Nearly 26 million people around the world die each year with serious suffering in part because of a huge gap in pain relief: The U.S. may be awash in opioid painkillers, but they're rare or unavailable in dozens of poor countries, says a new report.
The challenge is to improve palliative care in low-income countries while avoiding mistakes that led to the U.S. addiction crisis.
The report to be published Friday in The Lancet says one key is using off-patent morphine that costs pennies a dose — not profitable for drug companies that push pricier, more powerful opioids in rich countries, but critical to easing a health emergency.
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In some places, even children dying of cancer or children in treatment for cancer can't get pain relief, said University of Miami professor Felicia Knaul. She co-chaired a Lancet-appointed international commission that spent three years studying the disparity and what she calls "the moral obligation" to help.
"This report finally gives voice to the suffering and a roadmap to governments," Knaul said.
Of the few hundred tons of morphine and equivalent opioids distributed worldwide, less than 4 percent goes to low- and middle-income countries, the researchers reported.
How much is needed? The Lancet Commission provided the first global estimates of the need for palliative care, defined as "serious health-related suffering" from certain life-threatening conditions, including cancer, HIV and trauma.
Some 2.5 million children are among the annual count of nearly 26 million who die without adequate relief, the team calculated.
Another 35.5 million people a year have serious pain and suffering from those conditions but aren't dying, and most live in low- or middle- income countries.
The world's poorest countries have access to enough morphine to meet less than 2 percent of their palliative care needs, the report found. India fares little better, at 4 percent; China meets 16 percent of its need, and Mexico 36 percent.
The 2010 earthquake in Haiti highlighted the scarcity, as doctors lacked opioids for people who were severely injured or needed surgery, the commission noted.
Beyond painkillers, the panel urged health systems to make available an "essential package" of palliative care services that also includes medications to ease breathing problems, muscle spasms, complications of heart or liver failure, and depression and psychological suffering. The list also includes practical equipment like pressure sore-reducing mattresses, adult diapers — and a lock box for any needed morphine.
The Lancet panel looked to lessons from the U.S. opioid crisis, and from Western Europe, which has avoided similar abuse thanks to strict opioid monitoring and to universal health coverage for non-opioid treatments for chronic pain, said report co-author Dr. Lukas Radbruch, a palliative care specialist at Germany's University of Bonn.
Among the recommendations:
-Countries should use cheap, immediate-release oral and injectable morphine for severe pain. Closing the pain gap would cost $145 million.
—Don't allow drug company marketing to patients, physicians or other health care providers. In the U.S., prescriptions soared after marketing of newer opioids for less severe types of pain.
—Closely monitor morphine supply, and train health workers in proper pain treatment.
The $1.5 million study was funded by the University of Miami and Harvard University and with grants including from the U.S. National Cancer Institute, American Cancer Society and drug maker Pfizer. Another drug company, Roche, provided a grant to help the University of Miami disseminate the findings.
One specialist who has long warned that the U.S. addiction crisis could spread internationally said the proposal for poor countries to avoid patented opioids was a "sensible" approach.
Still, "I wish they had included a stronger warning regarding the risks of a pain management agenda being co-opted by profit-seeking pharmaceutical companies as it was in the United States," said Stanford University psychiatry professor Keith Humpreys, who wasn't involved in the Lancet report.