The War on Drugs: Implications for the Treatment of Pain

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Jason Nickerson
Jason Nickerson is an operational researcher who focuses on health systems in humanitarian emergencies and fragile states. He trained as a respiratory therapist and maintains a clinical practice in anesthesia in Ottawa, and completed a PhD in population health. Beyond health systems issues, Jason focuses on access to essential medicines, surgical care, and the treatment of respiratory diseases. Jason is a Clinical Scientist with the Bruyère Research Institute in Ottawa, Canada.

Today, a colleague, Amir Attaran, and I had a paper published in PLoS Medicine where we discuss some of the international legal constraints that hinder the availability of one of the world’s most basic and essential medicines: morphine. The paper, titled “The Inadequate Treatment of Pain: Collateral Damage from the War on Drugs” provides a critical look at the current realities of access to morphine in low-, middle-, and high-income countries, a topic that I have explored previously on this blog (here and here).

The reality is grim: 80% of the world’s population has no or inadequate access to effective pain medications, the majority of these people living in the world’s poorest countries. Furthermore, the reasons for this inequity are complex, though have a basis in prohibitionist drug policies that seek to restrict access to these drugs for fear of diversion and illicit use, in addition to economic forces that might make some drugs available and others not (for example, fentanyl – a more expensive and potent opioid – is available in some countries where morphine – a cheaper, more basic opioid – is not).

Pain is one of the most common diagnoses in clinical medicine. Is it morally defensible to restrict access to one of the most basic therapies – pain relieving drugs – to those who need them for medical purposes, in order to prevent the relatively small risk of diversion for illicit purposes? We, along with others (notably, Human Rights Watch), argue that it is not and that the treaties (specifically, the United Nations Single Convention on Narcotic Drugs) put in place to curb illicit drug production, trafficking and use have a dual mandate to influence national governments to enact laws and policies to control and reduce illicit drugs, but also to “ensure that adequate supplies of [narcotic and psychotropic] drugs are available for medical and scientific uses”. Conflicting, no?

In our paper, we advocate the need to shift responsibility for ensuring access to controlled narcotics for medical purposes to the World Health Organization, from the International Narcotics Control Board (INCB), who are currently responsible for simultaneously restricting and ensuring access to the same drugs. Our data show that despite the treaties’ 50-year existence, virtually no low-income countries have access to adequate amounts of morphine, compared to high-income countries who have substantially (sometimes 30- to 100-fold) more.

Interestingly, a series on addiction published on January 7th in The Lancet, features a related article by Robin Room and Peter Reuter which finds that “Over the past 50 years international drug treaties have neither prevented the globalisation of the illicit production and non-medical use of these drugs, nor, outside of developed countries, made these drugs adequately available for medical use.” The authors of this paper also highlight the need to revisit the treaties, though their approach advocates that individual countries consider opting out of provisions within the treaties. Fundamentally, the authors agree that the treaties impede governments’ abilities to deliver evidence-based public health services and enact evidence-based public health policies (though they make this argument in the context of addiction treatment).

Pressure needs to be mustered to reverse the current situation of unacceptably low access to essential pain medications. Morphine, among other controlled narcotics, is listed as an essential medicine by the World Health Organization, though given the poor access to it, it appears that few share the view that it is “essential”. Organizations working on health issues that are likely to necessitate pain relief and palliative care need to address head-on this need; HIV/AIDS and cancer are but a few of the illnesses for which palliative care needs to become commonplace for those at the end of life. While many agencies choose to focus on curative care or treatment, due attention needs to be given to ensuring that quality end-of-life care is available and accessible to those who need it.