'Massive' Suffering: Pain Relief in Less Affluent Countries

Roxanne Nelson, BSN, RN

October 18, 2017

Palliative care and pain relief continue to remain neglected elements of global healthcare, according to a major new article published online October 13 in the Lancet.

The report is the first to provide a worldwide estimate of the extent of serious suffering related to illness and injury and the resultant need for palliative care and pain relief.

More than 25.5 million people die every year without adequate relief for serious physical and psychological suffering ― nearly half of all deaths reported in 2015.

The report also states that an additional 35.5 million people require pain relief for reasons other than end-of-life care. The vast majority of these patients (>80%) live in low- and middle-income countries, where access to immediate-release morphine, an essential and inexpensive drug to relieve pain, is severely lacking.

Writing in a linked commentary, Richard Horton, MD, editor-in-chief of the Lancet, notes, "Death and disability are important metrics for describing the state of the world's health. But suffering is important too.

"Measures of suffering have been absent, and so the need for palliative care and pain relief services has been easy to miss," writes Dr Horton. "That excuse no longer holds. The scale of human suffering is massive ― 61 million people in 2015 and 6 billion physical and psychological symptom days annually (4 out of 5 of these days being accumulated in low-income and middle-income settings).

The scale of human suffering is massive. Dr Richard Horton

"The Commission has uncovered an appalling oversight in global health," he adds. "It is time for that oversight to be remedied."

A previous report initiated several years ago by the Palliative Care Working Group of the European Society for Medical Oncology (ESMO) showed that millions of cancer patients around the world are not receiving adequate pain relief with opioid analgesics because of regulatory restrictions and a lack of access and availability.

More than half of the global population resides in nations where there are legal and bureaucratic restrictions on opioid drugs. The restrictions were introduced to stop abuse and drug trafficking, but they also prevent patients from receiving pain relief. An estimated 5 billion people live in countries with little or no access to pain relief, even for those with advanced disease.

The ESMO report focused on cancer; the new report is more extensive.

Barriers to Care

The report from the Lancet Commission on Global Access to Palliative Care and Pain Relief resulted from a 3-year project that involved 61 coauthors from 25 countries. The participants developed a new conceptual framework for measuring the global burden of serious health-related suffering (SHS). They analyzed 20 life-threatening and life-limiting health conditions (including HIV, cancers, cardiovascular disease, injuries, and dementia) and 15 corresponding symptoms (including pain, fatigue, wounds, anxiety, and depression) that are frequently associated with the need for palliative care and pain relief.

The commission then identified cost-effective interventions for providing pain relief and palliative care.

Barriers to pain relief and palliative care are multifactorial. One is that the focus of existing measures of health outcomes is on extending life and productivity; very little attention is given to interventions that alleviate pain or increase dignity at the end of life.

A second is "opiophobia," or the existing prejudice and misinformation surrounding the appropriate medical use of opioids. Related to this is a concern for preventing the nonmedical use of internationally controlled substances "without balancing the human right to access medicines to relieve pain." The cost for delivering morphine-equivalent pain medication for all children with SHS residing low-income countries is $1 million per year, but that is a "pittance" compared with the $100 billion spent globally to enforce prohibition of drug use, the commission notes.

Other barriers that were identified include the focus on cure and extending life in medicine while neglecting caregiving and patient quality of life as patients near death, and an overall global neglect of noncommunicable diseases, which account for much of the need for palliative care.

Haves and Have Nots

Another issue highlighted by the commission is the profound inequality in access to morphine for palliative care. The average distribution of morphine equivalent opioids in 2010-2013 was 298.5 metric tons, but only 0.1 metric tons were distributed to low-income countries.

For example, the distribution to Haiti, one of the world's poorest nations, is 5 mg per SHS patient, which, by extrapolation, means that 99% of the need is going unmet. Wealthy countries get the lion's share. In the United States, the annual distribution of morphine is 55,000 mg per patient; in Canada, its 68,000 mg.

Mexico meets 36% of its need for pain/palliative care medication; China meets 16%; India, 4%; and Nigeria, 0.2%. But for many of the poorest nations, oral morphine in palliative care is virtually nonexistent.

As previously reported by Medscape Medical News, an analysis conducted by the International Narcotics Control Board (INCB) that was published last year showed that the use of opioid analgesics has substantially increased in many regions, but this use is decidedly unbalanced globally.

The worldwide use of opioid analgesic medicines doubled between the periods 2001-2003 and 2011-2013, but this increase in use was largely confined to North America, western and central Europe, and Oceania.

The INCB report shows that about 92% of morphine used worldwide is consumed by only 17% of the population, primarily in the United States, Canada, Western Europe, Australia, and New Zealand, where consumption has increased significantly since the early 1990s and where there is growing concern about prescription drug abuse.

In the current Lancet report, the authors used Western Europe as a benchmark, because in many of the countries there, patients have appropriate access to opioid analgesics for both palliative care and other healthcare needs. In the United States, national levels of access exceed the European benchmark, and inappropriate prescribing and misuse/abuse of opioids have been highlighted as an opioid epidemic, many patients do not receive adequate pain medication.

The cost of meeting the global need for oral morphine for palliative care, if the same prices were available for low- and middle-income countries as high-income countries, would be only $145 million. The commission notes that this is "equivalent to a very small fraction (0.002%) of total public health expenditure."

For low-income countries alone, the cost would be only $13 million, provided the drugs were available at the same price.

Key Messages

Overall, the commission presented several key messages in their report:

  • Alleviating the burden of pain, suffering, and severe distress that is associated with life-threatening or life-limiting health conditions and with end of life is a global health and equity imperative.

  • An affordable "Essential Package" of palliative care and pain relief interventions can ameliorate a large portion of preventable burden of SHS. The Essential Package would include essential medications that are generally available in most countries, as well as interventions for the relief of social and spiritual suffering, and can be made universally accessible.

  • A solution to increasing access to palliative care/pain relief is to publicly fund and fully integrate the Essential Package into national health systems as part of universal health coverage. Cost-effective models can be applied in all countries.

  • Action on an international level is needed to ensure that all patients have access to palliative care and pain relief, and a "well-functioning and balanced global system" must prevent misuse and abuse of medications while ensuring appropriate and adequate access to essential medicines.

  • Better evidence and priority-setting tools are needed to adequately measure the global need for palliative care, implement policies and programs, and monitor progress toward alleviating the burden of pain and other types of SHS.

"Safeguards need to be in place to ensure that opioid analgesics are not diverted for nonmedical use, and national experiences from many countries in Europe and from programs in Africa, Asia, and Latin Americas prove to us that safe access is achievable," said Felicia Knaul, PhD, co-chair of the commission, in a statement.

"In other words, we can and must replicate the best of the models that are working taking lessons from many countries in Western Europe," explained Dr Knaul, who is a professor in the Department of Public Health Sciences at the University of Miami in Florida. "Some 60 million sick and suffering people are counting on all of us for help."

The Lancet Commission was financially supported by the University of Miami Institute for Advanced Study of the Americas, the Harvard Global Equity Initiative, and the Office of the President and Provost at Harvard University and received grant support from the American Cancer Society, CRDF Global, the JM Foundation, the Mayday Fund, the National Cancer Institute, the Pan American Health Organization, and Susan G. Komen, and unrestricted gift support from Pfizer to the University of Miami and the Harvard T. H. Chan School of Public Health. Funds were also provided to Fundación Mexicana para la Salud, AC, and institutional support was provided by Fundación Mexicana para la Salud, AC, Tómatelo a Pecho, AC, and Harvard T. H. Chan School of Public Health. Dr Knaul and several coauthors have disclosed relationships with industry, as listed in the original article. Dr Horton has disclosed no relevant financial relationships.

Lancet. Published online October 13, 2017. Full text, Commentary

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