Accessibility to cancer pain relief drugs and the international drug control treaties

Whilst over 60 countries had set up national cancer control programmes with emphasis on pain management, the majority of countries reported impediments.

In the Sunday Times of 8 January 2017 Dr. Mihitha Ariyapperuma raised a number of interesting and pertinent points in a letter under the title ”Medications to manage pain and other symptoms should be accessible to doctors in Sri Lanka”. He recounted several close relatives of his who were terminally ill without the benefit of pain killers. As a young law student I myself witnessed my grandfather suffering from immense pain due to terminal cancer even after surgery.

In the mid- 80’ s, the World Health Oragnization’s Cancer Unit estimated that globally some 3.5 million cancer patients were needlessly suffering from pain due to difficulties in accessing pain killers. Dr. Stjernsward, the head of the Cancer Unit at that time, commissioned me to undertake some country visits to identify constraints in prescribing pain killers. This was followed by a questionnaire that was administered to all WHO member states. These studies highlighted that due to the misinterpretation of the international drug control treaties (the 1961 Single Convention on Narcotic Drugs and the 1971 Convention on Psychotropic Substances), countries were either reluctant to import the necessary pain killers or imposed unduly stringent regulations. In the Philippines, for instance, a doctor who prescribed a controlled substance for a patient was required to preserve the counterfoil of the prescription for a period of several years; if it was lost or misplaced he or she was liable to be imprisoned and struck off from the roll of eligible practitioners. Thus, many cancer specialists in Metro Manila simply refrained from obtaining the specially printed prescription pads for use. The WHO issued a booklet which provided what was called ‘ the pain relief drugs prescription ladder’ - starting with simple over- the- counter pain relief drugs it provided guidance on the different stages to introduce more potent pain killers. It soon became a widely sought after publication.

As controlled drugs, which included the potent pain killers, came under the purview of the International Narcotics Control Board (INCB), it was decided in 1989 to undertake a more in-depth study. I was one of the two co- authors of the draft INCB report entitled “Demand for and the Supply of Opiates for Medical and Scientific Needs”. This led to WHO World Health Assembly and United Nations Economic and Social Council resolutions reaffirming that the Conventions provide for a delicate balance between ‘legitimate use’ on the one hand and ‘misuse or abuse’ on the other and that these Conventions are not an impediment to the health-care systems importing/manufacturing and using needed quantities of opiates.

In 1995 INCB decided to follow-up on the implementation of the 1989 recommendations. Whilst over 60 countries had set up national cancer control programmes with emphasis on pain management, the majority of countries reported impediments. Among the common impediments mentioned were the following: concern over addiction to opiates; restrictive domestic laws; insufficient trained health- care workers; reluctance to prescribe due to concerns with legal sanctions; concerns about storage and theft or diversion; cost; lack of coordination for quantification of needs (annually approved by INCB); and, absence of national guidelines.

Since then some countries have made significant progress by updating domestic laws and training health- care workers. The creation of acute pain control teams who play a key role in meeting patient needs and assisting in preparing estimates of annually required drugs has been a particularly useful approach.

‘Freedom from pain’ is a ubiquitous slogan used by national cancer control programmes and patient associations. Freedom from pain is one of the dimensions of the ‘ Right to health’. For this right to become a reality, countries need to make a concerted effort to formulate appropriate laws; sensitise the medical profession; quantify annually needed amounts of opiates; allocate financial resources to cover the cost of import or manufacture; and identify best practices in patient care and drug storage and administration. Terminally sick cancer patients should be able to live (and die) with dignity without needlessly having to suffer from pain.

(The writer was a member of the World Health Organisation expert panel on cancer, Geneva

1987-1990.)