“The lack of pain treatment medicine is both perplexing and inexcusable.
Pain causes terrible suffering yet the medications to treat it are cheap, safe, effective and generally straightforward to administer.”
Access to pain treatment as a human right | BMC Med. 2010
Almost five decades ago, governments around the world adopted the 1961 Single Convention on Narcotic Drugs which, in addition to addressing the control of illicit narcotics, obligated countries to work towards universal access to the narcotic drugs necessary to alleviate pain and suffering.
Despite the existence of inexpensive and effective pain relief medicines, tens of millions of people around the world continue to suffer from moderate to severe pain each year without treatment.
Barriers to access to pain treatment globally include:
- the failure of governments to put in place functioning drug supply systems;
- the failure to enact policies on pain treatment and palliative care;
- poor training of healthcare workers;
- the existence of unnecessarily restrictive drug control regulations and practices;
- fear among healthcare workers of legal sanctions for legitimate medical practice; and
- the unnecessarily high cost of pain treatment.
The lack of pain treatment medicine is both perplexing and inexcusable.
Pain causes terrible suffering yet the medications to treat it are cheap, safe, effective and generally straightforward to administer.
Furthermore, international law obliges countries to make adequate pain medications available.
Over the last 20 years, the WHO and the INCB have repeatedly reminded states of this obligation. However, little progress has been made and tens of millions of people continue to suffer – both directly from untreated pain and from its consequences.
Under international human rights law, governments must take steps to ensure that people have adequate access to treatment for their pain. At a minimum, states must ensure the availability of morphine, the mainstay medication for the treatment of moderate to severe pain
There are many reasons for the enormity of the gap between pain treatment needs and what is delivered, but the chief among them is a willingness by many governments around the world to passively stand by as people suffer.
Excessive over-regulation by governments and the ignorance of healthcare providers conspire to create a vicious cycle of under-treatment.
As pain treatment and palliative care are not priorities for the government, healthcare workers do not receive the necessary training in order to assess and treat pain. This leads to widespread under-treatment and to a low demand for morphine.
Similarly, complex procurement and prescription regulations, and the threat of harsh punishment for mishandling morphine, discourage pharmacies and hospitals from stocking and healthcare workers from prescribing it, which again results in low demand.
A lack of the prioritization of opioid pain medicine is not a result of the low prevalence of pain but of the invisibility of its sufferers.
To break out of this vicious cycle, individual governments and the international community must fulfill their obligations under international human rights law.
Governments must take action to eliminate barriers that impede the availability of pain treatment medications.
They must develop policies on pain management and palliative care; introduce instruction for healthcare workers, including for those already practicing; reform regulations that unnecessarily impede the accessibility of pain medications; and take action to ensure their affordability
The Inadequate Treatment of Pain: Collateral Damage from the War on Drugs | PLoS Med. 2012 Jan;
Once widely supported, the “war on drugs” has become increasingly controversial, as the political realization sinks in that it has wrought more harm than good.
The Global Commission on Drug Policy, a collection of eminent former heads of state, businesspersons, and diplomats, bluntly declares that “the war on drugs has failed,” while simultaneously “[generating] widespread negative consequences for societies in producer, transit and consumer countries”.
The European Union’s Reuter-Trautmann report witheringly finds “no evidence that the global drug problem was reduced” following the intensified criminalization of drug abuse and trafficking in the late 1990s, and that the “enforcement of drug prohibitions has caused substantial unintended harms; many [of which] were predictable”.
That prohibitionist drug laws often impede treating addiction or reducing its harms is already familiar to the public health community.
However, it is less well recognized that these same failed policies of the war on drugs inflict tremendous collateral damage on the treatment of one of the most common ailments: pain.
Not just addicts, but arguably most of the world’s population are victims of the failed war on drugs.
Two treaties contain the foundation for many national drug control laws:
- the 1961 United Nations Single Convention on Narcotic Drugs, and
- the 1971 Convention on Psychotropic Substances.
Both these international laws are overseen by the International Narcotics Control Board (INCB), whose mandate is split awkwardly between promoting and controlling narcotic and psychotropic drugs and precursor chemicals.
The INCB is basically in the conflicted position of both promoting and throttling the drugs it regulates
Last year, the president of INCB admitted that the two sides of his legal mandate are out of balance:
while much attention goes to prohibiting the production, supply, and use of illicit controlled substances, “equal emphasis has not been placed on the other fundamental objective of the treaties of ensuring that [licit] controlled substances are available for medical and scientific purposes”.
It is in public health emergencies, however, that INCB’s estimates are the most punishing and deplorable for health
Regrettably, many national governments appear to have followed INCB’s example of not balancing narcotic drugs with the demands of public health.
It is now timely to rebalance drug policy, so that the requirements of pain patients for licit narcotics are met.
Pain has to be viewed not just as a clinical problem in need of better treatment modalities, but as a social problem in need of wiser international and national policies, laws, and institutions.
In conclusion, the war on pain, much like the war on drugs which eclipses it, is a failure, and a strict prohibition mind-set has served neither.
Five decades after the Single Convention, and two decades after the INCB initiated its last ineffective attempt at reforms, it would be exceedingly naïve not to conclude that this experiment has run its course.
Attention must now shift to creating better legal frameworks that extricate pain treatment from drug prohibition, and that formally transfer some responsibilities and funding from INCB to WHO, so that health equity plays a part in narcotics control policy.
To reject this conclusion is to continue embracing a cruel system in which persons needlessly lack treatment for pain, for the stubborn pursuit of narcotics prohibition, which others have found no longer desirable.
Untreated Pain, Narcotics Regulation, and Global Health Ideologies | PLoS Med. 2013 Apr;
Untreated Pain: A Global Health Problem
Chronic pain currently affects one in five adults, is more prevalent among women and the elderly, and is associated with physically demanding work and lower education.
Untreated pain has a profound impact on quality of life and can have physical, psychological, social, and economic consequences.
Inappropriately managed acute pain can result in immunological and neural changes, which can progress to chronic pain if untreated.
Clinical outcomes of untreated postoperative pain include increased risk of atelectasis, respiratory infection, myocardial ischemia, infarct or cardiac failure, and thromboembolic disease.
Common sequelae of untreated chronic pain include decreased mobility, impaired immunity, decreased concentration, anorexia, and sleep disturbances
Patients with chronic pain often experience social isolation, dependence on care givers, and impaired relationships with friends and family, and are four times more likely to experience depression or anxiety than those without pain.
The financial burdens of untreated chronic pain—absenteeism, income loss, healthcare costs, and workers compensation—place the same strain on countries as cancer and cardiovascular disease.
The prevalence of untreated pain is likely to increase as the population ages in many developed nations, and with the increasing global burden of chronic disease and HIV/AIDS.
Pain management is complex, and certain types of pain, including CNCP, may require multimodal approaches that combine pharmaceutical and non-pharmacological therapies.
Nevertheless, current pharmaceutical interventions are generally effective and, in high-income countries, a cheap and readily available means of reducing acute and chronic malignant pain.
Opioids are effective in treating moderate to severe pain and have been included on the WHO Essential Medicine list since 1986.
The Role of Narcotics Regulation
Access to pain management is a widely recognized human right, enshrined in international law. There should be no serious technical or financial obstacles to global distribution of effective pain treatments. Why then is there so much untreated pain?
While charged with simultaneously controlling illicit and scheduled drugs, and ensuring the availability of medications, the INCB and other international organizations including the UN Commission on Narcotic Drugs (CND) and the United Nations Office on Drugs and Crime (UNODC) have emphasized prohibition and law enforcement at the expense of access.
Critics contend that international drug control reform is essential for reducing the global burden of untreated pain. Noting that the INCB is “in the conflicted position of both promoting and throttling the drugs it regulates,” Nickerson and Attan recommend transferring its mandate for promoting medical use of licit narcotic and psychotropic drugs to the WHO. Similarly, Taylor recommends that the INCB use the Single Convention’s reporting, inspection, and non-compliance procedures to compel countries to expand medical availability of pain medications.
Pain and the Ideologies of Global Health
Many global health efforts embrace a “biomedical” model, which prioritizes the treatment and eradication of disease.
*While focusing on cure does not necessarily preclude care, it often means that resources are directed at treating disease, rather than addressing the suffering that it produces.
Many global health organizations embrace an alternative, “public health” model, emphasizing prevention through modification of human behavior and the physical and social environment
*Despite its commendable emphasis on prevention, health promotion, and the determinants of health, the public health model is no more likely to address untreated pain—which, as in the biomedical model, is often seen as a mark of failure.
Untreated Pain: The Global Health Priority
Funding for pain management, prevention, and cure should not have to compete with one another. While reform of narcotics regulation is vital, it must be accompanied by a concerted effort among global health funders, institutions, and organizations to place untreated pain at the top of the list of global health priorities. This effort must attend to the complexity of pain and promote multimodal, multidisciplinary pain management from the outset.