By Robin Porsfelt.
While the recent US ’opioid crisis’ has been widely reported, a second, less recognized, crisis related to opioids has been taking place, and is still ongoing, more quietly in countries with less Western media visibility. Whereas the crisis in the US is arguably related to an over-subscription to opioid-based pain relief, such as OxyContin, the second crisis could rather be seen as a case of too tightly regulated access to opioids in health-care systems. This is at least the argument of a recent report commissioned by The Lancet which proclaims that the world is experiencing an under-management of pain where as many as 25 million people are suffering partly as a result of regulatory and cultural approaches to the use of opioids.
Severe lack of access
The report was the result of a three-year study on the integration and access of pain relief and palliative care in health systems. It opens with a succinct description of the problem: “Poor people in all parts of the world live and die with little or no palliative care or pain relief. Staring into this access abyss, one sees the depth of extreme suffering in the cruel face of poverty and inequity” (Knaul, Farmer & Krakauer et al, 2017: 1).
Those suffering from lack of access to adequate medication are predominantly found in low-income and middle-income countries, often with terminal illnesses, and includes approximately 2.5 million children dying with, what the report terms, ‘serious health-related suffering’ each year (Knaul, Farmer & Krakauer et al, 2017: 2). Of the almost 300 metric tons of morphine-equivalent opioids distributed annually, only 0.1 metric tons reach health systems in low-income countries. This is something the report’s authors condemn as: “a medical, public health, and moral failing and a travesty of justice” (Knaul, Farmer & Krakauer et al, 2017: 1).
Addiction and pain relief
But what are the reasons for this state of potentially unnecessary suffering? In contrast to many other debates on access to medication, the problem is in this case not predominantly related to questions of scarcity, costs, or tightly enforced intellectual property rights to drugs, but rather a mix of cultural and regulatory factors. There are (at least) two factors that explain the pattern: One is a lack of visibility due to fragmented patient advocacy and exclusion of pain alleviation from standard measures of health. Another key factor is that opioids do not only fall under the scope of medical regulation but are also controlled substances under international drug conventions (Ibid.).
As substances such as morphine are listed and regulated as narcotic substances by the UN, they become part of a machinery of international checks and balances on their flow, including import quotas and reporting requirements. The UN treaties are based on two imperatives, on the one hand the limitation of harmful and addictive substances, and on the other hand to secure access to medically vital analgesics. In recent decades, the war on a drugs-compatible first imperative of strict control has become increasingly dominant, making such medication harder to access (Knaul, Farmer & Krakauer et al, 2017: 8).
A second related issue suggested by the report is ‘opiophobia’, described as prejudice and misinformation concerning medical use of opioids. Whereas a balanced approach to opioid prescriptions is needed, a prevalent fear of non-medical use and its side-effects among health-care providers, regulators, and patients have led to an underestimation of needs and insufficient medical use in many countries (Ibid.).
What’s to be done
Even though this inequity in pain relief is indeed under-acknowledged, potential solutions should at least, in theory, not be gridlocked by economic interests. As morphine and morphine-like medication is cheap to produce and commonly used in Western medical systems, the problem is rather about framing and contesting stigmatization. While acknowledging the risks with a too laissez-faire approach, there is a need to recognize the value in a controlled medical use of opioids to avoid unnecessary suffering as well.
A way to do so, as the report highlights, would for instance be a broadening of the third Sustainable Development Goal (SDG) on ensuring healthy lives and well-being for all. Currently, the battle against substance abuse is covered in the SDG target 3.5, a step forward however would be to include pain alleviation and access to pain relief as similarly essential objectives – for instance as part of SDG target 3.8 on universal health coverage. As a measure, this is of course not enough, but at the current stage, and given the documented ‘abyss’ of equity in pain treatment worldwide, simply diagnosing the issue as problematic per se would to some degree seem like progress.
 A member of a group of drugs to achieve analgesia, i.e. relief from pain. (editor’s note)
Knaul, F. M., Farmer, P. E., Krakauer, E. L., et al. (2017). Alleviating the access abyss in palliative care and pain relief––an imperative of universal health coverage: The Lancet Commission report. Lancet. DOI: 10.1016/S0140-6736(17)32513-8
Robin Porsfelt is a PhD fellow at the Department of Management, Society and Communication. He is part of a PhD cohort on time and societal challenges, with particular research interests in the sociology of valuation and global governance