Lack of access to opioids like morphine worldwide is leading to millions suffering preventable pain, the World Health Organization (WHO) has said, a majority from low income countries.
In its ‘Left Behind in Pain’ report released on June 16, the WHO expressed concern over the “significant harm and loss of life” this results in.
Pallium India Chairman Emeritus Dr. M.R. Rajagopal was one of the WHO consulting experts for the document, which explores the extent and causes of global variations in access to morphine for medical use and actions to improve its safe availability.
The report points out that the world faces two crises related to the use of opioids – inappropriate use and over-prescription – as also unregulated opioids being widely available. It cites the continued lack of access to morphine for medical use, particularly in low- and middle-income countries, and stresses it is an essential treatment and a gold standard for pain relief since 1977.
It says countries should continue to develop workforce capacity not only to meet the current demand for pain and symptom relief, but also in readiness for the growing demand due to ageing populations and chronic conditions. This is especially so in lower-income countries undergoing demographic transition due to ageing, and for health care professionals working in primary care and long-term care settings.
“Pain is suffering. Addiction is also suffering. Advocates for pain relief, bat from one side; addiction specialists bat from the other. The game goes on. Few talk about a balanced approach. This WHO report advocates for balance,” said Dr Rajagopal, about the document.
“Leaving people in pain when effective medicines are available, especially in the context of end-of-life care, should be a cause of serious concern,” says WHO Assistant Director General for Medicines and Health Products Yukiko Nakatani. “We must therefore urgently work to create a balanced policy for safe and timely access to morphine for those in medical need.”
Morphine is essential for relieving moderate to severe pain and treating severe breathlessness, especially at the end of life. Its medical uses span multiple clinical settings, including surgical, cancer, palliative, emergency, paediatric and long-term care. The Lancet Commission on Palliative Care and Pain Relief had endorsed it as the most basic requirement for palliative care.
Safe access to morphine is hampered by several factors, including a lack of coordination along the supply chain, inadequate physical, financial and skilled human resources, weak governance, and misconceptions. The report says the situation can be tackled by providing or extending safe access to more people in need, improving governance and resourcing, developing competencies and skills and raising awareness, but adds success will depend on collaboration and cooperation among all stakeholders.
Worldwide in 2021, over 80 per cent of the available morphine was distributed in North America, Europe, and other high-income countries while multiple barriers, including lack of availability, in others have led to a serious crisis.
Poorly controlled pain is disabling – it causes physical, psychological, social and spiritual suffering. It is estimated that people across the world live between six and 21 billion days in serious physical and psychological health-related suffering associated with a need for palliative care and pain relief. About one in two deaths every year worldwide are estimated to be associated with such suffering. Among these, 98 per cent are in low- and middle-income countries while 2.5 million are children.
The report suggests that achieving a balance must remain a high priority in many countries and globally and seeks to turn the struggle to achieve balanced policy into a global mission to promote actions that improve safe access so that no one will be left behind in pain or exposed to the harms of substance use disorder. Recommendations include facilitating rational use of morphine, establishing affordable pricing for morphine for medical use and setting up efficient distribution networks.
Changes in legislative and administrative requirements could enable health services to meet the growing need for morphine for medical use outside of health care settings. Opioids used to manage pain in palliative care do not hasten death and are harmless even when titrated to avoid distress in ventilation withdrawal.
Policies should be in place to establish affordable pricing for morphine for medical use, appropriate distribution networks and access for people with health conditions and those in long-term care facilities, home-based care and hospices.
The supply of strong opioids for medical use is regulated internationally by the United Nations Single Convention on Narcotic Drugs, 1961 and Convention on Psychotropic Substances, 1971 and is subject to the laws of individual countries. As a result, the supply process can be lengthy since it requires strong coordination among multiple parties involved in decision-making. Poor process coordination also disrupts its supply, which delays or obstructs access for those in need.