Her father stood by, helplessness personified. He later confessed that he had thought about killing the whole family and committing suicide. Tanvi’s mother had been behaving abnormally for weeks. Her 11 year old sister had left school. She had lost her childhood and had taken over the role of the mother.
Morphine brought amazing relief to the girl. Not total; but enough for her to sleep. The child lived for a few months more at home, on morphine.
Her father went back to work, though he had to leave work every two weeks to travel more than 100 kilometres to collect morphine. Her sister went back to school and her mother was helped by psychiatric treatment.
Millions of children and adults with serious illness, suffering in extreme pain, live in countries where it is difficult or impossible to access and receive strong pain relieving medication.
Even the restricted access to morphine that Tanvi was allowed is more than most people living in Lower and many Middle Income and Developed Countries could hope for.
Essential medicines for pain relief
According to the International Narcotics Control Board (INCB), an independent monitoring body responsible for implementing the United Nations international drug control conventions, and the World Health Organization (WHO), opioid analgesics such a morphine are essential medicines for the treatment or relief of pain, and palliative care.
However, under-treatment of severe pain is reported in the majority of countries. INCB estimates that over 5 billion people (75% of world’s population) live in countries with low or nonexistent access to controlled medicines for the treatment of moderate to severe pain. WHO also estimates that of the 20 million people requiring palliative care each year, only 3% (15%) receive the care they need.
In 1961 the United Nations agreed a treaty: The Single Convention on Narcotic Drugs. The aim of this agreement is to make sure that controlled medicines, such as morphine, are available for medical and scientific use – for example, the treatment of severe pain – while at the same time making sure that these substances are not misused – that is, not taken for any other reason than to solve a medical problem such as severe pain or breathlessness.
The obligation to prevent the misuse and non-medical use of opioids, as well as diversion and trafficking of controlled substances, has received far more attention than the obligation to ensure access of medicines for pain relief. This has resulted in many countries adopting laws and regulations that consistently and severely block access to controlled medicines.
In the decades since the Single Convention was signed, governments around the world have placed much more focus on the side of the treaty aiming to prevent misuse.
Tragically, this narrow focus has meant that many governments have passed laws making it extremely difficult, or in some cases impossible, for people in pain to get the treatment or relief they need.
Tanvi was eventually able to get morphine to treat her pain, but this is not the norm. Millions of people around the world are left to live their last days – and often to die – in excruciating, unbearable pain.
Studies have shown that up to 84% of patients with cancer and HIV and suffer severe pain. Unrelieved pain from advanced cancer, traumatic injury, AIDS, and other serious illnesses impacts all dimensions of quality of life, including the ability to participate in family, work, social and spiritual activities.
The crisis of under-consumption
National governments are required to report the amount of morphine and other controlled medicines that are consumed in their country each year.
The vast majority of countries report an under-consumption of opioid medications. At least 5 billion people live in countries affected by the crisis of under-consumption, and more than 18 million people die each year with pain that could have been treated.
The INCB has identified a number of reasons why opioid medications may not be available for the treatment of severe pain. Health professionals such as doctors and nurses might not realise that these medications are available to prescribe, they may not have been trained in how to use them, or they might be actively discouraged from prescribing these medicines.
Doctors, their patients, or the patients’ family members might worry that the person needing pain treatment could become addicted to these medicines. Also, there may be a social or cultural stigma surrounding the use of opioids for pain relief. Hospitals or clinics might not be able to afford to purchase these medicines, or doctors may fear prosecution due to overly strict laws – or overzealous enforcement of these laws – on opioid prescribing.
National laws and regulations may prevent hospitals purchasing, or doctors prescribing, these medications, or may limit the amount of medication that a patient can take home on one prescription.
For example, in some countries only certain specialist doctors are legally allowed to prescribe controlled medicines. Usually these doctors work in large cities, meaning that patients from rural areas or smaller towns need to travel large distances to renew their prescription. If the prescription can only be for a small amount of medication at a time, this means that the – often very sick – patients need to make this journey more often to get the medicines they need.
The crisis of over-consumption
This deprivation of medicines needed for pain relief stands in sharp contrast to the less extensive, but more publicised, problem facing a small number of high-income countries. Nations such as Australia, Canada, and the USA have higher consumption of prescribed opioids for medical purposes and increased abuse and diversion of prescription opioids and other substances.
It is estimated that between 26.4 million and 36 million people abuse opioids worldwide, with an estimated 2.1 million people in the US suffering from substance use disorders related to prescription opioid pain relief. The US Centers for Disease Control and Prevention (CDC) reported that in 2015 over 15000 deaths were associated with prescription opioids misuse. This has led to media reporting of an ‘opioid epidemic’ in this country.
Just like when opioids are under-prescribed, leaving patients in pain, lack of education of health care workers may lead to over-prescription of opioid medications. Most US physicians have little or no education in pain management and opioid prescription.
When doctors – and in some countries, nurses – are well educated in how to use opioids to manage pain, these medications are used correctly and precisely, and pain is controlled without dependence, diversion or misuse.
Deaths associated with prescription opioids often involve external, complicating factors. For example, 60% of deaths associated with prescription opioids involve alcohol and/or benzodiazepines, up to 30% of deaths have been associated with methadone, an opioid requiring increased provider training when used in pain management, and patients with mental health issues are at greater risk of prescription associated opioid overdose.
Aggressive marketing by opioid manufacturers, and sometimes financial incentives, may influence doctors’ decisions to prescribe these medicines. In the absence of thorough education in pain management, this can be dangerous. Several cities and states across the US are suing opioid manufacturers, claiming that aggressive and fraudulent marketing fueled the opioid epidemic in that country.
The US has identified other sources of diverted prescription opioids such as pharmacy thefts, pill mills, and illegal internet pharmacies, however, these sources are included when measuring legal consumption of opioids, thus inflating the consumption figures.
Ensuring and restoring balance
Balanced access to controlled substances for medical and scientific purposes is critical both to ensuring access to these medicines for the treatment of pain and other medical symptoms, and preventing and reducing their abuse and diversion.
Governments should educate healthcare professionals to prescribe, dispense and administer these medicines, make sure that national laws and policies allow them to do so and that there is a sufficient supply available to meet the individual medical needs of their patients.
Even though the misuse of controlled substances poses a risk to society, the system of controlling these substances should not be a barrier to their availability for medical and scientific purposes, and it should not interfere with the care of patients.
Countries such as Austria, Germany, and the United Kingdom report higher opioid consumption to the International Narcotics Control Board (INCB), while reporting low rates of non-medical use. This suggests that it is possible for a country to control misuse and diversion of opioids, without making laws that leave patients suffering in pain all over the world.
For more information, see a recently released collaborative statement from nine organisations: Access to controlled substances for medical and scientific purposes: Ensuring and restoring balance.
*Case study via Pallium India, names changed to protect identity
 National Institute on Drug Abuse 2014
 CDC Injury Prevention & Control: Opioid Overdose https://www.cdc.gov/drugoverdose/