Access to pain relief and essential opioids in the WHO South-East Asia Region: challenges in implementing drug reforms

Abstract

It is a justifiable assumption that more than 15 million people in the World Health Organization South-East Asia Region are experiencing serious health-related suffering, much of it caused by persistent, severe pain. Despite this burden of suffering, overall access to pain relief and palliative care services is abysmal. The lack of access to controlled drugs for pain management is striking: the average morphine equivalence in the region in 2015 was just 1.7 mg per capita, while the global average was 61.5 mg per capita. Until recently, implementation of national legislation to facilitate medical and scientific use of opioids has proven to be very complex and difficult to achieve. The effects on the region of the exploitative British opium trade in previous centuries prompted countries to adopt draconian legislation on opioids, focused on restricting illicit use. In India, the Narcotic Drugs and Psychotropic Substances Act of 1985, for example, stipulated harsh custodial sentences for even minor clerical errors in hospitals stocking opioids. Decades of persistent efforts by civil society resulted in the landmark amendment of the Act in 2014 to improve medical access, but implementation remains highly protracted. Although some progress has been made in recent years in Bangladesh, India, Nepal, Sri Lanka and Thailand, pain is a symptom that is grossly undertreated in most parts of the region. On both human rights and public health grounds, there is an urgent need for well-formulated drug policies to increase access to opioid medications, coupled with capacity-building and comprehensive public health systems incorporating palliative care.

What proportion of patients with chronic noncancer pain are prescribed an opioid medicine? Systematic review and meta‐regression of observational studies

“…The access to opioid analgesics in low‐ to middle‐income countries, which account for 80% of the world's population , is often limited, and pain is frequently undertreated . Although recent population growth in low‐income and middle‐income regions has been the highest in Africa, Asia and Latin America , we found only one study examining opioid prescribing for chronic noncancer pain in a low‐ or middle‐income country (India ).…”

“…Although recent population growth in low‐income and middle‐income regions has been the highest in Africa, Asia and Latin America , we found only one study examining opioid prescribing for chronic noncancer pain in a low‐ or middle‐income country (India ). Although South‐East Asia is home to one‐quarter of the world’s population , the consumption of opioids is low, partly due to tight government drug regulations restricting opioid access . The prescription of opioids to patients with chronic noncancer pain in other low‐ and middle‐income countries remains unclear.…”

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“… 29 In 2015, Nepal reported consumption of 0.27 mg morphine per capita, whereas the global average was 61.5 mg per capita. 30 Adequate public hospices with trained hospice care providers in rural areas need to be established.…”

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“…[ 32 ] This is particularly acute for opioids which are already unavailable in many settings. [ 33 ] Protocols should be available and training completed alongside expert back up by phone or in person. The most common symptom cluster is breathlessness and agitation[ 34 ] and this will need prompt and careful attention.…”