By: Alyssa Govindan
“The enormous gap between need and availability of opioid analgesics is growing and is increasingly skewed against people living in poverty.”- The Lancet Commission on Palliative Care and Pain Relief
What is palliative care?
It’s no surprise that people suffering from intense and chronic illnesses such as cancer or HIV endure a high level of pain, especially towards the end of their lives. In some places, we are able to treat that pain with palliative care services. Palliative care is a multidisciplinary approach that includes mental health services, hospice care and pain relief through opioids such as morphine, codeine, oxycodone, etc. However, the reality for many, especially those in lower-middle income countries (LMICs) is that it is nearly impossible to access such essential drugs. The following statistics exemplify the severe disparity between the rich and the poor when it comes to palliative care:
- Of the 298.5 metric tons of morphine-equivalent opioids distributed throughout the world per year, only 0.1 metric ton goes to LMICs.
- The United States produces or imports 31 times the amount of pain relievers it needs while countries like Haiti receive just 1% of its need and only 0.2% of Nigeria’s need is met.
- Over 61 million people are affected by serious health-related suffering. 80% of those people live in LMICs where palliative care is scarce or non-existent.
What are the obstacles to providing palliative care?
Perhaps the most daunting aspect of expanding palliative care and pain relief, especially in developing countries, is that the barriers are vast and abundant. It is not simply an issue of funding, policy, social stigma or adequate resources, but rather all of the above.
In our estimation, the most important barriers to overcome are around legislation and investment. Most laws in developing countries do not require palliative care and pain relief to be part of the healthcare system, making it extremely difficult and expensive for patients to access the drugs they need, if they are available at all. Even if non-profit or third party organizations wanted to step in to fund and provide palliative care services, they must get permission from the government beforehand. Lack of legislation exists because of a range of issues. Opiophobia instills the fear that addiction may become a deadly epidemic in policy makers’ countries just as it has here in the United States. Palliative care may also be seen as a luxury or second hand issue when so much attention in the pharmaceutical industry is put on extending life and productivity and not enough is put on alleviating pain and discomfort.
When western legislators and philanthropists oppose opioid distribution in developing countries based on the opioid epidemic that is sweeping America, it leaves many in agony. Referring to the anti-drug rhetoric used by the International Narcotics Control Board, Meg Ryan of Treat the Pain told the New York Times “That has a chilling effect on developing countries,” she said. “But it’s ridiculous — the U.S. also has an obesity epidemic, but no one is proposing that we withhold food aid from South Sudan.”
Investment in getting opioids that are already on the market to places and people that desperately need them is another major hurdle. Many drugs to combat painful diseases like cancer and HIV have already been produced. The issue is uneven distribution. Ironically enough, opioids are scarcest where they are most needed and most abundant where they are abused.
What are some solutions to expanding access to palliative care?
The Lancet Commission on Palliative Care and Pain Relief was established in October 2017 in response to the general neglect of palliative care and pain relief in global health and universal health coverage discussions. The Commission’s report introduced a new metric to measure suffering, addressed barriers and noted specific solutions for health systems to integrate palliative care and pain relief. It will proceed to track progress on the recommendations made.
To meet the global need for morphine at retail costs only $145 million per year. Let that sink in for a minute. Only $145 million per year. To treat all children with serious health-related suffering under-15 would cost just $1 million per year, a small portion of the $100 billion that governments spend on prohibiting drug use around the world. The relatively miniscule cost of introducing pain relief provides an opportunity to fill the gap quickly. The Commission determined an Essential Package which consists of the minimum palliative care that health systems should make universally accessible, even in resource-constrained and emergency settings. The Essential Package provides information on appropriate and cost-effective medicines; and pricing, human resources and staffing models that can be universally applied.
Investing in an Essential Package is one primary solution. However, there are other issues – including reducing stigma, creating regulation, educating populations about the use and misuse of opioids and exposing medical personnel to palliative care training – that should be addressed for palliative care to be broadly accessible.
What can the private sector do to expand palliative care?
The Lancet Commission details the steps that must be taken in order to incorporate palliative care and pain relief into universal health care in the future. One step includes a multistakeholder committee consisting of anyone who may be capable of assisting in policy making or delivery of palliative care. This opens the door for corporate leaders from all sectors and industries to act for the advancement of palliative care.
- Innovation- The medicines currently available to treat pain and suffering are adequate, however they are also susceptible to addiction – either because of their ingredients, dosage or formulation. Pharmaceuticals should work towards innovating products that provide relief without a high probability of causing addiction. In Uganda, liquid morphine is the main reason the country has the best quality of death among LMICs. The concoction of water, food coloring, preservatives and morphine powder is bitter and weak, making it highly unlikely for patients to become addicted.
- Training- Although in most high-income countries, only specialized medical professionals are authorized to administer opioids, general practitioners, nurses and community health workers can all be trained to deliver pain relief. The private sector has invaluable experience in developing secure supply chains and training programs which are necessary to ensure high-quality products and accessible palliative care services.
- Data Systems- In order to track patient records and properly administer individualized palliative care treatment, advanced data systems must be developed and put in place, especially in LMICs where current systems tend to be outdated and minimally used. Many businesses across all fields can dedicate their resources and expertise to helping health systems integrate accurate and dependable data systems.
- Lobbying and Advocacy- Without legislation that enshrines palliative care as an essential aspect of a modern healthcare system and for qualified, third-parties to administer pain relief, it is impossible to bring appropriate care to everyone. Corporations have proven extremely successful at lobbying for changes in legislation. By calling for accountability, pushing policy makers to act and advocating for low-cost palliative care solutions, companies across a variety of industries can join together in this fight.
Some developing countries that have started implementing initiatives for palliative care are Uganda and India. Despite the positive attention these programs have gained, they have only reached a small percentage of the population in need of pain relief.
Over the past few years, the Ugandan government worked with private philanthropies such as Hospice Africa and Treat the Pain to bring some modicum of pain relief to people who are suffering. Uganda developed professional education in palliative care, allowing nurses to administer pain relief as well as doctors. Medical students are required to study pain management as a part of their course load. In order to reduce confiscation and avoidable arrests, narcotics police were also taught about morphine, its affects and that it is a carefully administered medicine. These factors made it easier for patients to receive accurate information so they would be less likely to abuse palliative care drugs. Although Uganda is praised for its efforts, estimates show that only 11% of the population who needs morphine has access to it.
In Kerala, India the Neighborhood Network in Palliative Care (NNPC) is a community-owned program introduced in 2000. Trained community volunteers work with medical professionals to identify and treat certain chronic illnesses. The community volunteers employ outpatient clinics that are managed by doctor-nurse teams. The clinics also offer at home services. Because the NNPC is owned by the community, it is highly sustainable, while being financially-supported by the local and state governments.
These examples highlight the complexities of offering palliative care services and the strides that are yet to be made to ensure that care is expanded to entire populations. Many developing countries are ill-equipped to deal with the pain and suffering that can accompany long-term illness or terminal disease. Yet, despite the inherent controversy of the topic, more palliative care research and recent efforts should give us hope that all people, regardless of income, may soon be afforded the relief they deserve.