While the United States is trying to reduce the number of powerful painkillers prescribed because of the opioid epidemic, palliative-care patients in poor countries have little to no access to these drugs for pain — and millions die because of it.
According to a study from researchers at the University of Miami and Harvard University published in the Lancet, more than 19 million people in developing regions of the world died with pain in 2015. The study found that those patients did not have adequate access to the medications that would have relieved that pain.
The authors wrote that access to pain-relieving drugs for people receiving care for severe illnesses is difficult, if not impossible, in many low-income countries. The disparity, the study’s authors wrote, is a “medical, public health and moral failing and a travesty of justice” that leads to unnecessary suffering and death among adults and children throughout the world.
“Almost without exception, poor people in all parts of the world live and die with little or no access to pain relief or any other type of palliative care,” they wrote.
The authors wrote that 2.5 million children each year die from what they term serious health-related suffering, accounting for about a third of all deaths from pain in low-income countries each year.
“There’s no voice for people who aren’t going to make it and need this kind of care,” said Felicia Marie Knaul, a lead author and director of the University of Miami Institute for Advanced Study of the Americas.
“There are two things that are certain for everyone in this world: We’re all born and we’re all going to die,” she said. “We assume we can have a secure, pain-managed end of life, and if we need treatment we will have the security of pain management.”
Worldwide, more than 61 million people experience severe pain. In certain poor countries — including Kenya, Ethiopia and Sudan — all of the need for pain relief for patients with severe conditions goes unmet because of a lack of morphine. Other countries also are not meeting the needs of palliative-care patients: In Mexico, almost two-thirds of the needs of patients go unmet. In the United States and Canada, the annual distribution of morphine for palliative-care patients exceeds each patient’s need by more than 3,000 percent — more than four times the amount of morphine available to palliative-care patients in Western Europe.
“The enormous gap between need and availability of opioid analgesics is growing and is increasingly skewed against people living in poverty,” the study’s authors wrote.
A major reason the authors cite: In many parts of the world, access to these medications is limited. That is in part because of what they call “opiophobia,” or the fear of prescribing opioids outside of a hospital setting because of concerns they will be illegally passed on to others. Efforts to prevent the abuse of these drugs have “overshadowed and crippled” painkiller access for patients who need them, the authors wrote, leaving millions suffering from serious pain.
The solution, Knaul and the other authors argue, is to provide patients with immediate-release morphine in tablet form. Knaul said this medication, rather than a name-brand one, is “not a moneymaker” and is not marketed, so there is little incentive to overprescribe. By prescribing morphine in pills, patients can take the medication at home, cutting down on long and costly hospital stays, she said.
“There’s no necessary association between good access for medical need and overdosing,” Knaul said. “The only thing you get when not providing pain relief when pain relief is required is pain.”
Morphine is part of what the study’s authors call the “essential package” of pain relief that each country should implement by 2030, including training for doctors and nurses. It includes medicines such as ibuprofen to treat pain, antipsychotic medications and drugs to treat fungal infections. It also calls for catheters, lockboxes for opioid medications, adult diapers and human resources, including physical therapists and pharmacists. The authors said it will cost $145 million to close this gap worldwide. That amounts to $2.40 per capita in poor countries and $0.75 in more prosperous countries.
It should be up to each country to design and implement a system to dispense and monitor the medication, track data and measure effectiveness.
The situation is particularly acute among children and end-of-life patients in need of these medications, the study’s authors argue. And the situation is expected to get worse as the world ages. Between 2015 and 2050, the authors wrote, the number of people over 60 is expected to double, and the population of people over 80 is expected to triple, with the fastest growth occurring in Latin America, the Caribbean, Asia and Africa.
“Yet the interest, investment and indicators needed to guarantee universal access to safe, secure and dignified care until death and to ensure palliation of pain and suffering throughout life, are grossly inadequate,” they wrote.