Tackling Pain Seen As Vital To Debate On Noncommunicable Diseases And Care

Access to powerful painkillers, usually based on opioid substances, is a crucial part of progress towards tackling NCDs, according to the International Narcotics Control Board (INCB), a UN quasi-judicial body that is concerned with enforcing three global drug control conventions.

A map of the world, representing countries by the size of their opioid consumption rather than geographical spread. Note, Africa and Russia – which are among the regions that have the greatest restrictions on the use of medical opioids – have all but disappeared.

The rather surprising comments, from a drugs control body, came as Viroj Sumyai, president of the INCB, called for countries to stop using the rules as a reason to restrict access to opioids for those in extreme pain.

“International drug control treaties require state parties to ensure the access, availability and rational use of internationally controlled narcotic drugs and psychotropic substances for medical purposes,” he said at a side event on drug control, human rights and the Sustainable Development Goals at United Nations Headquarters earlier this month.

He has done this before. At a Global Conference on Noncommunicable diseases (NCDs) in Montevideo last year, Sumyai said 75 percent of people in low- and middle-income countries, and usually the poorest, have no access to the medicines that are vital for managing painful NCDs, such as cancers. He also suggested that an often hidden NCD is substance-use disorder, particularly drug use disorders.

His comments come at a time when palliative care, of which access to opioids is one part, is still very low on the agenda of the global health community. The latest draft of the Political Declaration on NCDs ahead of September’s UN meeting, discussed by civil society groups, has 33 paragraphs. However, there are none on palliative care and the entire document has scant mention of care for the dying and access to adequate pain relief for those suffering, most of whom have NCDs, according to Stephen R Connor, executive director of the Worldwide Hospice Palliative Care Alliance (WHPCA), and member of the WHO civil society working group.

“It has a couple of minor references but we had recommended inclusion of a dedicated paragraph on palliative care and put forward some language,” he said. “This is all about getting member states to insist on inclusion of palliative care language in the document. The whole focus of this [document] has been on prevention and control, and not care.”

The problem is, a huge number of middle income and low-income countries severely restrict access to legitimate registered painkillers. Medicines based on opioids, such as morphine, can be prescribed for end-of-life pain and those living with extremely painful NCDs such as cancers. Countries are expected to report to the INCB the volumes of opioid they require for medical purposes, in order to minimise diversion to the illicit trade in opioids and addiction. Countries throughout Asia and sub-Saharan Africa worried  about the dangers of opioids report inadequate volumes to support the number of people living and dying in extreme pain within their populations.

Two Global Drug Problems

The messages on opioids appear contradictory. While the INCB and the palliative care community calls for more access to opioids, they were named the most harmful drug type according to the latest World Drug Report, by the United Nations Office on Drugs and Crime (UNODC), released in late June. It said: “they accounted for 70 per cent of the negative health impacts associated with drug use disorders worldwide.”

And several countries including the United States, Canada, Australia and, now, in Europe, are reporting growing levels of dependence and worrying numbers of overdose deaths. The crisis has been most visible in the United States. The most recent figures from the US Centers for Disease Control (CDC) suggest that in 2016, 42,249 people died – 66 percent of all overdoses. That’s a massive jump in deaths compared with 2015, when 33,091 people died. Canada, Australia and parts of Europe are seeing problems too, according to the latest INCB report. Over 8,440 overdose deaths, mainly related to heroin and other opioids, were estimated to have occurred in Europe in 2015, a 6 percent increase compared with 2014.

“We have a huge problem with the majority of countries in the world not allowing access to pain relievers for people who are in dire need of pain relief, particularly end-of-life and cancer care,” explained Matthew Nice, global manager of the INCB’s Operational Partnerships to Interdict Opioids’ Illicit Distribution and Sales (OPIOIDS) Project, a strategy developed to track producers and sellers of illicit fentanyl. “There are also an awful lot of countries where the abuse problem is growing and we are concerned about that as a means to causing more harm to people around the world.”

INCB’s Nice said that it is vital the overdose epidemic does not inspire governments around the world to maintain restrictions on opioids to those who genuinely need it. “I really want to make sure it doesn’t sound like we are advocating that there should not be access to these substances,” he said. “There are a lot of countries where the legitimate access of really critical substances like fentanyl and morphine in particular, aren’t available. It’s a very complex landscape and language really, really matters.”

The fact is the poorest 50 percent of the world’s population receive less than 1 percent of all the morphine in the world. Meanwhile the richest 10 percent received 90 percent. That’s the global pain divide, according to a Lancet Commission issued last year on the subject of palliative care and access to opioids. Felicity Knaul, from the University of Florida and one of the commissioners responsible for the report, spoke at an NCD Alliance webinar early this year. She explained that access to morphine is a topic that largely been ignored within global health. “The commissioners felt that this was probably the most inequitable distribution in the combined centuries of global health expertise sitting there around that table,” she said.

At the UN high-level meeting in 2011, the palliative care advocacy community was able to secure access to appropriate opioids as one of the 25 indicators of the global Monitoring framework, to track the implementation of the NCD action plan. That indicator, number 20, measures just how much of these strong pain medicines countries allow their populations to consume compared with cancer deaths.

But no countries are using this indicator yet. And there’s no benchmark for countries to move towards, said Diederik Lohman, acting director of the Health and Human Rights Division at Human Rights Watch. “So yes, we have an indicator that can show how the situation develops over time but not a specific target or goal of what we want to achieve,” he said. “That makes it a kind of second class indicator, although it is still important that it’s there.”

Discussions at the UN high-level meeting and now, have persistently neglected the issue of care and minimising suffering, argue the palliative care community. Countries, perhaps, haven’t recognised that even if there were better prevention and control, many people would still die of noncommunicable diseases, and in unacceptable pain. “While a lot of people are dying prematurely as a result of noncommunicable diseases, that doesn’t mean that you don’t need to be focusing on what happens when people do get a noncommunicable disease and they progress to become incurable,” he added.

Additionally, the gap in the global architecture also exists because of the way things are measured. Of course, saving lives is extremely important, said Lohman. “But we are so geared towards calculating life years we may have added by making certain interventions or how many life years are lost if we are not making interventions,” he said. “We have completely lost track of the fact that, healthcare and medicine should also be about care and comfort. But since we are not measuring those as outcomes of what healthcare system should be doing, we end up not making policy around care and comfort.”

WHPCA’s Connor says it has been a great challenge to create measures that the rest of the global health community can use to quantify how widespread palliative care is. Accurate mortality and opioid consumption figures are extremely difficult to come by.

But, said Connor, the INCB is held in great esteem by many of the countries who report to it, and could be more forceful in getting countries to take palliative care and access to opioids more seriously. “The INCB are being much more responsive to this problem than they have been. But we’d still like them to take a more aggressive tact where there’s clearly a problem,” he said. “When you read the language of the reports, they’re very clear that this is potentially more serious than the individual problems we have in the US and a few other countries.”

Certainly, this year’s INCB report, looking at the state of the world’s drug problems pulls no punches when it discusses the opioid overdose crisis, as it’s now called.

It lays the blame squarely at the door of medical professionals who overprescribe the drugs for the wrong conditions and pharmaceutical companies that have been allowed to market and train doctors to prescribe their opioids inappropriately.

“These are the most powerful of the opioids we generally have in terms of palliative care,” said INCB’s Nice. “But they’ve been marketed and utilised for all sorts of pain relief situations where other medications may have been more suitable.”

It also says there is no proof that new formulations created to minimise dependence actually work, no matter what pharmaceutical companies say.

Ironically, the US has introduced its own restrictions over the last couple of years. But it has unwittingly, according to Nice, made the opioid crisis worse by driving addicts to use illicit fentanyl – black-market versions of fentanyl sold by nefarious organisations.


Image Credits: International Narcotics Control Board and WHO Global Health Estimates, 2015. See additional online material for methods..

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