Since 1996, the Pain and Policy Studies Group (PPSG) has been pointing out the stark differences in opioid consumption around the world through graphs and maps and most recently with Gapminder. But the above infographic by Kim Ducharme and Zia Sobhani takes the cake! To see the bloated shapes of US, Canada and Australia and a relatively normal Western Europe is not that surprising but the barely recognizable shapes of the remaining continents is startling!! There is a huge gap in global pain relief.
Public Radio International’s The World has highlighted Global Cancer issues in a special series Cancer’s New Battleground – the Developing World. It includes a segment, Dispensing Comfort, that addresses the lack of opioid (aka narcotics) in many low and middle income countries. PPSG had been a lonely voice on the issue for many years but now partners with an increasing number of organizations addressing the issue including the International Association for Hospice and Palliative Care, the Open Society Institute, Human Rights Watch, FHSSA, Livestrong, EAPC, ESMO, the World Palliative Care Alliance, regional and national palliative care associations and most recently UICC and its GAPRI program, a collaboration with the American Cancer Society.
Much debate has surrounded the importance of palliative care in low and middle income countries; “wouldn’t it be better to put resources into vaccines and prevention?” No one is suggesting that palliative care replace or be implemented in place of disease prevention or life prolonging strategies. All need to be packaged together as health systems are built. A good National Cancer Control plan should include palliative care, together with the appropriate allocation of resources. Importantly, those living with advanced cancer now and in the future need pain relief. Take, for instance, this Indian woman in extreme pain from breast cancer.
Yes for a few cents, she could get pain relief but in a country that is one of the major growers of poppies. Palliative care has not been a priority within struggling health care systems; nor has pain relief. Not only has it not been a priority there are many barriers that exist around the world. Both the public and doctors have a real fear of morphine, concerned that its use is a sign of imminent death or that addiction will occur even when used near the end of life. Many countries do not have morphine available and many countries have multiple regulations that significantly restrict access to opioid. The Ukraine is a country that have significant restrictions in the provision of opioids and in fact only has injectable morphine available to cancer patients in the home!
Arturo died some 3 months later, no not at his own hand, but still in pain but with some extra pain relief from unexpected sources (see Freedom from Pain). But is it acceptable for a man such as Arturo to die with untreated pain? Is it acceptable that thousands all over the world die in significant pain each day let alone the millions who live with cancer pain at any one time? Almost all of us would want to be pain free at the end of life, but for some reason it is human right that is denied to most of the citizens of the world.
To improve pain relief globally, PPSG, a WHO Collaborating Center for Pain Policy in Palliative Care, has developed an International Pain Policy Fellowship where champions in each country partner with officials from their government to improve the situation with 1) laws and regulations, 2) drug availability and 3) education of both the public and clinicians. The third cohort of fellows has the support of two major funders, Livestrong and the Open Society Institute. Livestrong supports the 3 fellows from India, 2 fellows from Bangladesh and 2 fellows from Sri Lanka (these three countries representing 20% of the world’s population). OSI supports a fellow from each of the Ukraine, Albania and Kyrgyzstan.
It is a slow process but important one. Already countries from the early cohorts (Cohort 1, Cohort 2) are making a significant changes in access to opioids. Uganda, Kenya, Panama, Colombia, Vietnam, Nepal. With the continued support of Livestrong and our other funders, and with our partners, PPSG will continue to work to ensure that the health care systems in the world ensure that they “dispense comfort.”