Physicians attempting to provide palliative care services in developing countries to patients with advanced cancer or HIV/AIDs face substantial hurdles because of opiophobia, an exaggerated fear about the risks of opioid analgesic use. Dr. Najib Babul, an accomplished developer of medicines to treat pain discusses how entrenched opiophobia has adversely impacted the delivery of pain relief to patients in developing countries.
A recent report from the United Nations High Commissioner for Human Rights states that 5.5 billion people, three quarters of the world’s population, live in countries where access to opioids is virtually non-existent and relief from moderate to severe pain inadequate. Most these people live in developing countries throughout Central America, Africa, Asia and Eastern Europe, where lack of knowledge, cultural barriers, concerns about opioid side effects and opioid addiction, and strict government drug control policies impede both opioid availability and opioid access in local hospitals, clinics and pharmacies.
Dr. Najib Babul notes that 185 countries are signatories to international regulation of opioids through the 1961 Single Convention on Narcotic Drugs, and its supplementary treaties, the 1971 Convention on Psychotropic Substances and the 1988 United Nations Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances. The Single Convention emphasizes the dual role of national governments in the prevention of opioid diversion into non-medical distribution channels while ensuring availability and access for medical and scientific purposes. The International Narcotics Control Board (INCB), an independent quasi-judicial body set-up to implement UN drug conventions notes that “one of the fundamental objectives of the international drug control treaties is to ensure the availability of narcotic drugs and psychotropic substances for medical and scientific purposes and to promote the rational use of narcotic drugs and psychotropic substances”.
Dr. Babul observes that “three decades ago, a World Health Organization (WHO) expert committee determined that cancer pain could be relieved in most patients if health care professionals used a simple analgesic method incorporating both opioid and non-opioid analgesics. This approach was subsequently endorsed by WHO for pain relief in patients with HIV/AIDS”. Dr. Babul adds “while all drugs to treat pain possess the potential to produce side effects ranging from mild and bothersome to severe and potentially life threatening, no class of drugs has provoked as much controversy as opioid analgesics due to their potential for addiction in a minority of patients and their considerable public health consequences when diverted to recreational drug users and opioid addicts”. However, unsupported and exaggerated claims of opioid abuse unfairly affect import and prescription policies around the globe. A report from the INCB estimates that 92 percent of global morphine consumption is confined to Western and Central Europe, North America, Australia and New Zealand — around 17 percent of the earth’s population.
UN agencies have repeatedly appealed to governments and health care professionals to implement the WHO analgesic method and eliminate barriers to both opioid availability and opioid access with only modest success. To be sure, patient access to opioids has improved in some countries. However, a 2012, WHO report estimated that “tens of millions” of people worldwide experience pain associated with late-stage cancer, HIV/AIDS and other painful conditions. Although the Single Convention is premised on the principle of equipoise between governmental obligations to prevent opioid diversion and misuse and its availability to patients in need of opioids for pan relief, many nations have been focused solely on creating highly effective closed distribution system for opioids. Little if any attention has been paid to improve the availability of opioid dosage forms to prescribing physicians and its access by patients with a legitimate medical need for pain relief. In many developing countries, efforts to prevent opioid diversion have often seriously interfered with the ability pharmaceutical companies to manufacture and distribute opioids, physicians to prescribe opioids and pharmacists to dispense opioids to patients suffering from moderate to severe pain.
Inadequate access to modern education and training on opioid pharmacology has exacerbated the issue among medical professionals in developing countries. Human Rights Watch reported that only five of the over 300 medical universities in India offer courses in palliative care, leaving physicians unfamiliar with how to carefully screen patients and safely prescribe opioids. Even at institutions which offer a pain curriculum, the content frequently fails to keep pace with the significant advances in knowledge about pain and opioid pharmacology. Outdated and inaccurate information about the benefits and risks of opioids can result in practices that limit the safe and effective use of opioid analgesics.
Results from various surveys in developing countries confirm that excessively punitive national laws, fear of side effects and addiction, a poor health care infrastructure, lack of knowledge about opioids, and fear of regulatory sanctions are among the key reasons for continued lack of patient access to opioids. Thus, many care providers serving large populations in India, Russia and Mexico refuse to treat pain with opioids, noted Dr. Babul. While progress has been made in a small number of nations, the continued need for education among clinicians is apparent, and much remains to be done to correct unfounded fears and misconceptions that impede the provision of opioid analgesics when it is indicated.
Dr. Najib Babul, PharmD, MBA is a pharmaceutical scientist, inventor, biotech entrepreneur and developer of medicines to treat acute, chronic, cancer and neuropathic pain with more than twenty years of experience in bringing new drugs to market. Dr. Babul is presently a drug development consultant to pharmaceutical companies and investment banks, specializing in the areas of clinical pharmacology, dosage form design, and clinical drug development for pain, rheumatology, and cancer supportive care.
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