Palliative care advocates often choose to distance themselves from ‘drug policy reform’ debates about national and global efforts to control and reduce the harm of illicit drugs. Indeed, many see people who use illicit drugs as ‘the problem’ that hinders legitimate access to opioids for pain relief.
Yet the challenge of improving access to opioids for palliative care is joined at the hip with drug policy reform and law enforcement. Fear of diversion, abuse and addiction actively conditions the scarcity of medical opioids in most countries. The same fear or – more accurately – phobia, has a chilling effect on medical education and results in stigmatisation and negative public health outcomes for both palliative care patients and people who use drugs who need to access treatment.
According to the International Narcotics Control Board (INCB) survey of countries where access to controlled medicines such as morphine and methadone is low-to-inadequate, fear of addiction is the main barrier to access. The scream Munch depicts in his famous painting can be seen to aggregate the screams of the millions of people whose doctors cannot or will not prescribe morphine or other painkillers because decades of fear have configured systems of law, education, medicine and culture, wherein fear of diversion, ‘abuse’ and addiction trump the ethical duty to relieve avoidable pain and suffering.
The fear-driven paradigm deprives more than 80% of the world’s population (5.6 billion out of 7 billion) of access to opioid medicines for pain, palliative care and dependency treatment. These people literally pay the price of this socially and politically generated fear with their lives, the quality of their lives, and their families’ and communities’ copathetic pain and suffering.
This fear-based approach to pain relieving medicines derived from ‘narcotic drugs’ – read opium poppies that have been used as medicine for millennia – is based on the 19th and early 20th century experience of European and US missionaries in China and the Far East who witnessed the deliberately induced ‘epidemic’ of dependence created or supported by their own governments (Great Britain and the US for the most part). Opinion leaders feared that the corrupting effect of ‘oriental’ opium ‘addiction’ would spread to the respectable middle classes in their home countries. There is a prolific literature on this, and many primary sources are archived at the World Council of Churches Ecumenical Centre in Geneva, where I have spent many happy hours of research.
But that was then, when there was no evidence-based addiction medicine as we know it today. Concepts such as ‘prevention’, ‘treatment’, ‘tolerance’, or the titration that is intrinsic to palliative care were unknown. Any and all use was stigmatised as ‘addiction’. That day and age was pre-HIV/AIDS, pre-injection drug use, and pre-palliative medicine. The only remedy at hand, to the social reformers who wanted to abolish the scourge, or ‘evil’ of addiction as they called it – since it hampered their missionary activities in the far reaches of the Empire – was what is now known as ‘supply control’. Supply control means literally eliminating all sources of narcotic drugs on the planet, except for the amount needed (an imaginary number in the early 20th century) “for medical and scientific purposes.” Resulting policies generated the model of forced crop eradication, punishment, and military policing that is popularly known as ‘the war on drugs’, creating large black markets, violent trafficking cartels, overflowing prisons and so on.
Three decades after the international treaty regulating narcotics was drawn up at the United Nations, we have relatively accurate data: The World Drug Report, published every year by the United Nations Office on Drugs and Crime (UNODC) estimates the number of people who have used an illicit drug in the past year is 243 million. The number of ‘problem drug users’, people who need opioid dependence treatment, is estimated at (an annually stable) 27 million, out of a world population of more than 7 billion. And globally, the number of people needing treatment for dependence disorder relative to availability mirrors the unmet need for palliative care: at least one in ten.
There is no need to fear the prospect of generalised dependence disorder as did previous generations. There is wide-ranging agreement about what causes it, how to identify it, and how to prevent it. However, the policies are severely lacking. We now know how to alleviate severe pain and symptoms resulting from cancer, terminal AIDS and other disorders. Again, appropriate policy lags behind palliative medicine’s rapid development as a recognised specialty. Morphine is cheap, easy to produce, and scarce. Yet countries like Uganda and Indian states like Kerala manage to subsidise it and teach their pharmacists to reconstitute morphine powder for the needs of their citizens.
Institutionalizing palliative care knowledge and practices more widely, alongside evidence-based prevention and dependency treatment, will dissipate and displace the fear generated by the old paradigm of the ‘evils of addiction’. Expanding clinical education about pain and dependence, and integrating both practices into primary healthcare are pragmatic first steps.