March 3, 2009

Executive Summary

"For two days I had agonizing pain in both the back and front of my body. I thought I was going to die. The doctor said that there was no need to medicate my pain, that it was just a hematoma and that the pain would go away by itself. I was screaming all through the night."
– An Indian man describing his stay in hospital immediately after a construction site accident in which he sustained spinal cord trauma.[1]
 "Cancer is killing us. Pain is killing me because for several days I have been unable to find injectable morphine in any place. Please Mr.  Secretary of Health, do not make us suffer any more…"
– A classified ad placed in a Colombian newspaper in September 2008 by the mother of a woman with cervical cancer.[2]
"Physicians are afraid of morphine… Doctors [in Kenya] are so used to patients dying in pain…they think that this is how you must die. They are suspicious if you don't die this way – [and feel] that you died prematurely."
– Physician at hospice in Kenya.[3]

In 1961, the world community adopted an international agreement-the 1961 Single Convention on Narcotic Drugs-that proclaimed "narcotic drugs…indispensible for the relief of pain and suffering" and instructed countries to make adequate provision to ensure their availability for medical needs. Today, almost fifty years later, the promise of that agreement remains largely unfulfilled, particularly-but not only-in low and middle income countries. In September 2008, the World Health Organization (WHO) estimated that approximately 80 percent of the world population has either no or insufficient access to treatment for moderate to severe pain and that every year tens of millions of people around the world, including around four million cancer patients and 0.8 million HIV/AIDS patients at the end of their lives suffer from such pain without treatment.

The poor availability of pain treatment is both perplexing and inexcusable. Pain causes terrible suffering yet the medications to treat it are cheap, safe, effective and generally straightforward to administer. Furthermore, international law obliges countries to make adequate pain medications available. Over the last twenty years, the WHO and the International Narcotics Control Board (INCB), the body that monitors the implementation of the UN drug conventions, have repeatedly reminded states of their obligation.  But little progress has been made in many countries.

Under international human rights law, governments must address a major public health crisis that affects millions of people every year. They must take steps to ensure that people have adequate access to treatment for their pain. At a minimum, states must ensure availability of morphine, the mainstay medication for the treatment of moderate to severe pain, because it is considered an essential medicine that should be available to all persons who need it and is cheap and widely available. Failure to make essential medicines available or to take reasonable steps to make pain management and palliative care services available will result in a violation of the right to health. In some cases, failure to ensure patients have access to treatment for severe pain will also give rise to a violation of the prohibition of cruel, inhuman and degrading treatment.

There are many reasons for the enormity of the gap between pain treatment needs and what is delivered, but chief among them is a shocking willingness by many governments around the world to passively stand by as people suffer. Few  governments have put in place effective supply and distribution systems for morphine; they have no pain management and palliative care policies or guidelines for practitioners; they have excessively strict drug control regulations that unnecessarily impede access to morphine or establish excessive penalties for mishandling it; they do not ensure healthcare workers get instruction on pain management and palliative care as part of their training; and they do not make sufficient efforts to ensure morphine is affordable. Fears that medical morphine may be diverted for illicit purposes are a key factor blocking improved access to pain treatment. While states must take steps to prevent diversion, they must do so in a way that does not unnecessarily impede access to essential medications. INCB has stated that such diversion is relatively rare.[4]

In many places, these factors combine to create a vicious cycle of under-treatment: because pain treatment and palliative care are not priorities for the government, healthcare workers do not receive the necessary training to assess and treat pain. This leads to widespread under-treatment and to low demand for morphine. Similarly, complex procurement and prescription regulations and the threat of harsh punishment for mishandling morphine discourage pharmacies and hospitals from stocking and healthcare workers from prescribing it, again resulting in low demand. This, in turn, reinforces the low priority given to pain management and palliative care. This low prioritization is not a function of low prevalence of pain but of the invisibility of its sufferers.

To break out of this vicious cycle, individual governments and the international community must fulfill their obligations under international human rights law. Governments must take action to eliminate barriers that impede availability of pain treatment medications. They must develop policies on pain management and palliative care; introduce instruction for healthcare workers, including for those already practicing; reform regulations that unnecessarily impede accessibility of pain medications; and take action to ensure their affordability. While this is a considerable task, various countries, such as Romania, Uganda and Vietnam, have shown that such a comprehensive approach is feasible in low and middle-income countries and can be successful. In pursuing steps to improve pain treatment, countries should draw on the expertise and assistance of the WHO Access to Controlled Medications Programme and INCB.

The international community should address the poor availability of pain treatment with urgency. The UN General Assembly Special Session on Drugs that will take place in Vienna in March 2009 is a unique opportunity to begin to do so. At the meeting, which will conclude a year-long review of the last ten years of drug policy, countries will set priorities for the next ten years of global drug policy. In Vienna, the international community should recommit itself to the mandate of the 1961 Single Convention for states to ensure adequate availability of controlled medicines for the relief of pain and suffering. For too long, the global drug policy debate has been strongly focused on prevention of the use and trade of illicit drugs, distorting the balance that was envisioned by the Convention. In March 2009, the international community should set ambitious and measurable goals to significantly improve access to opioid analgesics-pain medications made from opiates-and other controlled medicines worldwide over the coming ten years.

After March 2009, global drug policy actors, such as the UN Commission on Narcotic Drugs and INCB, should regularly review progress made by countries toward adequate availability of pain treatment medications, carefully analyzing steps taken to advance this important issue. Donor countries and agencies, including the Global Fund to fight AIDS, Malaria, and Tuberculosis and the U.S. President's Emergency Plan for AIDS Relief, should actively encourage countries to undertake comprehensive steps to improve access to pain relief medications and support those that do, including through support for the WHO Access to Controlled Medications Programme. UN and regional human rights bodies should routinely remind countries of their obligation under human rights law to ensure adequate availability of pain medications.

[1] Human Rights Watch interview, Kerala, India, March 20, 2008. The name of the patient is withheld for reasons of privacy.

[2] The ad appeared in the newspaper El Pais in Cali, Colombia, on September 12, 2008.

[3] Human Rights Watch interview with Dr. Weru of Nairobi Hospice, Nairobi, Kenya, June 2007.

[4] International Narcotics Control Board, "Report of the International Narcotic Control Board for 2008," United Nations, 2009.