier to good care is not medicine innovation but rather the lack of prioritization of pain control as a key part of treatment. Moreover, we need to change how people conceptualize palliative care. It is viewed as reserved for frail and dying people, which is perhaps why in the United States fewer than one in five young adults with advanced cancer get appropriate palliative care as part of their treatment.
Worldwide, most clinicians are still not properly trained in pain management and pain management specialists are very rare. Mozambique, a country of 35 million people, has just two physicians specializing in pain management. Zimbabwe, a country of 17 million people, has just two pain specialists. Pain management is often viewed as unimportant.
Even in countries with excellent medication availability, progress in palliative care is often stuck for deeply human reasons: misconceptions, regulation, governance and lack of training. The barrier to good care is not medicine innovation but rather the lack of prioritization of pain control as a key part of treatment. Moreover, we need to change how people conceptualize palliative care. It is viewed as reserved for frail and dying people, which is perhaps why in the United States fewer than one in five young adults with advanced cancer get appropriate palliative care as part of their treatment.
Worldwide, most clinicians are still not properly trained in pain management and pain management specialists are very rare. Mozambique, a country of 35 million people, has just two physicians specializing in pain management. Zimbabwe, a country of 17 million people, has just two pain specialists. Pain management is often viewed as unimportant.
by Morgan Fairless, In Development | Read more:
Image: By reference
[ed. Contrast this with the article below about the UK voting down assisted suicide. Because of Purdue Pharma and a few bad actors/pill mills, it's now almost impossible to get an opioid prescription. The pendulum has swung too far and millions of people are suffering. Examples of medical providers withholding opioids for people with terminal illnesses because they might get addicted in their last few months is insane.]
