While Americans are confronting an epidemic of prescription drug abuse, particularly for addictive painkillers, the reverse problem prevails in much of the world.
Many ill people with a legitimate need for drugs like oxycodone and other narcotics known as opioid analgesics cannot get them and are suffering and dying in pain, according to health officials, doctors and patients’ rights advocates.
In Russia, India and Mexico, many doctors are reluctant to prescribe these painkillers, fearful of possible prosecution or other legal problems, even if they believe the prescriptions are justified.
In Kenya, health officials only recently authorized the production of morphine, one of the most effective drugs for pain relief, after criticism that it was available in only seven of the country’s 250 public hospitals. In Morocco, the advocacy group Human Rights Watch reported in February, only a small fraction of physicians are permitted to prescribe opioid analgesics, which the country’s law on controlled substances identifies as poisons.
And in most poor and middle-income countries, these drugs are restricted and often unavailable, even for patients with terminal cancer, AIDS or grievous war wounds.
Plenty of reasons
The reasons include an absence of medical training, onerous regulations, costs, a focus on eliminating illicit drug use and, in some cultures, a stoic acceptance of pain without complaint. The problem has been amplified, public health experts say, by the stigmatization of the drugs, partly from fear of what has happened in the United States, where opioid misuse is a growing cause of death.
Reinforcing this view has been publicity about high-profile users like Prince, the pop star who died last month at his Minnesota mansion as friends sought help from an addiction specialist to treat what was apparently a dependence on opioid painkillers.
“While clearly there are issues with some prescribing practices, there’s also clearly a risk to vilifying these medicines,” said Diederik Lohman, associate director of the health and human rights division at Human Rights Watch.
In some countries, Lohman said, “a clerical error in a morphine prescription” can lead to criminal inquiries. “The fear associated with prescribing a medicine under strict scrutiny makes physicians afraid,” he said.
Afsan Bhadelia, a visiting scientist and palliative care expert at the Harvard School of Public Health, said “the biggest misconception” internationally regarding opioids was the need for tighter control.
“People do not have access to pain control for basic surgery,” she said. “People are going into the operating room and not having anyone mitigate their pain. It is a great injustice.”
Public perception
Liliana De Lima, executive director of the International Association for Hospice and Palliative Care, a Houston-based advocacy group, said global publicity about the American opioid epidemic “had brought this problem to the people, and that has had an effect on the fears.”
Despite international protocols dating back decades that entitle patients to pain relief and palliative care, access remains limited or nonexistent for many.
A report published in February from the International Narcotics Control Board, a United Nations agency, showed that most growth in the use of opioid analgesics has been in North America, Central and Western Europe, and Oceania. It remains low in Africa, Asia, Central America, the Caribbean, South America, and Eastern and Southern Europe.
WHO weighs in
The pain-relief problem was addressed by the World Health Organization in a report published in advance of a U.N. summit meeting on international drug policy in April, the first such review in nearly two decades.
“Ensuring the adequate availability of controlled substances for medical and scientific purposes,” the WHO said, was a commitment made by member states that had “yet to be universally achieved.”
It estimated that 5.5 billion people live in countries with “low or nonexistent access to controlled medicines for the treatment of moderate to severe pain.”
Dr. Dingle Spence, an oncology and palliative medicine physician in Jamaica, said that although opioids are available in her country, the supply is disrupted by so-called stockouts — demand exceeding supply — because of bureaucracy.
“There’s not enough understanding about timely ordering,” she said. “The amount of permits needed to bring them into the country slows down the timely flow.”