Really enjoying the Oxford Prioritisation Project!
One of my favourite comments from the Anonymous EA comments was the wish that EAs would post "little 5-hour research overviews of the best causes within almost-random cause areas and preliminary bad suggested donation targets." (http://effective-altruism.com/ea/16g/anonymous_comments/)
I expect average OPP posts take over 5 hours, and 5 hours might be an underestimate of the amount of time it would take for a useful overview without prior subject knowledge. But both that comment and the OPP seem to be of the same spirit, and it's great to see all this information shared through an EA lens.
I am aware that the formatting is poor, but the EA forum text editor is hard to deal with. Tips on how to improve would be appreciated.
Right now the best way to read Daniel's post is probably the Google Doc:
I'd second that - it's not the most wieldy text editor. Not sure how easy it would be to remedy. Going into the HTML gets you what you want in the end, but it's undue effort.
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.
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?
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.
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
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.
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.
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.
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
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.
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.
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.
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.
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.
Thanks Julia! Glad to have the chance to share
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.
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.
The first few chapters of the French translation are up! Read here !
The rest is in the works!
This link is expired unfortunately. Is there anything CEA/the forum could do to collate existing translations?
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