The path toward universal health coverage cannot neglect the access to essential medicines for pain management. Unfortunately, there is a dramatic gap in access to opioid narcotics for legitimate medical use, and the needs for palliative care and pain relief remains largely ignored in low- and middle-income countries, even for the most vulnerable groups such as children with terminal illnesses and those living through humanitarian crisis. What can the global health community do, to join efforts to fulfill the human right to adequate medical care also when it comes to pain management?

By Raffaella Ravinetto

Antwerp, Belgium

Access to Opioid Analgesics for Medical Purposes: a Global Unbalance

The Universal Declaration of Human Rights includes the right to medical care (1). Within medical care, opioid analgesics are indispensable for provision of pain relief, including but not limited to palliative care. Therefore, the World Health Organization (WHO) has included opioids in its Model List of Essential Medicines since the publication of the first list in 1977 (2). The presence in the WHO Model List clearly indicates that these medicines should be made timely available to all those in need.

Unfortunately, the availability of opioid analgesics remains dramatically inadequate in many countries. In 2006, the WHO estimated that each year pain treatment was not provided to tens of millions of patients in need, including those with end-stage HIV/AIDS, terminal cancer, accidents- or violence-induced injuries, chronic illnesses, post-surgery pain, as well as to women in labour and children with acute or chronic pain (3). The Lancet Commission on Palliative Care and Pain Relief estimated that in 2015, more than 80% of people with serious health-related suffering were living in low- and middle-income countries (LMICs), where access to palliative care and pharmaceutical pain relief is (very) limited or lacking (4). The findings of a multi-country study of the International Narcotics Control Board (INCB), based on the concept of defined daily doses for statistical purposes (S-DDD) per million inhabitants, revealed that the use of opioid analgesics more than doubled worldwide between 2001–03 and 2011–13, but that substantial increases were limited to North America, western and central Europe and Oceania (5). Countries in Africa, Asia, Central America, the Caribbean, South America, and eastern and southeastern Europe showed no substantial increase in use, due to a number of factors such as absence of training and awareness in medical professionals, fear of dependence, restricted financial resources, issues in sourcing, cultural attitudes, fear of diversion, international trade controls, and onerous regulations (5).

The multiplicity of barriers and challenges makes the “access problem” particularly complex for opioid analgesics; and in many LMICs, the underreporting complicates the accurate assessment of needs, with an important gap between actual needs, reported requirements and actual consumptions. Furthermore, problems of access are magnified during public health emergencies, in presence of unplanned and sudden additional needs.

International treaties such as the Single Convention on Narcotic Drugs (1961) and the United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances (1988) have been rightly established to prevent the harm and human suffering that derive from abuse of these substances. However, equal emphasis should be put on ensuring that opioid analgesics are made timely and universally available for legitimate medical use. In 2016, the UN General Assembly Special Session (UNGASS) Joint commitment to effectively addressing and countering the world drug problem explicitly addressed the need of ensuring the availability of and access to controlled substances, including opioid analgesics, for medical and scientific purposes, while preventing their diversion (6). Nonetheless, the needs for palliative care and pain relief remains largely ignored in LMICs, “even for the most vulnerable populations, including children with terminal illnesses and those living through humanitarian crisis, and even in the SDGs” (4).

What is the role for the global health community here? King and Fraser argued that global inequalities in untreated pain also result from lacunae in the “prevailing ideologies of global health”, which prioritize the treatment and eradication of diseases, while the need for pain management may be perceived as a mark of failure within the biomedical model (7). Therefore, it seems important that the needs of patients with pain are put high on the agenda of global health, including researchers and advocates. Collaborative research efforts could investigate, for instance, the effectiveness of the strategies adopted to strengthen awareness, education and training in this field; the impact of the COVID19 pandemic on access to opioid analgesics; and the access to opioid analgesics in specific groups and contexts (e.g. chronic pain in children, palliative care in humanitarian contexts, etc.). This could help to generate evidence to guide policy makers; to reorient the attention of the international community on the needs of under-researched contexts and communities; and eventually to strengthen the global efforts to fulfill the human right to adequate medical care including the management of pain.

References

1) UN General Assembly. Universal declaration of human rights. New York: United Nations, 1948. Available at http://www.ohchr.org/EN/UDHR/Documents/UDHR_Translations/eng.pdf

2) Richards GC et al. Relation between opioid consumption and inclusion of opioids in 137 national essential medicines lists. BMJ Global Health 2020;5:e003563. doi:10.1136/bmjgh-2020-003563

3) World Health Organization. Briefing note, Access to Controlled Medications Programme, Improving access to medications controlled under international drug conventions. Geneva. Available at https://www.who.int/medicines/areas/quality_safety/AccessControlledMedicinesProgr.Framework.pdf

4) Knaul F, et al. 2018. Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: The Lancet Commission report. The Lancet, 391: 1391–1454. DOI: https://doi. org/10.1016/S0140-6736(17)32513-8

5) Berterame S et al. Use of and barriers to access to opioid analgesics
Lancet 2016; 387: 1644–56

6) https://www.unodc.org/ungass2016/en/about.html

7) King NB, Fraser V (2013) Untreated Pain, Narcotics Regulation, and Global Health Ideologies. PLoS Med 10(4): e1001411. https://doi.org/10.1371/journal.pmed.1001411