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Lee_Sharkey comments on Increasing Access to Pain Relief in Developing Countries - An EA Perspective - Effective Altruism Forum

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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.