43

Increasing Access to Pain Relief in Developing Countries - An EA Perspective

In a nutshell:

  • The suffering experienced by patients without access to pain relief is very widespread and very severe.
  • When addressing access to pain relief directly, we can address regulatory impediments and attitude/knowledge impediments, though tractability is questionable. Addressing both regulatory and attitude/knowledge impediments is required for success. The subject is highly politicised, being intricately tied to policies and attitudes on narcotic drugs. A difficult political landscape make international solutions appear less feasible than national ones.
  • Development of novel painkillers is another avenue, but one that is unlikely to be an area for EA focus.
  • Actors working on this cause include large private philanthropists, public donors, international organisations and non-state actors, academia, and popular media.
  • The cause of increasing access to pain relief in developing countries is thus large in scale, low-moderate in tractability, and low-moderate in neglectedness. It is a terminal cause, having few long term indirect/flow-through effects. Measurement of the impact of interventions to increase access is difficult. Funding training programmes for local champions to work on this issue may be a promising avenue.

About the author: I am a public health consultant contracted to the World Health Organisation. My work aims to increase access to pain relief and palliative care through developing clinical guidelines for cancer pain relief and evaluating models of palliative care delivery. The opinions and assertions made here are my own and do not represent the beliefs of the World Health Organisation or its staff. 

 

Framing the issues: Pain and access to pain relief

It is worth clarifying that by increasing access to pain relief, we primarily mean increasing access to opioid analgesics. According to the World Health Organisation, they are essential medicines for treating moderate-severe physical pain. Other analgesics exist (e.g. ketamine, frequently used as an analgesic in developing settings and enjoys fewer international restrictions), but only strong opioid painkillers adequately treat the moderate-severe pain common in many medical illnesses.

Pain is a complex phenomenon, and the mental/physical distinction is an incomplete picture. The experience and mechanisms of the various flavours of suffering are interdependent. It is well known that physical pain, especially chronic pain, can cause depression. It is also well known that depression, stress, and anxiety can heighten the perception of physical pain. Indeed, psychosomatic pain is ‘physical’ pain caused by mental states alone. The founder of the palliative care movement, Dame Cicely Saunders, proposed the idea of ‘total pain’. A simple descriptive, non-mechanistic model, it recognises that physical, psychological, social, and spiritual suffering contribute to the patient’s overall negative experience in dependent ways.

Access to pain relief medications requires having both the medications and the ability to deliver them.  Palliative care is the context for much pain relief administration. Increasing access to pain relief in developing countries will benefit multiple areas of medical practice - surgery, obstetrics, and some emergency medicine to name a few. But it is palliative care that stands to benefit the most, pain relief medication being its primary instrument. It is important to note that palliative care is not only for the dying, nor is its focus solely physical pain reduction; it serves to alleviate the worst of suffering for those with life-threatening illnesses. International palliative care development is therefore almost synonymous with increasing access to pain relief medications, so I ask readers to permit some conflation of the terms. 

The problem - Widespread torture by omission

Trigger warnings: cancer, suicide, torture

Discussions on extreme human suffering frequently evoke examples of torture and overlook untreated medical suffering. This is availability bias. This is by no means to dismiss the trauma suffered by torture victims, but unalleviated medical suffering is comparably severe and significantly more common. Common life threatening diseases that require palliative care include cancer, cardiovascular disease, HIV, chronic lung disease, and diabetes. I cannot find good estimates, but it is reasonable to assert that the number of people tortured every year is dwarfed by the millions dying in unmet need of palliative care (ref). Without giving an exhaustive illustration, metastatic cancers alone slowly but surely splinter limb bones, destroy vertebrae, tear contiguous tissue, necrose in breasts, cause severe and unremitting head pain, and more. When they are capable, some patients take their own lives or attempt to (ref). The experiences of patients without access to adequate pain relief, “constitutes cruel, inhuman or degrading treatment or punishment”, according to the UN Special Rapporteur on torture and other such conditions (ref).

It may be unknown to EAs from the Anglosphere and Western Europe that almost nowhere else in the world is it easy to get adequate pain relief. Reasons for this lack of access are discussed below. In 2011, it was estimated that 5.5 billion (83%) people live in countries with low or non-existent access to adequate pain management (ref). The International Narcotics Control Board (INCB) estimates that 92% of all morphine is consumed in America, Canada, New Zealand, Australia, and parts of western Europe— only 17% of the world’s population (ref ; 2014 estimates). Therefore, if an individual outside these borders is to die of a common life-threatening disease (i.e. the majority of deaths), they run the real risk of an experience tantamount to torture by omission.

Causes of the problem

The causes of lack of access to analgesia and palliation are many and complex. They can be broken into three categories:

  1. Regulatory impediments,
  2. Attitude and knowledge impediments,
  3. Economic and procurement impediments.

Because (3) includes insufficient medical infrastructure, limited resources for the purchase of medicines, and barriers due to supply system capacity, this category is not typically addressed directly in efforts to increase access to analgesics (ref). Furthermore, pain relief medications such as morphine can be purchased at pennies per dose. I will therefore focus on (1) and (2).

More detailed explorations of the causes can be found in the references.

Regulatory impediments

Opioid medications are controlled substances under the various international Conventions on Narcotic Drugs. Under the Conventions, countries must estimate their requirements for controlled medicines and submit their estimates to the INCB, who will licence certain quantities of the medication to be produced or imported by that country. The reasons for these controls are obvious, and these regulations do not pose much of an impediment to access.

Countries are at leisure to place further controls on controlled substances. This is where significant access difficulties begin. According to the Conventions (and therefore binding under international law), states have a “dual obligation” to ensure that these substances are available for medical purposes and to protect populations against abuse and dependence. The politically motivated (ref) global War on Drugs is blamed for skewing states’ priorities away from access for medical purposes and towards measures to control illicit use.

Such measures often make it either very difficult or impossible for patients to get the medications. In Armenia for example, in order to get strong painkillers (ref):

  1. First, be a cancer patient. No other patient qualifies for opioid analgesia.
  2. The diagnosis must be confirmed through biopsy (taking a small sample from the tumour). Only three hospitals in Armenia offer this procedure. Note that some patients may be immobile.
  3. The oncologist must try several weaker painkillers before asking a panel to approve a prescription for morphine.
  4. A panel of 5 specialists must examine the patient at home and approve the morphine prescription.
  5. Each prescription requires four stamps and three signatures of approval.
  6. The patient or relative must travel to one of the few clinics or specialised pharmacies that carries morphine.
  7. The patient then receives enough injectable morphine (an unnecessarily invasive procedure when oral morphine is effective and cheaply available) to relieve severe pain for only a few hours.
  8. The prescribed amount is so small that patients or relatives must refill the prescription every 1-2 days.


Armenia is not an exceptional example; many countries have comparably restrictive regulations. In addition to patient difficulties, doctors in some countries work under fear of prosecution or even jail when prescribing opioid painkillers (example).

Attitude and knowledge impediments

If regulatory barriers are not enough, attitudes of patients and doctors create further impediments. A widely held belief in countries where opioid use is low is that the use of these medicines signifies the end of curative treatment for the patient; its use is seen as giving up. Fear of addiction and other adverse effects also inhibits use. Opiophobia - the fear of using opioid medications - often has deep social and cultural roots (ref) and is promulgated by patients, doctors, and policymakers alike. When properly used, the incidence of addiction and dependence is low, but fear remains inordinately high. Because opioids are so rarely used in most countries, most doctors don’t know how to use them even if they had the inclination.  In most of the world, opioid use is therefore not part of normal medical practice.

Attitudes and fears underpin the political will to change regulations and modes of clinical practice. This barrier is becoming increasingly significant with the opioid abuse epidemic plaguing the USA. There are good reasons to believe that this is, in part, the fault of irresponsible marketing by pharmaceutical companies (John Oliver does an entertaining exposé) and linked with some of the less desirable idiosyncrasies of the US health system. Nevertheless, policy makers in developing countries are able to point to the significant issues facing the USA and some other countries in order to justify the maintenance or development of policies that restrict access to controlled substances beyond what is reasonably warranted.

What are possible solutions?

Changing regulations

Under international law, states are already bound to provide adequate access to pain relief. The law is ignored, be it due to resource constraints or competing national priorities. Effective international enforcement of the law is highly unlikely when it appears that most countries are breaking it.

The policies of international organisations are generally in accord that states restrict too much access controlled medications at the expense of medical use (e.g. ref). The development of further general-level international policies is unlikely to contribute heavily to a solution.

The world drug problem is a complex catastrophe with many facets. Improvement in one area (access to pain medications) demands improvements in others for satisfactory solutions (e.g. addiction and dependence treatment and rehabilitation programmes, medication security infrastructure, countermeasures for diversion of prescribed medications, adequate training for medical staff and carers, etc). On an international level, high-level policies need translated into specific, actionable ones. This inevitably requires international consensus. While health typically enjoys relative freedom from politicking compared with other key areas of international development, access to controlled medicines is an exception. I have witnessed the derailment of World Health Assembly drafting sessions for important policy measures on the public health dimensions of the world drug problem by a single uncooperative country. This came despite the same country agreeing to the high profile Outcome Document of the UN General Assembly Special Session on the World Drug Problem (ref) just two months earlier, which promoted the high-level principles that the World Health Assembly document attempted to convert into action.

While it is hard to generalise for all countries, scope for change at a national or state level seems more promising. Typically, local champions of the cause find some success after years of effort. India is a good case study for how advocacy on a national level in this area can lead to institutionalised change. Much state-level progress is still required before the majority of patients can benefit in India, however. An EA seeking to change regulations would target larger countries with centralised health system governance where some political will makes the problem tractable. In a brief advocacy publication (the Preventable Pain Pandemic), I targeted Mexico and India for their size and extant political momentum. Where there is little political will and reactionary policies on controlled medicines (e.g. in some post-soviet countries), change seems much less tractable.

Education

Education of medical staff on administration of opioid medications is required before patients can experience increased access. Lobbying for the inclusion of palliative medicine and administration of opioid medications in undergraduate medical and nursing curricula seems a promising long term strategy. Guidelines on the proper administration of opioids are essential to justify relaxing restrictions. But it’s not only doctors and nurses that need education - the attitudes of patients, carers, and policy makers also determine practice. Their attitudes tend to depend on those of the general population. A sizeable proportion of the population needs to be educated on appropriate attitudes to pain relief medication. While mass education programmes have worked in areas such as sexual health and HIV, it is not obvious whether initiatives in this area can produce the required attitude changes to generate political will on this issue.

With limited resources, it is possible that establishing local centres of good practice through targeted education and regulatory change could galvanise change on a national level. Indeed, palliative care organisations in the state of Kerala, India, served this function and catalysed national progress in access to analgesics. Thus, initial targeted investments may mobilise activity and funding nationally, but overall tractability is unclear.

Other approaches

An approach that bypasses politics would have a much greater chance of success. The development of novel pain killers that are significantly less addictive, less dangerous, and less prone to abuse would make pain relief administration more palatable to patients, medical staff, and policymakers. Some headway has been made in this regard (example - brought to my attention by Chris Leong), but it is uncertain if this should be a focus area for EAs for the following reasons:

  • For-profit incentives are enough to motivate research in this area.
  • If successful, it would take some time before the new medication is affordable in developing countries, during which the attitudinal and regulatory landscape may have changed significantly in developing countries in favour of increasing access to existing painkillers.
  • The medications developed, even if they have markedly lower adverse effects, are likely to belong to the opioid class and therefore subject to the same regulatory barriers as older members of the class (although they may spur regulatory change if sufficiently safe). 

Who else is working on it?

A range of organisations exist that aim to increase access to pain relief medications.

Open Society Foundations (ref) provides grants globally for work in access to pain relief and palliative care development. I cannot find figures, but I frequently come across work that they have funded in this domain. Public donors include PEPFAR, DFID, GIZ, the EU, and several others.

Direct work is carried out by a range of actors. High-level policies and guidelines are developed by organisations such as the World Health Organisation, the UN Office on Drugs and Crime (UNODC), and global and regional palliative care associations. National palliative care associations, where they exist, often do much to promote the cause in their country. Valuable work is also performed by Human Rights Watch, who have helped to popularise access to pain relief as a human rights issue and expose examples of violations (ref).

Notable academic work in this area is carried out by the Pain and Policy Studies Group of University of Wisconsin-Madison (link). Among other activities, they monitor global opioid consumption data and run ‘International Pain Policy Fellowships’ (link), which train national champions of the cause to identify and overcome barriers to the use of opioids in their countries. The programme has had numerous in-country successes. If the Pain and Policy Studies Group (PPSG) can be convinced to receive charitable funding for this venture, it might provide a viable future option for EAs interested in this cause area, but data are very few and the impact of this programme is hard to measure.

Popular media lends some attention to the cause (example - a moving Al Jazeera documentary). The Economist Intelligence Unit ran a study on the quality of death throughout the world, a component of which involved evaluating access to pain relief medications (ref).

Substantial work on the ground is carried out by numerous national and local civil society and medical organisations that are too many and too heterogenous to list here. While these groups are essential to the end goal of increasing access to pain relief, and while many are funding constrained, my intuition says an EA should probably aim to donate to or work on upstream bottlenecks to maximise impact.

Issues for further investigation

Overall impact:

The impact of increasing access to pain medications is unclear. The problem is large in quantity, and severe in quality. Negative utilitarians or EAs with a focus on extreme suffering will especially value access to analgesia. But it is not obvious whether suffering alleviated by increasing human access to pain relief is greater than can be achieved by other global health interventions or EA cause areas such as animal charities. Increasing access to these medications probably has extremely small long term indirect effects relative to other health or development interventions (though there is some evidence that palliative care is a cost effective health intervention by reducing hospitalisations, thus enabling money to be spent elsewhere in the health system). There is nevertheless something significant to be said for upholding a minimum amount of human dignity, currently denied to those without access to pain relief. And because the dead cannot advocate their past plight, there is at least one reason to believe that the cause may be neglected compared with other global health causes. 

We should include the downside risks of increasing access to analgesics in our impact considerations. While the majority of adverse effects may be avoidable under a well designed access framework, a small number of cases of addiction, dependence, side effects, diversion, abuse, and overdose are almost inevitable with existing painkillers. This does not justify the stringency of current regulations in most countries, but the lessons of the USA and other opioid-afflicted countries cannot be overlooked when designing and implementing interventions to increase access to analgesia in the developing world.
 

Funding opportunities for EAs:

I am not aware of good opportunities for donations from EAs who wish to donate to this cause. As mentioned above, the PPSG International Pain and Policy Fellowship seems like an especially impactful programme, potentially. More detailed investigation would be needed before a recommendation can be made to donate there. At present, they do not advertise the possibility for individual donations. Identifying advocacy organisations in large countries with some political will (preferably with centralised health system governance) may provide a high impact investment opportunity but, again, measurement is a difficult issue.

 

 

Comments (17)

Comment author: Julia_Wise 02 February 2017 01:45:50PM 16 points [-]

I had no idea things were so bad in this area.

I'm so pleased to see this kind of research on the Forum! Thank you for the work that went into this.

Comment author: Lee_Sharkey 02 February 2017 09:06:33PM 5 points [-]

Thanks Julia! Glad to have the chance to share

Comment author: Austen_Forrester 01 February 2017 05:22:02PM 7 points [-]

Thank you, Lee, for this eye-opening and thorough introduction to the issue of lack of access to analgesics. I can't believe the scale of the problem! With the immense scale and striking neglectedness of the problem, and the potential for leaps in gains with changes to state/national policies, I'm sure it deserves a high priority for changemakers.

Causes like this are why I've always thought that effective altruism is just as important to be taken up in poor countries as much as rich ones – internal changemakers are invaluable here, as you've stated. University of Wisconsin's fellowship program does look promising. I'm sure they would accept external money if there was enough interest. Good luck with this important cause, Lee! Don't let any close-minded person tell you increasing access to analgesics isn't a suitable cause for EA's because it's not easily quantifiable.

Comment author: Lee_Sharkey 01 February 2017 09:28:21PM *  6 points [-]

Thanks Austen!

Yes, it's actually very large. So large, in fact, that it seems to be taken for granted by many people in those countries with low access.

I've withheld strong judgement on whether it should be a cause area that other EAs should act on. I think it could be a particularly attractive area for EAs with certain ethical preferences.

Before funding programmes such as PPSG's, further analyses of the cause and the programme(s) are warranted. I'd be open to suggestions on how to carry those out from anyone with experience, or I'd be happy to discuss the matter with anyone interested in taking it forward themselves.

Comment author: egastfriend 07 February 2017 02:48:54AM *  2 points [-]

Great analysis! Very fair and balanced.

As you point out, increasing the prescriptions of opioids in the US lead to an enormous disaster -- drug overdoses now kill more Americans each year than car crashes. The regulatory environment in the US isn't great, but it's decades ahead of what most developing countries have. The fact that the US still hasn't figured out a sensible policy to managing prescription opioids makes me very skeptical that developing countries could pull it off safely.

E.g., look at these two articles. This one points out that there are already deceptive marketing practices around opioids happening in China: https://www.bloomberg.com/news/articles/2016-12-18/china-s-oxycontin-boom-is-a-goldmine-for-this-drugmaker And this one looks at the aggressive expansion of painkillers into developing countries: http://www.scmp.com/news/world/article/2057240/big-push-opioid-epidemic-killing-oxycontins-us-market-so-makers-target

Rather than trying to expand access, the better strategy may be to advise developing countries on drug control policies to be able to better monitor opioid misuse and handle the inevitable increased availability of drugs.

Note: I'm working on a tech startup that helps people who overuse substances.

Comment author: Lee_Sharkey 07 February 2017 09:08:36AM *  1 point [-]

Thanks for those links. It's troubling to hear about some of the promotional techniques described, though I can't say it's surprising.

While US regulations have been developed decades before their equivalents in many developing countries, it's not necessarily a mark of quality. In the article I refer to less desirable idiosyncrasies of the US health system (i.e. aspects of the consumer-based model; pain as a fifth vital sign), which have exacerbated the crisis there and will not necessarily exist in some developing countries. Yet, while I hesitate to paint all developing countries with the same skeptical brush when it comes to developing adequate regulations, I agree with you more than I disagree. I say that a small amount of adverse outcomes are almost inevitable, and it's really difficult to judge where the positives outweigh the negatives.

I still think expanding access should be part of the strategy. The approach promoted by WHO, UNODC, INCB, is to aim for a 'balanced in policies on controlled substances'. The trouble is that countries are all too keen to control the downsides of using narcotic drugs at the expense of the upsides. So I think that what you're suggesting may already be the approach being taken, but the emphasis needs to compensate for states' existing imbalance.

And what you're doing sounds interesting! Feel free to post links

Comment author: Austen_Forrester 02 February 2017 11:17:13PM 2 points [-]

One good thing about this space is that, unlike so much other policy work, access to pain relief doesn't have corporations interfering by paying off government, etc. If anything, corporations would stand to gain by increasing access to pharmaceuticals. So much other policy advocacy is stifled by corporate interference, so palliative care has a huge advantage in that regard. Would it be possible for advocates to work with pharma corporations to lobby for increased access? I know that sometimes governments have good regulations in place but can't find corporations willing to supply/distribute the country with the meds, which I find baffling.

Do you think that an effective strategy for pain relief would be to first convince a Ministry of Health of the importance of palliative care? Rather than putting drugs as the forefront of advocacy, perhaps getting government to agree to the principle of palliative care and pain control first would be more productive because once they agree to that, it is a given that narcotics are necessary.

Increasing pain relief is a notable cause in so many ways. It is a major issue in moderate income countries such as in former Soviet nations. Africa may be the worst, but pain relief restriction is by no means limited to the poorest regions of the world. Just shows that the best altruistic opportunities aren't always in the poorest countries. I would think that the more developed countries would be a priority target for advocacy because they would actually have functional health care systems that would permit implementation of increased palliative care.

From what I've studied so far, I don't see how you can say that increased analgesic access is low-medium in neglectedness and tractability. Dr. Kathleen Foley says that University of Wisconsin's fellows only spend 15% of their time on this and usually make progress in their respective countries. If true, that demonstrates that this issue is severely neglected and tractable with long-term pay-offs, at least in some countries.

Is it possible for existing major global health initiatives to lead this cause? PEPFAR is well-funded and pain relief is part of AIDS treatment. I know you mentioned them, but perhaps they haven't put an appropriate portion of their funding towards this area for political reasons.

Comment author: Lee_Sharkey 03 February 2017 01:20:09AM *  2 points [-]

Hi Austen,

Thanks for all your interest!

I would have to disagree on your point about corporate influence. Pharma has been implicated heavily in the current opioid epidemic in the States and elsewhere. See the John Oliver expose for a light introduction (link above). In this area, if anything, there is even more reason to be wary of pharma influence because the product is so addictive when misused. Pharma does do some positive work - I'm aware of a BMS-funded training hospice in Romania (Casa Sperantei). I've only heard good things about it.

You've hit on an accepted strategy for promoting pain relief access/palliative care. One only knows one has succeeded in making a MoH care about the area when it does something about it, such as developing a policy. The 'public health approach' to increasing access to pain relief/palliative care, supported by WHO, recognizes policy as the foundation on which other progress can be built. Without it, success in other areas of the approach (namely medicine availability, education, and implementation) is much less likely. Kathy Foley and colleagues introduce the public health approach here http://www.jpsmjournal.com/article/S0885-3924(07)00122-4/pdf

Regarding tractability:

The issue is likely to be more tractable in some countries than in others, and so it's hard for me to give anything but a range.

I'm adding retrospective justification for my choice of low-moderate tractability here, but compare this cause to similar ones assessed by 80k. The scores given to them according to their scoring matrix are: Smoking in the Developing World - 3/6; Health in poor countries - 5/6; Land Use Reform - 3/6;

(Where 3 is "Some possible ways to make progress, with significant controversy; Significant uncertainty about how to approach, solution at least a decade off; many relevant people don’t care, or some supportive but significant opposition from status quo.")

Judging by the rest of the scoring matrix I think a range of 2 - 3.5 in most countries is appropriate, which roughly correlates to low-moderate in my book.

So I think I would stand by my choice of low-moderate. I probably a proclivity for pessimism so perhaps I'm not being generous enough about its solvability here. The problem may be highly tractable in some countries but I feel that to recognise it in the range would misrepresent the issue. As for Wisconsin, I would hesitate to proclaim its effectiveness before more specific analysis. So even if they only spend 15% of their time on it, that may not mean much in terms of tractability or neglectedness. It does seem promising though.

Other funding: There are reasons other than politics that PEPFAR may not have chose to fund palliative care measures. Preventive measures may just be way more cost effective in the long run. I haven't looked closely into it.

An area where palliative care is of growing interest is in multidrug resistant TB.

Comment author: Austen_Forrester 03 February 2017 06:01:15PM 1 point [-]

I'm a little confused as to why you are trying to promote a cause that you think is low priority and financially inefficient. Anyhow, I don't find your anti-corporate stance convincing. Lack of corporate involvement (ie. to distribute analgesics) is the missing link preventing some countries from having functional palliative care in some countries according to Dr. Foley. It's important to work with all stakeholders for progress in any space. The affordable anti-retroviral movement made progress by working with pharma. The risks of working with industry in the public's interest can be minimized with appropriate controls.

Access to properly regulated mobile phone, internet, and financial services have greatly helped the poor and require corporate involvement. Unfortunately, they are underutilized because SJW's like to maintain their purity and reject corporate involvement. I hope your palliative care movement doesn't suffer from the same self-defeating ideology.

Comment author: Lee_Sharkey 04 February 2017 04:19:53PM *  2 points [-]

Hi Austen,

Just to clarify, I'm not trying to promote or demote the cause. I'm aware that the cause is of interest to some EAs, and as someone in a good position to inform them, I thought something like this would help them make their own judgement :) I'm just sharing info and trying to be impartial.

Sorry if I my comments gave the impression that I thought it was low priority and financially inefficient. To reiterate I've withheld strong judgement on its priority, and I said I haven't looked into its financial efficiency compared with other interventions. Because its importance/effectiveness depends heavily on ethical value preferences, both of these question are hard for me to take strong stances on.

My apologies for seeming contrary here, but I'm not taking an anti-corporate stance either. I made those points because the way you had originally put it made it seem like you believed that access to pain relief was unique in that corporate influence didn't carry much risk compared with other causes. Unfortunately, it isn't so. Of course pharma involvement is essential, yet the history of this very cause illustrates the risks. I'd agree with you that lack of corporate involvement is the missing link in some aspects of increasing access, but we should both be specific about the sectors we're talking about to avoid appearing broadly pro-corporate or anti-corporate, which we both agree is unhelpful.

I haven't got a wide enough grasp of the palliative care movement to say if it suffers from an anti-corporate agenda. 'Global health' in general tends to be pretty anti-pharma, and it's hard to argue that the short-term externalities of the existing capitalistic model of drug development and production favours the 'Global health' agenda over the agenda of 'health in the developed world'. So Global health's culture of being anti-pharma is at least understandable, even if it relies on discounting the potentially-positive long-term externalities of the capitalistic model. It's hard to say if access to pain relief/palliative care is more antagonistic to pharma than the rest of Global health. If it is suspicious of opioid manufacturers being involved in other aspects of the movement such as policy, then, without being too SJW, I actually think they actually have good reason to be so, given the history.

Comment author: Elizabeth 02 February 2017 09:34:19PM *  3 points [-]

I'm super happy to see people taking this seriously. Why the emphasis on opioids? My understanding is they're bad for chronic pain because you acclimate so quickly, and they usually don't affect pain that is purely neurological. Cannibidiol works better for many people, is overwhelmingly safer (http://www.nytimes.com/roomfordebate/2016/04/26/is-marijuana-a-gateway-drug/overdoses-fell-with-medical-marijuana-legalization), and can be grown at home. Kratom has a reputation for being good, although I know less about it.

Comment author: Lee_Sharkey 02 February 2017 10:40:58PM 5 points [-]

Hi Elizabeth,

I focus on opioid medications for the same reasons that I don't focus on cannabinoids:

  • There isn't strong expert consensus on the effectiveness of cannabinoids. This may change as the search for alternative drugs, particularly for chronic pain, intensifies. While there are some areas that will likely see their use increase (you justly highlight neuropathic pain), my understanding is that current evidence doesn't reliably indicate their effectiveness for severe pain. All this said, there are good reasons to believe they are understudied, both as single interventions and as adjuvants. I should perhaps have elaborated on this and similar research avenues in the article. Thank you for bringing attention to this issue.

  • Opioid medications, although controlled and functionally inaccessible, are legal medicines in all countries. With few, well-evidence cannabinoid medications approved for use, and only in a handful of countries, it's unlikely that fighting to approve members of a controversial drug class of questionable efficacy for many medical indications is the best way to bring pain relief to patients in developing countries (It could be incredibly effective if generating widespread acceptance of cannabinoid medications, through a long causal chain, ended up driving more rational controlled substances policies. But this is far from a neglected and tractable cause).

For the above two reasons, the movement to increase access to opioid medications has historical precedent on its side and solid expert consensus on their efficacy (even if their dangers are debated). It seems that they comprise an essential component of the best solution (however imperfect) to the gross deficiency of analgesia in the majority of contexts globally. But you're correct to highlight what may be the least explored part of the analysis.

Comment author: tomstocker 06 February 2017 09:36:52PM 3 points [-]

I'm really happy to see this article - I mentioned it to givewell a while ago but they weren't interested. For me this hits what I see as the moral priority more than a lot of the other projects and options on the go.

Simple, complex and neuropathic pains respond differently to different anaelgasics. Opioids v effective for simple pain over the short term, e.g. surgeries, broken bones etc. Neuropathic and complex pain don't have good equivalents for pain relief and patients are stuck with cannabinoids, anti-epileptics and anti-depressants (or, ketamine, ironically, if it wasn't so restricted in the developed world for its noted impact on organ function).

Not a reason not to back access to opioids in the developing world.

Least well explored part IMO is the impact of pain control on the nature of medicine and doctor-patient interaction etc. because the west may have fallen into a trap that it may be a shame to hasten in the developing world.

Comment author: Lee_Sharkey 07 February 2017 09:27:23AM *  2 points [-]

Hi Tom,

Great to hear that it's been suggested. By the looks of it, it may be an area better suited to an Open Philanthropy Project-style approach, being primarily a question of policy and having a sparser evidence base and impact definition difficulties. I styled my analysis around OPP's approach (with some obvious shortcomings on my part).

I could have done better in the analysis to distinguish between the various types of pain. As you say, they are not trivial distinctions, especially when it comes to treatment with opioids.

I'd be interested to hear your take on the impact of pain control on the nature of medicine and the doctor-patient dynamic. What trends are you concerned about hastening exactly?

Comment author: tomstocker 07 February 2017 08:14:01PM 1 point [-]

The shift from patient as recipient of medicine from clinician with authority (old style developed world and much of e.g. Africa) to patient as consumer. There are good and bad things with this transition. Pain, pain control and patient perceptions are just under-studied as a nexus. Not a reason not to go ahead, just my biggest worry with this stuff. (I personally don't think risk of death / side effects are much of a worry at all when we're talking about opioid availability in inpatient settings).

Comment author: Elizabeth 08 February 2017 04:04:55AM 0 points [-]

I'm concerned in almost the opposite direction- that having the doctor as gatekeeper to something the patient legitimately needs, with the threat of taking it away if the patient doesn't look sick enough, corrupts the doctor-patient relationship and the healing process.

Comment author: Denkenberger 06 February 2017 02:02:21AM *  1 point [-]

Control Board (INCB) estimates that 92% of all morphine is consumed in America, Canada, New Zealand, Australia, and parts of western Europe— only 17% of the world’s population (ref ; 2014 estimates).

If we think of 100 units and 100 people, this means 92 units are spent on 17 people and 8 units are spent on 83 people, which means the unlucky countries are only using 1/56 as much per person!