World Cancer Day: Living and Dying in Pain: It Doesn’t Have to Happen
By PainSA (painsa.org.za), a non-profit organisation with the mission to improve the management of pain in Southern Africa
4th February 2017 Living and dying in pain: it doesn’t have to happen. This is a statement that we should not have to make. Surely it is imperative that people suffering pain get the clinical attention they need to relieve pain. This is what they expect will happen when they present to their doctor complaining of pain.
One of the barriers to good pain management reported by the Worldwide Hospcie Palliative Care Alliance is access to opioid medication to manage severe pain and there are international efforts to address these barriers. In 2014, the World Health Assembly adopted a resolution identifying that access to palliative care and pain relief are human rights.
This resolution (WHA 67.19) urges member states to undertake actions to improve access to palliative care including “to review and, where appropriate, revise national and local legislation and policies for controlled medicines, with reference to WHO policy guidance, on improving access to and rational use of pain management medicines, in line with the United Nations international drug control conventions”.
The World Health Organisation (WHO) published guidance to Cancer Pain Relief in 1986 and in 1998 published Cancer Pain Relief in Children so the information required to control pain is available. However, access to opioid medication is not controlled by the WHO. Access to opioid medication, termed narcotic drugs, is controlled by the International Narcotics Control Board and law enforcement agencies guided by the following conventions: 1) Single Convention on Narcotic Drugs, 1961 (amended 1972); 2) Convention on Psychotropic Substances, 1971; and 3) United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, 1988.
The International Narcotics Control Board (INCB) has repeatedly stated that its role is to ensure a balance between the supply of and demand for narcotic drugs for medical and scientific purposes and helping to prevent the illicit drug cultivation, production, manufacture, traffic and use. There are two further bodies that control access to narcotic drugs – the Committee on Narcotic Drugs (CND) established to supervise application of the international drug control treaties and the United Nations Office on Drugs and Crime (UNODC). So there is a large emphasis on drugs and crime and not sufficient attention paid to ensuring access of opioids for pain relief.
The WHO has acknowledged that “the international drug control treaties came into being to prevent the abuse of substances that can induce dependence” and states that, “equal emphasis has not been placed on the other fundamental objective of the treaties of ensuring that controlled substances are available for medical and scientific purposes. As a result, the health benefits that can be derived from medicines containing controlled substances remain inaccessible to the large majority of people around the world”.
Efforts to create a “Drug-Free World” have resulted in profound imbalance in policy and significant harms, leaving many millions in pain, and with substance-use disorders, without the medicines they need”. WHO estimates that 85% of the world population (5.5 billion people) live in countries with “low or non-existent access to controlled medicines for the treatment of moderate to severe pain”.
Opioid consumption data for 2013 on most of the African continent is much lower than the global mean consumption of opioids with only South Africa using more opioids, 9.1 Morphine Equivalent (mg/capita) than the global mean of 6.28 ME mg /capita.
This whole situation derived from the US “War on Drugs” started as one of Richard Nixon’s election cmpaigns. The War on Drugs has failed. There has not only been failure to achieve drug-free world but also serious, negative, unintended consequences. A huge criminal blackmarket has been created. There has been prioritisation of law enforcement over health and a global perception of people who use drugs as criminals.
This year the Presidents of Mexico, Guatemala and Colombia requested urgent debate in the UN General Assembly on the question of the world drug problem as these countries have had serious negative consequences resulting from the war on drugs. This request was supported by 95 UN member states in the context of increasing calls for drug policy reform and debate. The civil society organisation, the International Drug Policy Consortium (IDPC), also called for a more balanced, health-based approach to drug policies.
The IDPC describe that globally there are estimated to be 246 million people who use drugs, one in ten of whom experience problems linked to their drug use. The IDPC advocate for a public health response to the problem of drug misuse and propose prevention programme that address risk factors for drug abuse and identification of protective factors. They advocate for harm-reduction programmes including needle exchange programmes, substitution treatment and availability of naloxone for opioid overdose. They also emphasise the importance of drug dependence treatment and call for alternatives to criminalising drug dependence that results in arrest and incarceration.
In preparation for the UNGASS debate, the African Union decided to submit a document outlining the Common African Position (CAP). The South African Depuity Minister of Social Development chaired the meeting of representatives from African countries to develop a document to submit to Vienna. This document states that the world drug problem requires an “integrated approach to drug supply, demand reduction and harm reduction strategies as well as ensuring the availability of controlled substances for medical and scientific use”.
CAP describes that “consumption of drugs and drug addiction must be considered as public health problems that have socio-economic root causes and consequences. Drug education should be prioritised in education curricula. People who use drugs must be given support, and must benefit from treatment, health services and protection.”
CAP calls “for greater support to ensure the provision of opiates and other essential and controlled medicines for palliative care and pain relief”.
The United Nations and member states have committed to a more humane and rational approach to controlled medicines. Human Rights Watch welcome the long and substantive stand-alone section on access to medication in the statement derived from the UNGASS debate; highlighting that previously controlled medicines were tucked away under the Demand Reduction section despite the conceptual misfit.
What about use of controlled medicines in practice?
Pain is a complex problem requiring “impeccable assessment and treatment”. This problem requires a multidisciplinary approach, including patient education and involvement, empowering patients to control their pain. Clinicians should be educated and skilled in assessment and management of pain. It is essential to listen carefully and respectfully to the person complaining of pain and to work together to achieve improvement of their pain experience.
We need to recognise and work to ensure freedom from pain.
PainSA (painsa.org.za) is a non-profit organisation with the mission to improve the management of pain in Southern Africa. The Society promotes research and training on the diagnosis and management of pain, emphasising the need for a multi-disciplinary, team approach to managing pain. PainSA is a chapter of the International Association for the Study of Pain.