Prisoners of Pain

PRINCETON – Last month, an Egyptian court sentenced Laura Plummer, a 33-year old English shop worker, to three years in prison for smuggling 320 doses of tramadol into the country. Tramadol is a prescription opioid available in the United Kingdom for pain relief. It is banned in Egypt, where it is widely abused. Plummer said that she was taking the drug to her Egyptian boyfriend, who suffers from chronic pain, and that she did not know she was breaking Egyptian law.

The UK media have been full of sympathetic stories about Plummer’s plight, despite the fact that she was carrying a quantity in excess of that for which a UK doctor can write a prescription. Whatever the rights and wrongs of Plummer’s conviction and sentence, however, the case illuminates an issue with much wider ramifications.

Last October, the Lancet Commission on Palliative Care and Pain Relief issued an impressive 64-page report arguing that relieving severe pain is a “global health and equity imperative.” The Commission is not the first to make such a claim, but its report brings together an abundance of evidence to demonstrate the seriousness of the problem. Each year 25.5 million people die in agony for lack of morphine or a similarly strong painkiller. Only 14% of the 40 million people requiring palliative care receive it.

The report begins with a doctor’s account of a man suffering agonizing pain from lung cancer. When the doctor gave him morphine, he was astonished by the difference it made; but when the patient returned the next month, the palliative-care service had run out of morphine. The man said he would return the following week with a rope; if he could not get the tablets, he would hang himself from the tree visible from the clinic’s window. The doctor commented: “I believe he meant what he said.”

Citizens of affluent countries are used to hearing that opioids are too easy to get. In fact, according to data from the International Narcotics Control Board and the World Health Organization, access to these drugs is shockingly unequal.

In the United States, the quantity of available opioids – that is, drugs with morphine-like effects on pain – is more than three times what patients in need of palliative care require. In India – where the man threatening to hang himself was from – the supply is just 4% of the quantity required; in Nigeria, it’s only 0.2%. People in the US suffer from over-prescription of opioids while people in developing countries are often suffering because of under-prescription.

Although it is generally the poor who lack access to opioids, the main problem is not, for once, cost: doses of immediate-release, off-patent morphine cost just a few cents each. The Lancet Commission argues that an “essential package” of medicines would cost lower-middle-income countries only $0.78 per capita per year. The total cost of closing the “pain gap” and providing all the necessary opioids would be just $145 million a year at the lowest retail prices (unfairly, opioids are often more expensive for poorer countries than richer ones). In the context of global health spending, this is a pittance.

People suffer because relieving pain is not a public policy priority. There are three main explanations for this. For starters, medicine is more focused on keeping people alive than on maintaining their quality of life. And patients suffering a few months of agony at the end of life are often not well positioned to demand better treatment.

Third, and perhaps most important, is opiophobia. The misplaced fear that allowing opioids to be used in hospitals will fuel addiction and crime in the community has led to tight restrictions on their use, and clinicians are not trained to provide them when they are needed.

While opioids can be harmful and addictive, as America’s current crisis demonstrates, the fact that something can be dangerous is not sufficient reason to impose extreme restrictions on its clinical use. Risks are justified when the expected benefits clearly outweigh the expected harms. Policymakers in the developing world are making a choice to impose what the WHO calls “overly restrictive regulations” on morphine and other essential palliative medicines. Low or zero access is neither medically nor morally justified.

Designing a system that provides adequate access to morphine without encouraging over-prescription or leaking drugs onto the black market is tricky but not impossible. The Lancet Commission draws attention to the Indian state of Kerala, where trained volunteers are at the center of community-based palliative care, bolstered by international collaboration with the WHO, university researchers, and non-governmental organizations. There is no incentive to over-prescribe, and no evidence of opioid diversion.

Another model worthy of study, the Commission says, is Uganda, where a hospice run by an NGO supplies the national public health-care system with oral morphine.

Laura Plummer’s smuggling of painkillers was doubtless foolish; her experience in an Egyptian jail will be a personal tragedy. But if her story is true, she is also a victim of the excessively tight restrictions on opioids that prevented her boyfriend from obtaining tramadol legally.

Plummer’s case thus highlights a broader misfortune: that so many citizens of developing countries are denied effective pain relief by governments in the grip of opiophobia. This is not merely foolish; in the words of the Lancet Commission, it is also a “medical, public health, and moral failing and a travesty of justice.”