Ten percent of the world consumes 90% of the morphine. At first glance that’s just another statistic about haves and have nots. But it’s more stark than that - particularly if you have cancer in a country where access to pain relief is limited.
Pharmaceutical companies have little interest in producing cheap oral morphine because profits are only marginal. In Ukraine, for example, that means only injectable morphine is available. So patients with chronic cancer pain need injections several times a day and may be left without relief for hours in between.
But there is another problem - the way pain relieving drugs are seen in many countries. Legislation that uses language such as “addictive drugs” to describe pain relief leads to the belief that these drugs, even in controlled circumstances, facilitate crime and corruption. Such medication can be the only way to avoid a horrific end to many lives: among them the 12 million people with cancer; those with advanced heart, lung or kidney diseases; progressive neurological diseases; HIV/AIDS or tuberculosis.
The various legal and regulatory barriers mostly relate to the prescribing and dispensing of opioids (medications that relieve pain, such as morphine).
Attitudes among healthcare professionals vary from country to country. Often there is fear of the possibility of prosecution from prescribing analgesics such as paracetamol and ibuprofen and a desire to avoid taking any responsibility in a murky area. Even when a law might recognise that controlled medicines are necessary, healthcare staff can be wary of the potential of being investigated and disproportionate punishments that might await them.
The under-treatment of cancer pain is a major public health crisis in both developing economies and many parts of the less developed world. There have been isolated efforts by international organisations to address the problem, but the headline is that little headway has been made.
Research led by the European Association for Palliative Care looked at treatment of cancer pain across 76 countries between 2010 and 2012 showed highly restrictive regulations on what patients receive in Africa, Asia, the Middle East and Latin and Central America.
Very few countries provided all seven of the medicines we consider essential for the relief of cancer pain. In many countries, less than three of them were available and often unsubsidised by the government. Availability is usually limited.
Restrictions for cancer patients include regulations that limit their entitlement to prescriptions, how long their prescriptions last, and what drugs they can have. There is often a great deal of bureaucracy surrounding the whole prescribing and dispensing process.
Eastern Europe is a crisis area. Essential pain killing medicines are unavailable in Lithuania, Tajikistan, Belarus, Albania, Georgia and Ukraine.
There are problems elsewhere, including Russia, Montenegro, Macedonia and Bosnia-Herzegovina, where regulations limit doctors’ ability to prescribe opioids even for patients in severe pain and healthcare providers and pharmacists are intimidated by legal sanctions. All this contravenes regulations from the World Health Organisation which recommends doctors should be able to prescribe pain relief according to each person’s individual needs.
There is a lack of training for doctors and other healthcare staff on this matter. Often legislation fails to help. We need more debate and education for healthcare officials and decision makers if palliative care is to become a normal part of healthcare. Excessive legislation needs to be stripped away and more attention paid to providing safe and secure distribution systems that allow everyone access to pain killers, as a human right, no matter where they are.