After the hospital sent Nguyen Van Dung home to die, his family watched helplessly as he wasted away from complications due to AIDS. And he did not go gently. “He was in such pain,” says Dung’s 73-year-old mother. “It was like seeing him on fire.”
Haunted by his screams, Dung’s sister bought him heroin to ease his pain. Street-grade heroin is hardly an ideal medical choice; it is also illegal. Last month, shortly after Dung’s death, a judge in Nha Trang sentenced his sister to three years in prison. Drug possession — “for any reason,” explained the judge — is against the law.
Whether you will have access to pain treatment depends largely upon where you live. Africa, which has most of the world’s AIDS victims, is a painkiller wasteland. In India, more than a million cancer and AIDS sufferers die each year in extreme pain as cumbersome regulations and paperwork make it nearly impossible to get prescription painkillers. (India produces much of the world’s legal opium, yet nearly all of it is exported to Western pharmaceutical companies.)
In East Asia, where European colonial powers once used opiates to subdue much of the population of Indochina, governments retain an almost pathological aversion to opiates of any kind. The geography of pain relief is so skewed that the seven richest countries consume 84% of the world’s supply of legal opiates, according to the International Narcotics Control Board, an independent agency that enforces U.N. conventions. For the estimated 10 million people who are suffering from untreated pain, relief is often found only on the black market, or in death.
The reason that most people have little or no access to morphine is opiophobia, says Dr. Eric Krakauer, a Harvard Medical School professor who helped Vietnam rewrite its medical-use opiate laws. Misinformation about clinical morphine use is rife; even some doctors believe that anyone using morphine will become a drug-crazed addict. While long-term opiate users will become dependant, the effect is reversible. Lost in the discussion, says Krakauer, are morphine’s benefits, particularly to terminal patients with severe and chronic pain.
Two hundred years after it was first isolated from the opium poppy, morphine remains the best drug doctors have to relieve severe pain. It is cheap to produce and can be manufactured for pennies a pill. Morphine also eases the feeling of not being able to breathe, which often happens in the final stages of dying. “It’s painful to watch,” says Krakauer, who believes his own mother was not given enough morphine in her last days at a hospital in Cincinnati, Ohio. “People think that pain and shortness of breath are an inevitable part of death … For dying patients, strong opiates can take away both the pain and the feeling of drowning.”
Pain-law reformers blame the disparity of access to morphine on the decades-old war on drugs. Both legal and illegal drugs fall under the domain of the International Narcotics Control Board. While the agency is tasked with determining the supply of opiate-based painkillers, among other legal drugs, that each country can import, most of its attention and resources go to tackling the world’s supply and sale of illicit drugs. But the group has as much responsibility to provide legal drugs as it does to control illegal ones, says David Joranson, founder of the University of Wisconsin’s Pain & Policy Studies Group, which works with governments to reform their palliative-care laws. In the process of trying to stem the global trade of illegal heroin, “morphine is controlled to the point of not being available,” he says. “The whole thing is like trying to get a car to go backward and forward at the same time.”
The small but growing pain-reform movement is working to bring all countries in line with World Health Organization (WHO) standards, which call for adequate pain relief. But the work has been agonizingly slow. One of the few success stories is Vietnam. Two years ago, the government completely revamped its medical-opiate laws. Maximum daily dose limits were lifted. District and commune health posts were allowed to dispense morphine. Hundreds of health care workers were trained to prescribe opiates.
But even under Vietnam’s progressive laws, patients are finding it difficult to get pain relief. Doctors fear that they will be suspected of diverting morphine to the black market if they prescribe “too many” pills, says Dr. Nguyen Phi Yen, deputy director of the National Cancer Hospital’s palliative-care department. Few doctors dare to hand out more than seven days’ worth of drugs — though by law they can now prescribe a 30-day supply. Pharmacists can also fall under suspicion, so most choose simply to not stock morphine. The pharmacy in the hospital where Yen works — one of only two that dispense oral morphine in the entire city of Hanoi — is filled with a silent collection of gaunt patients and worried relatives waiting to get their prescriptions filled. “Yes, we are concerned that morphine might get diverted to the black market,” says Yen, looking at the crowd. “But we also can’t let patients suffer.”
For Tho Thi Thoan, a farmer in the northern province of Hai Duong, the reforms did little good. Doctors sent her home to die after her breast cancer had metastasized and began eating through the left side of her body. Though her case was terminal, Thoan was given only a week’s worth of oral morphine at a time. With local pharmacies unwilling to stock morphine, Thoan’s husband had to make the journey by motorbike to Hanoi each week. Soon Thoan built up a tolerance, and the medication was not enough. “She needed more pain relief,” says her husband, but the doctors wouldn’t give her more. “It was terrible. She cried. I cried.” In December, Thoan, age 40, died at home and in agony.
The number of people who will need pain relief will rise sharply in the coming years. In the next decade, mortality from HIV/AIDS is projected to increase fivefold in Africa. Cancer, once regarded as a disease of industrialized nations, is now occurring in epidemic proportions in developing countries, where smoking and exposure to carcinogens are on the rise. The WHO predicts that by 2020 there could be 15 million new cancer cases every year — a 50% increase — and most of them will be in the developing world. Most sufferers, too, will die from their disease: because of a lack of early detection and access to treatment, by the time cancer patients in the developing world see a doctor for the first time, 80% will be terminal.
Until doctors feel confident prescribing opiates and pharmacies are willing to dispense them, families will be faced with stark decisions as to how to ease the suffering of those sent home to die, says Kimberly Green, a palliative-care expert in the Hanoi office of Family Health International, a health-development organization. Drugs bought on the street are unlikely to be safe or affordable and could, as they did with Nguyen Van Dung’s sister, result in a prison sentence. In the face of intolerable pain, many will choose to take that risk, but it’s not a fair choice to have to make. More needs to be done, says Green. Something is wrong when it’s “easier to buy heroin than it is to buy morphine.”
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