Global pain a “health catastrophe”

THE availability of good pain management in developing nations remains “very scattered, very variable and often deficient”, according to leading Australian palliative care specialist Emeritus Professor Ian Maddocks.

“The WHO used to say there are three areas we need to address if good pain management is going to happen: government policy, availability of drugs and the training of people to use them, and at various levels many countries are deficient in one or more of those things”, Professor Maddocks told MJA InSight.

Australian expert in global health law Jonathan Liberman told MJA InSight that international attention was now focused on the importance of providing equitable access to pain management.

They were commenting on an essay in PLOS Medicine by Canadian authors who described the worldwide prevalence of untreated pain as a “health catastrophe”. (1)

The authors wrote that conservative estimates by the WHO suggested one million terminal HIV/AIDS patients, 5.5 million cancer patients and 800 000 trauma patients had little or no access to treatment for moderate to severe pain. The burden was highest in the developing world and among the poor, elderly, mentally ill, children, women and ethnic minorities.

“Reducing global inequities in untreated pain will require a concerted effort by global health funders, institutions and organisations to place untreated pain at the top of the list of global health priorities”, they wrote, adding that calls to action had so far fallen on deaf ears. They said many global health efforts prioritised treatment and eradication of disease over pain management.

Mr Liberman, director of the McCabe Centre for Law and Cancer in Melbourne (a joint initiative of Cancer Council Victoria and the Union for International Cancer Control, which established the Global Access to Pain Relief Initiative in 2009), agreed there was a crisis in the global access to pain management, but said there had been significant recent international activity to address the issue.

He said there had been much follow-up work since the United Nations (UN) General Assembly’s 2011 political declaration on the prevention and control of non-communicable diseases acknowledged the importance of palliative care. (2)

Last month, international drug regulatory and health agencies convened in Vienna for the annual session of the UN Commission on Narcotic Drugs in which the need to improve the global availability of opioid analgesics was discussed.

“There is a collective realisation among the Vienna-based international drug regulatory agencies that promoting the availability of opioid analgesics for medical use is an essential part of the Single Convention on Narcotic Drugs and that more needs to be done to achieve that”, Mr Liberman told MJA InSight.

“A lot more needs to change, but I don’t think it’s true to say any more that nobody thinks this is a problem”, said Mr Liberman, who worked on the revision of the UN Office of Drugs and Crime model laws to better balance opioid availability with the prevention of diversion and abuse.

Professor Maddocks said access to oral opioids, which were cheap and effective, was often limited in developing countries. He said in many cases, drug companies preferred to sell the more expensive, slow-release formulations.

He said even if the drugs were available, doctors were often hesitant to use them because of the various constraints put on the availability of opioids in different countries. Training in the proper use of analgesics was lacking in many countries.

However, Professor Maddocks said Uganda had provided an “excellent example” of the provision of opioids for pain relief and palliative care, by importing morphine powder and making up morphine syrup for patients with AIDS and cancer. (3)

– Nicole MacKee

1. PLOS Medicine 2013; Online 2 April
2. UN General Assembly 2011; Political declaration on prevention and control of non-communicable diseases
3. Lancet 2003; 362: 1812-1813

Posted 8 April 2013