Institutional barriers for access to opioid analgesics

Categories: Opinion.

Although it is good to see the inclusion of a stand alone section on access to controlled medications, the draft reveals a limited understanding of the negative impact of the international drug control conventions on public health.

The document’s subtitle: ‘Our joint commitment in effectively addressing and countering the world drug problem’ contains language that is biased towards a law-enforcement approach to controlled substances.

Systemic human rights violations in the War on Drugs

In this article, I will focus on access to medicines controlled under the three UN Drug Control Conventions, but first, I will refer to a guest editorial by Damon Barret, Director of the International Centre on Human Rights and Drug Policy.

He describes the evolution of his thinking on the relation between human rights violations and the War on Drugs.

Initially, he saw these violations as collateral damage, but now he considers them to be a systemic problem.

What states are legally required to do under the UN drug control treaties can be exceptionally risky from a human rights perspective.

For example, he points out that the application of the death penalty for drugs increased after the 1988 drug trafficking convention was adopted.

Today, Barret considers human rights violations in the War on Drugs as institutional violations caused by the conventions.

Barriers to accessing controlled medicines

My views on the relation between the drug control system and the barriers to accessing controlled medicines developed similarly. I used to distinguish four categories of barriers:

  1. legislative and policy barriers
  2. (lack of) knowledge of pain management
  3. false and unjustified attitudes towards controlled medicines by healthcare professionals, patients, and their families; and
  4. economic and logistic barriers.

In my opinion, the category of economic and logistic barriers is less important to focus on: although controlled medicines are expensive in some countries, this results from the other barriers.

Red tape and low turnover make handling costs high and competition limited. Both lead to high prices.

Therefore, pricing problems may be automatically resolved with the resolution of the other barriers.

Institutional barriers

I no longer believe that these four categories of barriers represent the full picture. What we have failed to identify are the institutional barriers for access to controlled medicines.

There are rules in the conventions which are so complicated that it is very difficult for countries to apply them consistently and correctly. For instance, there are at least nine different import/export procedures described in the three conventions.

In practice, the capacity to develop annual estimates – that is, the estimated amount of controlled substances needed in-country and submitted annually to the International Narcotics Control Board (INCB) – is limited in many countries, resulting in some countries not submitting them, and others not submitting a sufficiently high estimate to meet the needs for pain treatment. 

Moreover, countries needing more medicines than foreseen in the course of the year often do not submit supplementary estimates, even though this is not difficult to do through INCB. These complications ensure that international procurement problems with controlled medicines will remain.

Barriers within UN bodies

Not only the conventions, but also the UN bodies governing these conventions may represent barriers to access to opioid analgesics.

In the Commission on Narcotic Drugs (CND), there is a continuous battle going on, where certain countries recommend drug controls on even more substances.

For example, the Commission refused loosening controls on dronabinol when WHO so recommended, and it has adopted resolutions calling for tightening of national controls of the important medicines ketamine and tramadol.

Due to limited budget, the WHO also does not fully assess and re-assess which substances should be placed under the drug control conventions and in which schedule.

WHO has less than $0.5m available for access to medicines, including for substance evaluation, which stands in sharp contrast to the estimated $50 billion spent elsewhere in the system on drug law enforcement globally.

In this way, substances such as cannabis and heroin continue to be classified as substances without “substantial therapeutic advantages,” despite successful application as medicine in various countries for years.

Measuring consumption of controlled substances

Other barriers arise through the INCB. Measuring development of the consumption of controlled substances is key to developing and evaluating national policies.

INCB annually publishes country level data but restricts access to its database to academic institutions.

INCB statistics are collected with the collaboration of all governments. They are collective property and should be freely accessible in the public domain.

A recent report from INCB was called: “Availability of internationally controlled drugs: Ensuring adequate access for medical and scientific purposes, indispensable, adequately available and not unduly restricted.”

The report defined “not adequate opioid analgesic consumption” 30 times lower than the level defined as adequate in WHO research, and consequently, it calculated country needs incorrectly.

The report suggests for some industrialised countries that their consumption is too high, while the level of pain management is about adequate in these countries.

INCB is an authoritative body many governments listen to. However, it does not have any medical mandate.

The inaccurate message from the INCB report is supposedly the most serious institutional barrier for improving access to controlled medicines, including to opioid analgesics.

Willem Scholten is a Consultant on Medicines and Controlled Substances based in the Netherlands. His specialities are pharmaceutical regulatory affairs and drug control policies, with a special interest in realising access to adequate pain management for those 5 billion people who have no access.

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