November 9, 2017

A World of Hurt: The International Lack of Palliative Care

By

Many of the world’s population need better pain relief, and better palliative care.

On Oct. 19, 2017, The Lancet published its Commission’s report on the international lack of palliative care and pain relief. It is a 64-page tale documenting the woeful state of unrelieved global suffering.

Everywhere on earth, The Lancet reported, “people live and die with little or no palliative care or pain relief.” The Commission describes an “access abyss” in which the poor live and die in extreme suffering without hope of receiving pain-relieving medications. They describe the fact that most of humanity lives in a world of hurt:
http://www.thelancet.com/commissions/palliative-care

The report cites poor global public health planning for pain relief and poor physician understanding of pain relief as the two major causes of the international shortfall of palliative care. Specifically:

  1. International health policy and investment have been focused on curing disease and extending life. While this has led to dramatic successes, such as the eradication of smallpox and the reduction of polio, little focus has been given to health interventions to alleviate pain at the end of life. This is due to global neglect of non-communicable diseases, where the need for palliative care is highest.

  2. “Opiophobia” is the “prejudice and misinformation about the appropriate medical use of opioids.” This has resulted in a focus on preventing the nonmedical use of opiates without improving access to opiates for pain relief. “Opiophobia” causes doctors to worry more about addictions of the dying than the palliation of their suffering.

The article documents the astounding maldistribution of pain relievers known as “morphine equivalent opioids” (MEOs). Of the almost 68,000 pounds (340 tons) of MEOs distributed worldwide, only an estimated 225 pounds is dispensed in low-income countries. In Haiti, for example, only 5mg of MEOs per patient are available, leaving 99 percent of palliative care needs unmet. In Haiti’s wealthier northern neighbor, the United States, MEOs are available at a staggering rate of 55,000 mg per patient. The MEOs in the U.S. meet more than 3,000 percent of needs, versus less than 6 percent of MAO needs in Haiti. Worse yet, Haiti has almost four times the MEOs of Nigeria, where a mere 0.8 mg of MEOs are available per patient. This deficit leaves almost everyone there with “serious health-related suffering” (SHS) in pain. SHS is defined as suffering that “cannot be relieved without medical intervention that compromises physical, social, or emotional functioning.”

But it is not only the poor countries’ poor who experience SHS needlessly, but also the rich countries’ poor – and, frequently, the rich countries’ rich. In poorer nations, this vulnerable group lacks the access to “inexpensive, essential, and effective intervention” to relieve their physical torment. In our country, there are frequent reports that despite the 55,000 mg of MEOs available per patient, many patients live with unrelieved SHS. In the authors’ opinion, this is “a medical, public health, and moral failing” by the global health community, which includes our part of the globe – the U.S. America’s patients enduring SHS are also in this world of hurt.

Relief of meaningless, unnecessary physical pain is a right of all patients in all places. In our homeland, where, again, there are 55 kilograms of opiates available per patient, our fellow countrymen and women still experience unrelieved SHS. It is not a matter of a lack of drugs, but a lack of appreciation that pain is agony for the sick and their loved ones, that pain destroys the person as well as the body, and that mitigating unnecessary suffering is an ethical obligation.

At the center of this hurting world is the painfully skewed maldistribution of pain-relieving medications. The World Health Organization (WHO) has estimated that 80 percent of the world’s population either has very limited access or no access to pain relievers. The International Narcotics Control Board reported that in 2014, a mere 17 percent of the world’s population consumed 92 percent of the MEOs administered worldwide. This disparate distribution of opioids is grimly illustrated by the fact that while an estimated 12 million people died in pain for lack of opioids between 2016 and 2017, over 64,000 Americans died from an excess of them.

In a poignant counterpoint to The Lancet report, just seven days after it was published, President Donald Trump declared the “opioid crisis in the USA to be a public health emergency.” The glut of opiate medications in America has resulted in an increase in unnecessary deaths, but not a decrease in unnecessary pain. The living are dying from a surplus of narcotics, while the dying are suffering from a lack of them. The world’s dying are tormented by the severe maldistribution of opiates, while at home our dying suffer from the gross misdistribution of them.

This globalization of pain has been revealed by many journals and organizations. More than five years ago, the New England Journal of Medicine published an editorial titled “Painful Inequities – Palliative Care in Developing Countries, in which both the global burden of pain and the global initiatives to relieve it were discussed. Back then, in 2012, a total of 150 countries were identified where “morphine is simply not available.” The editorialists summed this up with the pithy observation that “people dying in pain are generally invisible:” http://www.nejm.org/doi/citedby/10.1056/NEJMp1113622

One of the international agencies addressing pain around the world is Global Access to Pain Relief (GAPRI). GAPRI estimated that as many as 5 billion people live in countries with “little or no access to pain medications.” This population includes more than5 million terminal cancer patients. Their website provides a short graphic article on the problems and solutions to unrelieved pain throughout our world. It is harrowing to peruse: http://www.uicc.org/global-access-pain-relief-initiative-gapri-one-pager

Another part of GAPRI’s pain-relieving program is the American Cancer Association’s ambitious “Treat the Pain Program,” which has the goal “to make effective pain medicines universally available by 2020.” In addition to working with governments and international health partners, Treat the Pain’s other goal is to raise international awareness that poorer people of the world feel pain just like the wealthier people do. Pain is everywhere on our planet, but pain medications are not: http://treatthepain.org/

Unrelieved global pain is not only “the medical, public health, and moral failing” as the Lancet Commission called it – it is more disgracefully an economic failure. The cost of meeting the global need for pain relieving opiates is approximately $145 million, which, according to the Lancet Commission, is “equivalent to a very small fraction (0.002 percent) of total public health expenditure.” The money is not spent because the problem is not seen.

The problem of unrelieved suffering in every corner of our world is appallingly invisible. The farther the problem is from our homes, the more invisible it becomes, until it vanishes from our consciousness and consciences. This is not, however, merely an income- or geographic-specific problem. Many in the wealthy nations of the world, despite being awash in opiates, suffer just like those in poorer countries at the end of life, but the poor of the world suffer much more intensely, much longer, and in much greater despair. The poor often have no physicians to champion their plight. They are often so ill, in so much pain, and so politically disenfranchised that they are powerless to advocate for themselves.

If we are to preserve the dignity of the dying of our world, we must palliate their suffering. Palliative care is a right of all people in pain, at home and abroad. This problem is “generally invisible” only because we choose not to see what the Lancet Commission and others are revealing. We need to examine their revelations with our eyes wide open and see that many, many people who share our planet live in a world of hurt. They need better care, better pain relief, and better palliative care.

Attempting to meet these needs will not only preserve the dignity of the dying, but our dignity as their fellow human beings as well.

Michael A. Salvatore, MD, FACP

Dr. Michael Salvatore was a pulmonary medicine/critical care physician for 35 years. Since 2012 he has been the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. After earning his MD at the University of Arizona, he trained in internal medicine and PULM/CCM at Duke University. Dr. Salvatore is a member of the RACmonitor editorial board.

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