The elderly woman arrived with her husband at the hospital in southern India in excruciating pain. She had cancer in her head and neck, and was forced to spend most of her time immobile, lying on her back because moving hurt too much. Still, she endured a trip of several hours to visit the facility in Kochi, a city in the southwestern state of Kerala. Doctors in the hospital's oncology department looked her over, determined she was in the late stages of the disease, and tried to send her away with nothing more than aspirin and other over-the-counter painkillers that were essentially useless in relieving her agony.
Eventually, the woman and her husband ended up in the hospital's anesthesiology department in the office of Dr. Nandini Vallath. The physician administered a dose of intravenous morphine, and as the drug took effect, the woman's body eased and she began to weep.
"I remember this patient sitting up and crying because it was the first time she had any relief from medication, after months of begging for help," Vallath said. At the time, Vallath had no training in long-term pain management for the gravely ill — a field known as palliative care — and no morphine tablets to give the couple when they left. The nearest facility with such medicines was five hours away, and she referred them there, even though she had doubts that they would make it.
"I felt terrible that I couldn't give them anything to take home," she said.
Three months later, the woman's husband return to her office with his head shaved.
"I knew his wife had died," Vallath recalled. "He made a point to travel those many hours to tell me the news, because he cared for that one day and those few hours of pain relief."
The woman that Vallath briefly treated is one of an estimated half million Indians that die every year of cancer with little or no reprieve from pain. Most of them don't even get the minimal, fleeting care that Vallath was able to provide. Countless others receive no meaningful relief after painful accidents, burns, or invasive surgery. Doctors often prescribe nothing stronger than ibuprofen, acetaminophen, and other over-the-counter pain meds.
As diplomats and health officials leave New York after the UN General Assembly's special session on drugs (UNGASS) this week, most will return to countries facing situations similar to India's. While certain wealthy countries like the United States are awash in prescription opioids, which has led to rising rates of abuse and a surge in overdose deaths, precisely the opposite problem besets mostly poorer countries. Roughly 5.5 billion people — three quarters of the world's population — have insufficient or no access to morphine, codeine, and other controlled substances used for pain relief.
The reasons for the crisis include international controls mandated by the UN, stifling local bureaucracies, stigma against the use of prescription opioids, insufficient training and knowledge among doctors, and a lack of awareness among patients that such options even exist. In some countries, cheap morphine tablets are paradoxically less available than more expensive opioids because their profit margins are unappealing to pharmaceutical companies.
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Under three UN drug conventions that date back to 1961, the International Narcotics Control Board (INCB) keeps tabs the licit consumption of controlled substances, including morphine and other opioid analgesics. Countries must track and report their consumption of controlled drugs to the INCB's offices in Vienna. Every year by the end of June, they must notify the INCB of their estimated drug requirements for the coming 12 months. According to INCB officials, most requests are approved.
"Our position is not the impede medical needs," said Stefano Berterame, chief of the INCB's Narcotic Control and Estimates Section. And yet, with few exceptions, the global painkiller shortage isn't going away.
An outcome document that was adopted on Tuesday during UNGASS includes an entire section devoted to the the availability of controlled substances. The text, which is meant to influence global drug policy in the coming years, calls on UN member states to consider "removing unduly restrictive regulations and impediments" that prevent people from accessing drugs like opioids for legitimate medical reasons.
"The outcome document that was negotiated really for the first time pays significant attention to the issue," said Diederik Lohman, an associate director with the health and human rights division at Human Rights Watch. Previous UN statements, as recently 2014, "tucked away" access issues under efforts to reduce demand for drugs. "It was really an afterthought," Lohman said.
Next month, the World Health Organization and the UN's Office on Drugs and Crime (UNODC) will release model legislation on controlled substances that governments can choose to mirror in their domestic laws. Already, countries like Mexico, Kenya, and Nigeria have made progress in increasing availability. But even as governments remove certain legal impediments, as India did two years ago, the task of getting relief to those in pain can be daunting.
In India, access to opioids like morphine tablets was never widespread in the period after the country achieved independence from Britain. In 1985, at the height of the international drug war, Indian lawmakers imposed strict criminal penalties, including long jail terms, for errors in tracking opioids. Following the law's passage, a simple clerical error could send a pharmacist to jail.
"After that, opioids became almost totally unavailable," said Dr. M.R. Rajagopal, founder of the Indian palliative care organization Pallium. Today, Rajagopal estimates that less than 2 percent of Indians have access to opioids like morphine, and that less than 1 percent are able to receive comprehensive palliative care.
"People don't complain, and this is the horrendous part of it," he said. "It's unbelievable what's happening, not only in India, but in most developing countries."
Rajagopal blames the dearth of pain medication in India on the country's political class, doctors who become disinterested when they can't heal someone, and British colonial authorities, who first introduce laws limiting the movement of opium domestically. Countries like the US, which created overwhelming stigma against the medical use of controlled substances by pushing hardline interpretations of the UN drug treaties, only compounded the problem.
Vallath, the Indian doctor who provided morphine to the dying cancer patient, is a consultant at the the WHO-sponsored Trivandrum Institute of Palliative Sciences in Kerala, which Rajagopal runs. In 2014, following advocacy efforts, Indian legislators amended the 1985 narcotics act, removing many of the restrictions on opioids.
Budgeting for palliative care is still dysfunctional, however, and both Vallath and Rajagopal say that entire generations of doctors haven't been trained to use morphine. Few Indian medical colleges offer lessons on palliative care.
In some ways, India is better prepared to meet demand for controlled pain medicines. Unlike many lower-income countries, India has a well-developed pharmaceutical industry that produces medicine both for domestic consumption and export. It's also one of the few countries in the world that legally produces opium, which private companies use to manufacture injectable morphine or pills that can cost as little as a penny and a half per tablet.
But because morphine tablets sell so cheaply, companies are sometimes hesitant to produce them even with higher demand. In recent years, there's also been a push to sell hospitals fentanyl, a much pricier, more powerful, and longer-acting synthetic opioid. Similar dynamics occur all over the world.
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"Morphine is a very cheap drug and should be available, but sometimes it is not produced, maybe because the pharmaceutical companies do not see a profit in it," said Berterame.
Elsewhere in the developing world, particularly in sub-Saharan Africa, governments and health workers have forgone internationally controlled substances entirely. Instead, they make use of ketamine, a dissociative analgesic that remains unscheduled internationally despite efforts from China to restrict it.
Even after the passage of the UNGASS outcome document and efforts to increase awareness about access to pain medication, the overprescription of opioids in the US threatens to once more to create a stigma. The pharmaceutical company behind OxyContin claimed the drug was non-addictive, leading doctors to prescribe it and other opioids at levels far beyond what many palliative care experts consider appropriate. In 2014, more than 14,000 Americans died from overdoses of prescription opioids alone.
Beterame says it's much easier for wealthy countries like the US to curtail overprescription than it is for a state like India to ramp up distribution of morphine. "I do not see in the US that there will be an epidemic of pain that will go unattended," he said.
Meanwhile, in India, despite the 2014 reforms, doctors are still largely in the dark about pain management.
"I studied medicine in a proper, authorized institution," said Vallath. "I never heard the words 'palliative care' except by chance from someone who had exposure to it. I didn't get it from the institution where I got my training, and even today, when I speak to medical colleges today, it's a new term for them."
Recalling the woman who visited her office and later died, Vallath said she felt emotional when the husband expressed his gratitude for her help and became motivated to pursue palliative care.
"She probably went back to suffering," said Vallath. "It's so terrible to know how thankful they were for those few hours."
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