Fear of Addiction as a Barrier to Access to Opioid Medications in the LMICs

FEAR… and the Problem of Access

to Essential Controlled Medicines

in the LMICs

Katherine Pettus, PhD

International Association for Hospice and Palliative Care

More than 80% of the world’s people (5.5 billion) have no access to strong opioids for pain control, palliative care and dependency treatment$

Morphine and methadone unavailable in most countries$

Fear of addiction main barrier to prescribing and use

Presenting Problem

Result of old fear paradigm

Global distribution morphine

Distribution of morphine consumption in 2009, as reported by the International Narcotics Control Board.$FROM THE FOLLOWING ARTICLE:$

Access to opioid analgesics and pain relief for patients with cancer$Shalini Dalal & Eduardo Bruera$

Nature Reviews Clinical Oncology 10, 108-116 (February 2013)

BRIEF BACKGROUND$old paradigm$

• Opium, morphine, heroin, all used to be legal, over the counter-medicines until early C20$

• Missionaries and social reformers, then physicians and pharmacists wanted to abolish/regulate $

• Prohibition treaties integrated into frame international politics and relations of C20$

• Different criminological and clinical contexts — no treatment or recovery services. $

• Supply reduction considered only solution to widespread “addiction” problem$

!

Historical context: Supply Reduction

• Intention of C20 drug control treaties to reduce licit supply to only the amount needed for medical and scientific purposes!

• Nobody knew how to calculate correct amounts — many still don’t know$

• Political emphasis on control, punishment, law enforcement, NOT PROVISION for medical purposes$

• 1988: “A drug free world, we can do it” UNGASS slogan!

FEAR

• Of pain, of death (patient)$

• Of being unable to care for loved one (family)$

• Of vulnerability/dependence (patient and family)$

• Of “addiction” (patient and family)$

Language creates usOld Paradigm

Generated to control licit/illicit drug use$

• language of “evil,” “addiction” and “slavery”$

• based on 19th and 20th century religious, imperial perceptions of “Oriental, Negro, and Mexican” drug use, PWUD$

• no evidence or scientific method to evaluate substances$

• pre- palliative care, HIV/AIDS, widespread IDU

Narrative of “slavery”

addict - To addict originally meant "to award as a slave"; an addict now is a slave to his/her habit, from Latin addictus, which, in Roman law, meant "a debtor awarded as a slave to his creditor.” !We need to use different words.

Language in 1961 Single Convention on Narcotic Drugs

Recognizing that addiction to narcotic drugs constitutes a serious evil

for the individual and is fraught with social and economic danger to mankind,$

!Conscious of their duty to prevent and combat this evil,$

!Considering that effective measures against abuse of narcotic

drugs require co-ordinated and$universal action

Primary Barriers to Access

Government/Official dimension$

Fear of addiction to opioids (physicians/general)$

Fear of diversion$

Inadequate healthcare resources, such as facilities and healthcare professionals$

Lack of national policy or guidelines related to opioids

“Poison” and “Dangerous Drug”

!!Estimated “Problem drug users” 16-38 million Injecting drug users: 16 million !

• Estimated 3 million are HIV infected

• HIV Epidemic driven by prohibition of NPS and OST not drug use per se

!People with no access to essential opioid medicines for pain,

palliative care, opioid dependency treatment: 550 billion

Who pays the price of fear?

Different perspective?

99%

0%0%Problem drug usersInjecting drug usersNo access to opioid medinces

Reframing the debate?

Dispel the Fear

Attend to Language, Process and Outcomes$!!

EDUCATE AT MULTIPLE LEVELS

Change expectations $

• slow, multi-generational process$

• took several generations to get here$

Change the Conversation $

• use different language $

• “long term heavy use”,, tolerance, titration, harm reduction

!

PROCESS

Target Different Outcomes

Institutionalise $• palliative care$

• (2014 WHA resolution) requires EOMs$• increasing NCDs and ageing populations$

• harm reduction services$• holistic treatment$

INSTITUTIONALISE KEY SERVICES Include all affected…justice

OrganizePSR$

IDHDP$Physicians for Human

Rights$Physicians for the

Prevention of Nuclear War$