The disparity in available pain medicine between rich and poor countries is the most pronounced health inequity in the world, says Amir Attaran, Associate Professor and Canada Research Chair in Law, Population Health and Global Development Policy at the University of Ottawa.
In their 2012 PLOS Medicine paper, "The Inadequate Treatment of Pain: Collateral Damage from the War on Drugs," Attaran and Ottawa colleague Jason Nickerson explain that the International Narcotics Control Board (INCB) binds countries to pain medicine quotas. These quotas vary tremendously. But they don't vary by need. They vary by income.
"There was a five thousand fold difference in per capita availability of pain meds between the countries that were the best off and the countries that were the worst off. I cannot think of another disparity in global health that has a five thousand fold difference," Attaran said.
This hurts the people who need pain medicine the most. The World Health Organization estimates that 83% of the world's population - 5.5 billion people - have "low to non-existent" access to pain medicine for moderate to severe pain. This includes over 1 million end-stage HIV/AIDS patients and 5.5 million terminal cancer patients.
Though nearly 50% of the world's cancer patients and 90% of the world's HIV/AIDS patients live in low-to-middle income countries, they only receive 6% of the world's morphine supply. North America and Europe, on the other hand, receive close to 89% of the world's morphine.
When the time comes to fill out the paperwork, this inadequate supply serves as a baseline estimate - and makes inequity the country's normal. Attaran and Nickerson write,
These estimates are based on the country's own prediction of its pain treatment needs for the projected year, frequently using data on the number of treatments consumed in the previous year. Thus, a country that consumed low amounts of drugs in previous years can become trapped in a cycle of reduced access in subsequent years, divorced from any epidemiological measure of actual clinical need.
The INCB implements the two UN treaties on drugs, the 1961 Single Convention on Narcotic Drugs and the 1971 Convention on Psychotropic Substances. Their mandate should put them in a bind. On one hand, they are mandated to control these substances in the war on the drugs. On the other hand, they are mandated to promote them in the war on pain. But preventing a societal bad (substance abuse) - at least in poor countries - has been far more important than enabling a societal good (pain relief).
"To some extent, licit use of narcotics will always open the door and invite some illicit use. I mean, I think that's inevitable," Attaran said. "The question is, does one accept that risk of illicit use as a societal adverse effect of the licit clinical benefit that can be gained by appropriate access to those medicines?"
Though Attaran and Nickerson are concerned in this paper with global health disparities, we also see this ethical trade in the US. In 2010, the Senate held a special listening session, "The War on Drugs Meets the War on Pain: Nursing Home Patients Caught in the Crossfire." In the testimony, we meet an 86 year old woman with intense pain from spinal surgery whose Percocet couldn't be filled. Her pain became so unbearable that she required a second hospitalization in order to get her pain medicine, before returning to the nursing home. We also meet an end-stage HIV patient who couldn't receive narcotics for 18 hours because his electronic records lacked a signature. Even in a country where supply is relatively great, the need of people in pain goes unmet.
DEA measures to crackdown on substance abuse has had the predictable effect of a crackdown on people in pain. This isn't getting better. In January, an FDA committee voted to move hydrocodone combination medicine into the restrictive schedule 2 category of controlled substances. Here's what this means. A nurse at a long-term care facility cannot communicate a schedule 2 prescription to a pharmacy, which means a patient must wait until she is seen by a doctor. Like the 86 year old woman we met earlier, this could mean a second hospitalization, simply for pain management.
These harsh rules might make sense, if they worked to fight addiction. But they don't. Not only have drug laws not weakened the market for illegal drugs, as Evan Wood and colleagues point out, they've actually strengthened it: drug prices have fallen, purity has increased, and supply has grown. Countries such as Russia, China, and US have some of the harshest drug laws and the highest number of injection drug users. Meanwhile, on global and local scales, the poor and elderly are punished in vain.
Attaran sees this problem getting worse. "This will grow in significance as noncommunicable diseases do. Most communicable diseases kill you really quickly and without a lot of pain. HIV/AIDS being the exception, right? You're not going to have prolonged, serious pain if you get malaria. On the other hand, if you get cancer, count on it. As NCDs grow in prominence, this will be a bigger deal. And not just fatal NCDs, but ones that are simply morbidity causing, such as arthritis, this will be a bigger deal."
This blog originally appeared on April 26, 2013 at PLOS Blogs Public Health Perspectives.